Psychological first aid

Psychological first aid (PFA) is a technique designed to reduce the occurrence of post-traumatic stress disorder. It was developed by the National Center for Post Traumatic Stress Disorder (NC-PTSD), a section of the United States Department of Veterans Affairs, in 2006. It has been endorsed and used by the International Federation of Red Cross and Red Crescent Societies, Community Emergency Response Team (CERT), the American Psychological Association (APA) and many others. It was developed in a two-day intensive collaboration, involving more than 25 disaster mental health researchers, an online survey of the first cohort that used PFA and repeated reviews of the draft.^[1]

According to the NC-PTSD, psychological first aid is an evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism to reduce initial distress and to foster short and long-term adaptive functioning. It was used by non-mental health experts, such as responders and volunteers. Other characteristics include non-intrusive pragmatic care and assessing needs. PFA does not necessarily involve discussion of the traumatic event and avoids any activity associated with "debriefing" as that technique has been associated with increased rates of PTSD.^[2]

• Protecting from further harm
• Opportunity to talk without pressure
• Active listening
• Compassion
• Addressing and acknowledging concerns
• Discussing coping strategies
• Social support
• Offer to return to talk
• Referral

• Contact and engagement
• Safety and comfort
• Stabilization
• Information gathering
• Practical assistance
• Connection with social supports
• Coping information
• Linkage with services

Before PFA, there was a procedure known as debriefing. Debriefing was a necessary step in a commercially available training intended to reduce PTSD called "Critical Incident Stress Management" (CISM) . It was intended to reduce the incidence of post traumatic stress disorder (PTSD) after a major disaster. PTSD is now widely known to be debilitating; sufferers experience avoidance, flashbacks, hyper-vigilance, and numbness. Debriefing procedures were made a requirement after a disaster, with a desire to prevent people from developing PTSD. The idea behind it was to promote emotional processing by encouraging recollection of the event. Debriefing has origins with the military, where sessions were intended to boost morale and reduce distress after a mission, however the US Department of Defense discontinued the practice in 2002 due to evidence indicating that the practice increased PTSD rates.^[3] Debriefing was done in a single session with seven stages: introduction, facts, thoughts and impressions, emotional reactions, normalization, planning for future, and disengagement.^[2]

Debriefing was found to be at best, ineffective,^[4][5][6][7] and at worst, harmful^[8] with some studies finding that PTSD rates actually increased as a result of debriefing.^[2] There are several theories as to why debriefing increased incidence of PTSD. First, those who were likely to develop PTSD were not helped by a single session. Second, being re-exposed too soon to the trauma could lead to retraumatization. Exposure therapy in cognitive behavioral therapy allows the person to adjust to the stimuli before slowly increasing severity. Debriefing did not allow for this. Also, normal distress was seen to be pathological after a debriefing and those who had been through a trauma thought they had a mental disorder because they were upset. Debriefing assumes that everyone reacts the same way to a trauma, and anyone who deviates from that path, is pathological. But there are many ways to cope with a trauma, especially so soon after it happens.^[9][2]

PFA seems to address many of the issues in debriefing. It is not compulsory and can be done in multiple sessions and links those who need more help to services. It deals with practical issues which are often more pressing and create stress. It also improves self-efficacy by letting people cope their own way. PFA has attempted to be culturally sensitive, but whether it is or not has not been shown. However, a drawback is the lack of empirical evidence.^[10] While it is based on research, it is not proven by research.^[11] A 2024 integrative review concluded that the substantial variation in PFA protocols limits the ability to reach scientific conclusions.^[12] Like the debriefing method, PFA has become widely popular without testing, however debriefing is linked to harmful outcomes whereas PFA specifically avoids debriefing.^[13]

• Allen; et al. (2010). "Perceptions of PFA Among Providers". Journal of Traumatic Stress. 23 (4): 509–513. doi:10.1002/jts.20539. PMID 20623598.
• Bisson, Jonathan I.; Lewis, Catrin (31 July 2009), Systematic review of psychological first aid, World Health Organisation, retrieved 30 May 2017
• Cain; et al. (2010). "Weathering the Storm". Journal of Child and Adolescent Trauma. 3: 330–343. doi:10.1080/19361521.2010.523063. S2CID 144518414.
• Everly, G. S.; Lating, J. M. (2017). The Johns Hopkins guide to psychological first aid. Johns Hopkins University Press. OCLC 957724673.
• Fox; et al. (2010). "Effectiveness of PFA: Research Analysis". Disaster Medicine and Public Health Preparedness. 6 (3): 247–252. doi:10.1001/dmp.2012.39. PMID 23077267. S2CID 23857265.
• Gray, Matt J.; Maguen, Shira; Litz, Brett T. (2004). "Acute Psychological Impact of Disaster and Large-Scale Trauma: Limitations of Traditional Interventions and Future Practice Recommendations". Prehospital and Disaster Medicine. 19 (1): 64–72. doi:10.1017/s1049023x00001497. ISSN 1049-023X. PMID 15453161. S2CID 20164465.
• Rose, Suzanna C; Bisson, Jonathan; Churchill, Rachel; Wessely, Simon (22 April 2002). "Psychological debriefing for preventing post traumatic stress disorder (PTSD)". Cochrane Database of Systematic Reviews (2): CD000560. doi:10.1002/14651858.cd000560. PMC 7032695. PMID 12076399.
• Schafer, A.; Snider, L.; van Ommeren, M. (2010). "Psychological First Aid Pilot: Haiti Emergency Response Intervention". War Trauma Foundation. 8 (3): 245–254. doi:10.1097/wtf.0b013e32834134cb. S2CID 75512259.
• Uhernik & Husson. 2009. PFA: "Evidence Informed Approach for Acute Disaster Behavioral Health Response". Compelling Counseling Interventions. 271–280.
• Vernberg; et al. (2008). "Innovations in Disaster Mental Health: PFA". Professional Psychology: Research and Practice. 39 (4): 381–388. doi:10.1037/a0012663.