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In the past decade, professionals in the field of posttraumatic early intervention have made increasing efforts to identify and endorse interventions that have the potential to reduce suffering and/or facilitate recovery following mass traumatic events. There are few well-controlled studies related to any particular intervention in this context, and difficulties in obtaining empirical support as well as lack of a conceptual framework have impeded the development of definitive recommendations. Therefore, during the past 12 months, a team from National Child Traumatic Stress Network and the National Center for PTSD, including Alan Steinberg, Melissa Brymer, Eric Vernbert, Robert Pynoos, Patricia Watson and Josef Ruzek, in consultation with a diverse group of disaster response professionals have attempted to bring their expertise to bear in developing a Psychological First Aid (PFA) manual. In response to Hurricane Katrina, work on the manual was accelerated to ensure its release via both organizations’ Web sites (see http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp to review the manual).

The eight PFA “core actions” or components of PFA and their associated goals are listed to the right. These core actions and goals constitute the basic objectives of very early assistance provided within hours or days following an event. (The developers of the PFA manual currently are working on a second manual, tentatively labeled Secondary Psychological Aid (SPA), which includes CBT-based strategies that can be delivered in the first weeks postevent and require more time for delivery.) Note that many of the components of PFA are not specifically psychological in nature but focus on meeting basic needs (e.g., physical safety, interpersonal connectedness) and supporting postevent functioning. PFA also involves orienting survivors to the disaster response site, helping them navigate services, and allowing them the opportunity to share their thoughts and feelings or experiences, if desired. PFA allows room for those who do not wish to discuss the trauma to avoid doing so. The actions are intended to be delivered in a flexible way, using strategies that meet the specific needs of children, families and adults. The amount of time spent on each goal will vary from person to person, and with different circumstances according to need.

Core Actions of Psychological First Aid

  1. Contact and Engagement: Goal is to respond to contacts initiated by affected persons, or initiate contacts in a non-intrusive, compassionate and helpful manner.
     
  2. Safety and Comfort: Goal is to enhance immediate and ongoing safety, and provide physical and emotional comfort.
     
  3. Stabilization (if needed): Goal is to calm and orient emotionally overwhelmed/distraught survivors.
     
  4. Information Gathering: Current Needs and Concerns: Goal is to identify immediate needs and concerns, gather additional information, and tailor psychological first aid interventions.
     
  5. Practical Assistance: Goal is to offer practical help to the survivor in addressing immediate needs and concerns.
     
  6. Connection with Social Supports: Goal is to help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends and community helping resources.
     
  7. Information on Coping: Goal is to provide information (about stress reactions and coping) to reduce distress and promote adaptive functioning.
     
  8. Linkage with Collaborative Services: Goal is to link survivors with needed services and inform them about available services that may be needed in the future.

The various PFA components are increasingly endorsed for universal application after mass violence or disaster, in part because they are considered to hold little potential for harm, and they do not contain elements (such as systematic emotional processing) hypothesized to be potentially harmful for some in the immediate aftermath of trauma.

The PFA manual has been designed, as far as possible, to be consistent with research evidence, applicable in field settings, tailored to the full developmental spectrum and culturally informed. It is intended for use by mental health responders who provide acute assistance following trauma in a variety of settings (shelters, schools, workplaces, etc.). The manual contains detailed, concrete examples of statements that can be made by providers to assist in delivery of the intervention activities. Modules are accompanied by a set of handouts for survivors, with information on many aspects of posttraumatic recovery and coping.

While PFA has not been systematically studied yet, experience in the field suggests that it will be acceptable to and well-received by consumers. It is, however, important to remain cautious in our estimation of what early interventions can accomplish in terms of prevention of long-term functional and symptomatic impact. It is unknown whether most early intervention activities are associated with significant improvements in functioning. There is a great need for both program evaluation and randomized controlled trials that will evaluate the effectiveness of psychological first aid principles in a number of contexts.

This research should include a range of outcomes, including not only PTSD, but also substance abuse, depression, anger and violence, interpersonal and role functioning, utilization of helping services, and physical health. Research on service utilization indicates that the majority of individuals exposed to a traumatic event will not choose to seek mental health services; therefore, a careful study of what interventions are acceptable and supportive of natural recovery trajectories may be called for prior to strong recommendations for any mental health intervention. Care should be taken to include the preferences of recipients as disaster mental health response procedures are planned.

As McNally and colleagues (2003) note, “the bottom line is that in the immediate aftermath of trauma, professionals should take their lead from the survivors and provide the help they want, rather than tell survivors how they will get better (p. 68).” With this in mind, the PFA manual has been designed to be flexible and targeted at practical assistance and skill-building related to the current concerns and needs identified by survivors themselves.

Note: A training session based on the Psychological First Aid Manual has been added to the scheduled ISTSS annual meeting panel session: Psychological First Aid Across the Developmental Life Span (see “21st Annual Meeting Promises Strong Lineup—Highlights Hurricane Katrina and Other Mass Disasters.”)

Patricia Watson, PhD, and Josef I. Ruzek, PhD, are with the National Center for PTSD and are co-chairs of the ISTSS Early Intervention Special Interest Group.

References
McNally, R.J, Bryant, RA, & Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 4, 45–79.

National Child Traumatic Stress Network, National Center for PTSD (2005). Psychological First Aid: Field Operations Guide, http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp.

For more information and resources on hurricane recovery, visit the Web sites of the National Child Traumatic Stress Network (www.NCTSN.org) and the National Center for PTSD (www.ptsd.va.gov).