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Objective

With no intervention, a traumatic event can cause serious long-term psychological harm for a small percentage of those exposed to the trauma, potentially leaving one unable to successfully function at work and/or socially. To minimize or prevent these dangerous results of a traumatic event, professional services should be available immediately after the event is experienced for those who need the support of a mental health professional. In most cases, those exposed to trauma can be best helped by connecting them to their primary and existing social supports, including family, friends, faculty, staff and local community helping resources.

Psychological First Aid (PFA) is designed for trained mental health professionals to coordinate and administer psychological and practical support with the help of partnering agencies or mental health professionals, to identify, assist and appropriately respond to emotional, practical and psychological needs of survivors of a traumatic event.

Situational Overview

This procedure will be used by ������ý following any traumatic event to facilitate the healing process of those affected by the event.

Psychological First Aid

Psychological First Aid is an evidence-informed modular approach to assist children, adolescents, adults and families in the immediate aftermath of disaster and terrorism.  Psychological First Aid is designed to reduce the initial distress caused by traumatic events and to foster short- and long-term adaptive functioning and coping. Principles and techniques of Psychological First Aid meet four basic standards. They are:

1. consistent with research evidence on risk and resilience following trauma;
2. applicable and practical in field settings;
3. appropriate to developmental level across the lifespan; and
4. culturally informed and adaptable.

Consistent with the research evidence, Psychological First Aid does not presume all survivors will develop severe psychopathology, but instead fosters an understanding that disaster survivors and others impacted by such events will experience a broad range of reactions (e.g. physical, psychological, cognitive, spiritual). Some of these reactions will cause sufficient distress for the individual and may be alleviated by support from compassionate and caring disaster responders and the person’s primary support networks. Psychological First Aid is an intervention strategy that can be woven into the basic disaster response mechanisms for ������ý.

Who is Psychological First Aid For?

Psychological First Aid intervention strategies are intended for use with children, adolescents, parents/caretakers, families and adults. Other populations include healthcare workers, law enforcement officers, firefighters, emergency medical service professionals, and other first responders and disaster relief workers.

Who Delivers Psychological First Aid?

Psychological First Aid (PFA) is designed for delivery by a variety of response units. All members of the ������ý community who provide acute assistance as part of the organized disaster response effort should be trained in the basics of providing PFA. These providers may be imbedded in a variety of response units, including the Counseling Center, the Employee Assistance Program, University Police, Residential Life and others as deemed appropriate by ������ý. In situations involving a large number of University community members, other agencies and mental health professionals may need to partner in this response as they are willing and able.

When Should Psychological First Aid Be Used?

PFA is a supportive behavioral intervention for use in the immediate aftermath of disasters and other traumatic events. It is intended to blend into the general ������ý University response structure early in disaster stabilization and recovery efforts.

Where Should Psychological First Aid Be Used?

Psychological First Aid is designed for delivery in diverse settings. Trained and qualified ������ý employees may be called upon to provide PFA in all areas of the campus community.

Strengths of Psychological First Aid

• Psychological First Aid includes basic information-gathering techniques to help mental health specialists make rapid assessments of survivors’ immediate concerns and needs and how to implement supportive activities in a flexible manner.
• Psychological First Aid relies on field-tested, evidence-informed strategies that can be provided in a variety of disaster settings.
• Psychological First Aid emphasizes developmentally and culturally appropriate interventions for survivors of various ages and backgrounds.
• Psychological First Aid includes important elements of risk communication and education via the use of materials and handouts that provide information for youth, adults and families for their use over the course of recovery in contending with post-disaster reactions and adversities.

Basic Objectives of Psychological First Aid

• Establish a human connection in a non-intrusive, compassionate manner.
• Enhance immediate and ongoing safety, and provide physical and emotional comfort.
• Calm and orient emotionally-overwhelmed or distraught survivors.
• Help survivors to articulate immediate needs and concerns, and gather additional information as appropriate.
• Offer practical assistance and information to help survivors address their immediate needs and concerns.
• Connect survivors as soon as possible to social support networks, including family members, friends, neighbors and community helping resources.
• Support positive coping, acknowledge coping efforts and strengths, and empower survivors; encourage adults, children and families to take an active role in their recovery.
• Provide information that may help survivors to cope effectively with the psychological impact of disasters.
• Facilitate continuity in disaster response efforts by clarifying how long the Psychological First Aid provider will be available, and (when appropriate) linking the survivor to another member of a disaster response team or to indigenous recovery systems, mental health services, public-sector services and organizations.

Delivering Psychological First Aid

Behave professionally

• Operate only within the framework of an authorized disaster response system.
• Model sound responses; be calm, courteous, organized and helpful.
• Be visible and available.
• Maintain confidentiality as appropriate.
• Remain within the scope of your expertise and your designated role.
• Make appropriate referrals when additional expertise is needed or requested by the individual.
• Be knowledgeable and sensitive to issues of culture and diversity.
• Pay attention to your own emotional and physical reactions, and actively manage these reactions.

Preparing to Deliver Psychological First Aid

In order to be of assistance to disaster-affected communities, the provider must be knowledgeable about the nature of the event, the post-event circumstances, and the type and availability of relief and support services.

Pre-planning and Preparation

Pre-planning and preparation becomes particularly important when working as a ������ý University PFA provider. Prior knowledge of professional competencies (expectations and limitations), agreed upon response guidelines, organizational control, incident command structure and working guidelines of other ‘partner’ agencies is critical to a cooperative and functional response. Flexibility, open-mindedness and cooperation will be highly regarded skills early in the response.

Entering the Setting

Psychological First Aid begins when a disaster mental health specialist enters an emergency management setting in the aftermath of a disaster. Successful entry involves working within the framework of an authorized Incident Command System (ICS) in which roles and decision-making are clearly defined. It is essential to establish communication and coordinate all activities with authorized personnel or organizations that are managing the setting.

Effective entry also involves orienting yourself to the setting (e.g., leadership, organization, policies and procedures, security, psychiatric support) and available services. As you provide Psychological First Aid, you need to have accurate information about what is going to happen, what services are available and where services can be found. This information needs to be gathered as soon as possible, given that providing such information is often critical to reducing distress and promoting adaptive coping.

Providing Services

In some settings, Psychological First Aid may be provided in designated areas. In other settings, Psychological First Aid providers may circulate around the facility to identify those to be approached for assistance. Focus your attention on how people are reacting and interacting in the setting. Individuals who may need assistance include those showing signs of acute distress. This includes individuals who are:

• Disoriented
• Confused
• Frantic
• Panicky
• Extremely withdrawn, apathetic or “shut down”
• Extremely irritable or angry
• Individuals who are exceedingly worried

Decide who may need assistance or would benefit most from contact with you and plan for how to contact them within the time and constraints of the setting. 

Maintain a Calm Presence

People take their cue from how others are reacting. By demonstrating calmness and clear thinking, you can help survivors feel that they can rely on you. Others may follow your lead in remaining focused, even if they do not feel calm, safe, effective or even hopeful. Psychological First Aid providers often model the sense of hope that affected persons cannot always feel while they are still attempting to deal with what happened and current pressing concerns.

Be Sensitive to Culture and Diversity

Sensitivity to culture and ethnic, religious, racial and language diversity is central to providing Psychological First Aid. It is critical to both outreach efforts and service provision. Providers should be aware of their own values and prejudices, and how these may coincide or differ with those of the community being served. Helping to maintain or reestablish customs, traditions, rituals, family structure, gender roles and social bonds is important to helping survivors cope with the impact of a disaster. Information about the community being served, including how emotions and other psychological reactions are expressed, attitudes toward governmental agencies and receptivity to counseling should be gathered with the assistance of community cultural leaders who represent and best understand local cultural groups.

Be Aware of At-Risk Populations

Individuals that are at special risk after a disaster include:

• Children (especially children whose parents have died, were significantly injured or are missing)
• Those who have had multiple relocations and displacements
• Medically frail adults
• The elderly
• Those with serious mental illness
• Those with physical disabilities or illness
• Adolescents who may be risk-takers
• Adolescents and adults with substance abuse problems
• Pregnant women
• Mothers with babies and small children
• Professionals or volunteers who participated in disaster response and recovery efforts
• Those who have experienced significant loss of their possessions (e.g., home, pets, family memorabilia, etc.)
• Those exposed first hand to grotesque scenes or extreme life threat

The prevalence of exposure to pre-disaster trauma may be higher among economically disadvantaged populations. As a consequence, minority and marginalized communities may have higher rates of pre-disaster trauma-related mental health problems and are at greater risk for developing problems following disaster. Mistrust, stigma, fear (e.g., fear of deportation) and lack of knowledge about disaster relief services are important barriers to seeking, providing and receiving services for these populations. Those living in disaster-prone regions are more likely to have had prior disaster experiences, although having dealt well with a disaster in the past may be helpful in the current situation.

Psychological First Aid Core Actions

Contact and Engagement: Goal: To respond to contacts initiated by affected persons or initiate contacts in a non-intrusive, compassionate and helpful manner.

Safety and Comfort: Goal: To enhance immediate and ongoing safety, and provide physical and emotional comfort.

Stabilization (if needed): Goal: To calm and orient emotionally overwhelmed/distraught survivors.

Information Gathering: Current Needs and Concerns: Goal: To identify immediate needs and concerns, gather additional information and tailor Psychological First Aid interventions.

Practical Assistance: Goal: To offer practical help to the survivor in addressing immediate needs and concerns.

Connection with Social Supports: Goal: To help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends and community helping resources.

Information on Coping: Goal: To provide information (about stress reactions and coping) to reduce distress and promote adaptive functioning.

Linkage with Collaborative Services: Goal: To inform and link survivors with available services needed at the time or in the future.

These core goals of Psychological First Aid constitute the basic objectives of providing early assistance (e.g., within days or weeks following an event) and will need to be addressed 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.

Contact and Engagement

The first contact with a survivor is important. If managed in a respectful and compassionate way, it can help establish an effective helping relationship and increase the person’s receptiveness to further help. Your first priority should be to manage contacts with persons who seek you out, especially if a number of people approach you simultaneously. Make contact with as many individuals as you can. Often this will be very brief, but even a brief look of interest and calm concern from another person can be grounding and helpful to people who are feeling detached or overwhelmed.

Others will not seek your help but may benefit from assistance. When you identify such persons, timing is important. Do not interrupt conversations. You may try to make nonverbal contact first (e.g., by returning eye contact). Do not assume that people will respond to your assistance with immediate positive reactions. It may take time for some survivors or bereaved persons to feel some degree of safety, confidence and trust. If an individual declines your offer of help, respect his/her decision and indicate when and where Psychological First Aid providers will be available later on.

Safety and Comfort

Restoration of a sense of safety is an important goal in the immediate aftermath of disaster. Comfort and a sense of safety can be supported in many ways. Some strategies to accomplish this include:

• Do things that are active (rather than passive waiting), practical (using available resources), and familiar (drawing on well-learned behaviors that do not require new learning) can increase a sense of control over the situation.
• Get current accurate and up-to-date information, while avoiding exposure to inaccurate or re-traumatizing information via media, official updates and informal conversations.
• Get connected with immediate practical resources (ways to connect with loved ones).
• Get information that is focused on how responders are making the situation safer.
• Be connected with others who have shared similar experiences.

Ensure Immediate Physical Safety

Make sure that individuals and families are physically safe to the extent possible in the situation at hand. If necessary, re-organize the immediate environment to increase physical and emotional safety. For example:

• Find the appropriate officials who can resolve safety concerns that are beyond your ability to control, such as threats, weapons, etc.
• Remove broken glass, sharp objects, furniture, spilled liquids and other objects that could cause people to trip and fall.
• Place barriers to prevent intrusions by unauthorized persons.
• Make sure that persons who may be at risk for falling (i.e. physically frail individuals) are in areas that don’t require the use of stairs or are located in lower levels of the shelter.

If there are medical concerns requiring urgent attention, contact the appropriate unit leader or medical support immediately. Remain with the affected person or find someone to stay with the affected person until help can be obtained. Other safety concerns involve:

• Threat of harm to self or others: Look for signs that persons may hurt themselves or others (e.g., expresses intense anger towards self or others, exhibit extreme agitation). If so, seek immediate support for containment and management by medical, EMT assistance, or a security team.
• Shock: If an individual is showing signs of shock (pale, clammy skin, weak or rapid pulse, irregular breathing, dull or glassy eyes, unresponsive to communication, lack of bladder or bowel control, restless or agitated), seek immediate medical support.

Enhance Sense of Predictability, Control, Comfort, and Safety

Information can help to re-orient and comfort children and families and can include information about:

• What to do next
• What is being done to assist them
• What is currently known about the unfolding event
• Available services
• Stress reactions
• Self-care, family care and coping

In providing information:

• Use your judgment as to whether and when to present information. Does the individual appear able to comprehend what is being said, and is he or she ready to hear the content of the messages?
• The most useful information is that which provides assistance in addressing immediate needs, reduces fears, answers pressing questions, addresses current concerns and supports coping efforts.
• Use clear and concise language while avoiding technical jargon.

Provide Simple Information about Disaster Response Activities and Services

Ask survivors if they have any questions about what is going to happen, and give simple accurate information about what they can expect. Be sure to ask about concerns regarding current danger and safety in their new situation. Try to connect survivors with information that addresses these concerns. If you do not have specific information, do not guess or invent information in order to provide reassurance. Instead, develop a plan with the person for ways you and he/she can gather the needed information.

Attend to Physical Comfort

Look for simple ways to make the physical environment more comfortable. If possible, consider things like temperature, lighting, air quality, access to furniture and how the furniture is arranged. To reduce feelings of helplessness or dependency, encourage affected persons to participate in getting things needed for comfort (e.g., offer to walk over to the supply area with the person rather than retrieving supplies for them). Help them regain or exercise their ability to soothe and comfort themselves and others around them. 

Promote Social Engagement

Facilitate proximity to other people as appropriate. It is generally soothing and reassuring to be near other people who seem to be coping adequately with the situation. On the other hand, it is upsetting being near others who appear very agitated and emotionally overwhelmed. If they have heard worrying information from others or circulating rumors, help to clarify these and correct misinformation.

Children, and to some extent adolescents, are particularly likely to look to adults for cues about safety and appropriate behavior. When possible, place children near adults or peers who appear relatively calm given the circumstances and shield them from close proximity to highly distressed individuals. Offer brief explanations to children and adolescents who have observed extreme reactions in other survivors.

As appropriate, encourage people who are coping adequately to talk with others who are currently distressed or not coping as well. Those coping adequately may have concerns about being burdened by others’ fears and anger. However, you can reassure them that talking to people, especially if the conversation focuses on things that people hold in common (for example, coming from nearby neighborhoods or sharing new information), can help them support one another. This often reduces a sense of isolation and helplessness in both parties. If feasible, provide access to age-appropriate materials that foster soothing activities.

Protect from Additional Traumatic Experiences and Trauma Reminders

Protect survivors from unnecessary exposure to additional trauma and trauma reminders (e.g., reduce exposure to the suffering of others). Psychological First Aid providers should look for ways to minimize additional distressing experiences. When necessary, try to shield survivors from reporters, other media professionals, onlookers or attorneys. Help protect their privacy.

If survivors have access to media coverage (e.g., television or radio broadcasts), point out that excessive viewing of such coverage can be highly upsetting, especially for children and adolescents. 

Stabilization (if needed)

Most individuals affected by a disaster or other traumatic incident will not require stabilization. Expressions of strong emotions, even muted emotions (e.g., numb, indifferent, spaced-out, or confused), are expectable reactions to disaster and do not of themselves signal the need for additional intervention beyond ordinary supportive contact.

Stabilize Emotionally-Overwhelmed Survivors

Observe individuals for signs of being disorientated or overwhelmed. Signs include:

• Looking glassy eyed and vacant – unable to find direction
• Unresponsiveness to verbal questions or commands
• Disorientation (e.g., engaging in aimless disorganized behavior)
• Exhibiting strong emotional responses, uncontrollable crying, hyperventilating, rocking or regressive behavior
• Experiencing uncontrollable physical reactions (shaking, trembling)
• Exhibiting frantic searching behavior
• Feeling incapacitated by worry
• Engaging in risky activities

If the person is too upset, agitated, withdrawn or disoriented to talk, or shows extreme anxiety, fear or panic, the Psychological First Aid provider should consider:

• Is the person alone or in the company of family and friends? If family or friends are present, it may be helpful to enlist their aid in comforting or providing emotional support to the distressed person. Alternatively, you may take a distressed individual aside to a quiet place or speak quietly with that person while family/friends are nearby.
• What is the person experiencing? Is he/she crying, panicking, experiencing a “flashback” or imagining that the event is taking place again? When intervening, address the person’s primary immediate concern or difficulty rather than simply trying to convince the person to “calm down” or to “feel safe” (neither of which tend to be effective).

For children or adolescents, consider:

• Is the child or adolescent with his/her parents? If so, briefly assess the situation to make sure that the adult is coping. Focus on empowering the parents in their role of calming their children. Do not move in and supplant the parents and be careful to avoid making any comments that may undermine the parents’ authority or ability to handle the situation. Let them know that you are available to assist in any way that they find helpful.
• If emotionally-overwhelmed children or adolescents are separated from their parents or if their parents are not coping well, refer below to the options for stabilizing distressed persons.

Options for stabilizing distressed persons include:

• Respect the person’s privacy and give him/her a few minutes alone. Tell the individual that you will be available if they need you or that you will check back with them in a few minutes to see how they are doing and if there’s anything you can do to help at that time.
• Remain present and offer a drink or chair rather than trying to talk directly to the person, as this may contribute to cognitive/emotional overload. Make small talk, talk to other persons in the vicinity, do some paperwork or in other ways demonstrate that you are occupied with other tasks but available should the person need or wish to receive further practical or emotional help.
• Offer support and help him or her focus on specific manageable feelings, thoughts and goals. 

Talking Points for Emotionally-Overwhelmed Survivors

Adults or Caregivers

• Intense emotions may come and go like waves.
• Shocking experiences trigger strong and healthy, but often upsetting, self-protective “alarm” reactions in the body.
• Sometimes the best way to recover is to take a time-out (e.g., breathe deeply, go for a walk).
• Friends and family are very important sources of support to help you calm down.

Children and Adolescents

• These feelings come and go like waves in the ocean. When you feel really bad, that’s a good time to talk to your mom and dad to help you calm down.
• Even adults need help at times like this.
• Many adults are working together to respond to the disaster and to help people who were affected.
• Staying busy can help you deal with your feelings and start to make things better.
• Caution adolescents about doing something quickly just to feel better without discussing it with a parent or trusted adult.

If the person appears extremely agitated, shows a rush of speech, seems to be losing touch with the surroundings or is experiencing ongoing intense crying, it may be helpful to:

• Ask the individual to listen to you and look at you.
• Find out if they know who they are, where they are and what is happening.
• Ask him/her to describe the surroundings and say where both of you are.
• Clarify what has happened and the order of events (without graphic details).

Information Gathering: Needs and Current Concerns

Gathering and clarifying information begins immediately after contact, and is ongoing throughout Psychological First Aid (as appropriate). As immediate needs and concerns are identified and addressed, it is useful to gather and clarify additional information.  Remember that in most Psychological First Aid service delivery contexts, time, survivors’ needs and priorities, and other factors will limit information gathering. However, although a formal assessment is not appropriate, the provider may ask pertinent questions to obtain and clarify a variety of issues that can inform decisions about:

• Need for immediate referral
• Need for additional services
• Offering a follow-up meeting
• Using components of Psychological First Aid that may be helpful

It may be especially useful for the provider to ask some questions to clarify the following:

Nature and severity of experiences during the disaster: Children, adolescents and adults who have had the most serious forms of exposure to direct life-threat to self or loved ones, injury to self, or witnessing injury or death may likely experience more severe and prolonged distress. Those who felt extremely terrified and helpless may also have more difficulty in recovering.

For people with these experiences, provide information about post-disaster reactions, information about coping and offer a follow-up meeting.

Death of a family member or close friend: Loss of loved ones under traumatic circumstances is devastating and over time can greatly complicate the grieving process.

For those with loss, provide emotional comfort, information about coping, social support and traumatic grief, and offer a follow-up meeting.

Concerns about immediate post-disaster circumstances and ongoing threat: Especially in regard to complicated emergencies, concerns over immediate and ongoing danger can be a major source of distress.

For those with these concerns, help with obtaining risk-related information.

Separations from or concern about the safety of loved ones: Separation from loved ones and concern over their safety constitute additional sources of distress in the aftermath of disaster. 

For survivors with these concerns, provide practical assistance to help locate and reunite family members or develop a strategy for seeking information about persons of concern.

Physical illness and need for medications: Pre-existing medical conditions and need for medications constitute additional sources of post-disaster distress and adversity. Immediate medical concerns need to be given a high priority.

For those with medical conditions, provide practical assistance in obtaining medical care and medication. Connect with additional services if needed.

Losses incurred as a result of the disaster (home, school, neighborhood, business, personal property or pets): Extensive material losses and their associated post-disaster adversities can significantly interfere with recovery and are often associated with feelings of depression, demoralization and hopelessness over time. 

For those with losses, provide emotional comfort, practical assistance to help link with available resources and information about coping and social support.

Extreme feelings of guilt or shame: These extreme negative emotions can be very painful, difficult and challenging, especially for children and adolescents. Remember that children and adults may be ashamed to discuss these feelings. One approach would be to listen carefully for signs of these emotions in their comments.

For those with these negative emotions, provide emotional comfort and information about coping.

Thoughts about causing harm to self or others: Disasters can evoke overwhelming feelings of grief, anxiety, depression and anger. Getting a sense of whether an individual is having thoughts about causing harm to self or others should be handled sensitively.

For those with these thoughts, escort them to counseling services.

Lack of adequate supportive social network: Lack of adequate family and community support can greatly interfere with the ability to cope with distress and post-disaster adversity.  

For those in this situation, provide links to available resources and services, information about coping and social support, and offer a follow-up meeting.

Prior alcohol or drug use: Exposure to trauma and post-disaster adversities can exacerbate ongoing substance use, cause relapse of past substance abuse or lead to new abuse.

For those with potential substance use problems, provide information about coping and social support, links to appropriate services and offer a follow-up meeting.

Prior exposure to trauma and loss: Those with a history of exposure to trauma or loss may experience more severe and prolonged post-disaster reactions and a “rekindling” of prior trauma reactions.

For those with prior exposure, provide information about post-disaster reactions, information about coping and offer a follow-up meeting.

Prior psychological problems: Those with a history of psychological problems may experience an exacerbation of these problems and more severe and prolonged post-disaster reactions.

For those with prior psychological problems, provide information about post-disaster reactions, information about coping and social support, links to appropriate services, and offer a follow-up meeting.

Specific youth, adult and family concerns over developmental impact: Interference with anticipated developmental activities and opportunities resulting from disaster and post-disaster circumstances may cause distress and concern.

For those with developmental concerns, provide information about coping and links to appropriate services. 

It is also useful to ask a general open-ended question to make sure that you have not missed any important information.

The Psychological First Aid provider will need to use judgment about how to gather this information, how much information to gather and to what extent to ask questions while remaining sensitive to the needs of the person. If the survivor identifies multiple concerns, summarize these and help to identify which issue is most pressing.

Practical Assistance

Assisting the survivor with current or anticipated problems is a central component of Psychological First Aid. Ongoing adversities and continuing problems resulting from a disaster can add significantly to the stress level of the survivor, distract from self-care and help maintain distress reactions. Also, survivors may welcome a pragmatic focus on a current problem that is uppermost in their mind. Often, it is important to help them with problem-solving in regard to important problems.

Discussion of immediate needs occurs throughout a Psychological First Aid contact and, as much as possible, you should help the affected individual address those needs.  Assistance may be helpful because problem-solving may be more difficult for the survivor under conditions of stress and adversity.

Identify the Most Immediate Need(s)

If several needs or current concerns have been mentioned by the survivor, it will be necessary to focus on them one at a time. For some needs there will be immediate solutions (e.g., getting something to eat, phoning a family member to reassure them that the survivor is OK). It will not be possible to rapidly solve other needs (e.g., locating a lost loved one, returning to previous routines, securing insurance for lost property, acquiring care giving services for family members), but it may be possible to take concrete action steps that address the problem (e.g., completing a missing persons report or insurance form, applying for care giving services).

Clarify the Need

Talk with the survivor to specify the problem. If the problem is understood and clarified, it will be easier to identify practical steps that can be taken to address it.

Discuss an Action Plan

Discuss what can be done to address the individual’s need or concern. The survivor may indicate what he or she would like to be done or you can offer a suggestion. Knowing what services are available ahead of time will ensure that appropriate assistance can be provided about services related to obtaining food, clothing, shelter, medical, mental health, spiritual care services, financial assistance, help in determining the location of missing family members or friends and volunteer opportunities for those who feel a need to contribute to relief efforts. Inform survivors about what they can realistically expect in terms of potential resources and support, qualification criteria and application procedures.

Act to Address the Need

Follow through in making an active response. For example, help the person make contact or set an appointment with a needed service or assist the person in completing paperwork.

Connection with Social Supports

Enhance Access to Primary Support Persons (Family and Significant Others)

An immediate concern for most affected persons is being able to communicate with individuals with whom they have a primary relationship (e.g., spouse/partner, children, parents, other family members, close friends, clergy). Social support can play a strong role in recovery from trauma. Therefore, an important Psychological First Aid objective is to take practical steps to enable the person to make contact (in person, by phone, by email) with individuals for whom the person feels the greatest concern (e.g., a child or frail elderly parent from whom the person has been separated) or the greatest need to be with right now at that moment.

Encourage Use of Immediately Available Support Persons

If individuals are disconnected from their social support network, encourage them to make use of immediately available sources of social support (i.e., yourself, other relief workers, other affected persons), while being respectful of individual preferences. For example, it can help to offer adults reading materials (e.g., magazines, fact sheets) and discuss the material with them. When people are in close proximity to each other, ask them as a group if they have questions or requests with which you can help. These group discussions can help provide a starting point for further conversations and encourage social connectedness.

Discuss Support-Seeking and Giving

You can help survivors understand the value of social support and how to be supportive to others. For instance, you can share that experts recommend that connection with others is an important factor in recovery from a disaster. Let them know that there are differences between normal stress and traumatic stress that can cause people to want to avoid traumatic memories or feel flooded by the memories. Let them know that, following trauma, some people choose not to talk about traumatic experiences at all or not until a later time when they feel secure enough re-visit the experience. And when a person feels comfortable talking, he/she may need to discuss the event on numerous occasions. Spending time with people one feels close to and accepted by, without having to talk, can feel good.

When Support is Not Working:

You may need to inform individuals that if someone they care about is showing extreme social isolation or withdrawal, they can help the person choose specific ways to be involved with other people in a way that they feel will be helpful. A friend or loved one may need to also know that there are other people who can listen if more help is needed (i.e., primary care doctor, chaplain, support group, or counselor). Let them know that positive social support, in any way that is acceptable to them, is one of the most crucial factors in recovery from a disaster. They can enlist help from others in their social circle so that they all take part in supporting the person. They can also encourage their friend/loved one to get involved in a support group with others who have had similar experiences, or accompany them in seeking professional help.

Information on Coping

Disasters can be disorienting, confusing and overwhelming. Various types of information can help to re-orient children and adults to their situation. Such information includes:

• What is currently known about the unfolding event
• What is being done to assist them
• What services are available
• Post-disaster reactions and how to manage them
• Self-care, family care and coping

Psychological First Aid providers should use judgment as to when to present information and provide the type of information that is most pertinent and useful. The most useful information provides assistance in addressing immediate needs, reducing distress, addressing current concerns and supporting positive coping efforts.

Provide Basic Information about Stress Reactions

If appropriate, it may be useful to briefly discuss common stress reactions being experienced by the survivor. Stress reactions may be alarming for survivors. Some will be frightened or otherwise distressed by their own responses to an event; some may view their reactions in negative and distressing ways (e.g., my reactions mean, “There’s something wrong with me,” or “I’m weak”). Therefore, individuals may benefit from explanations about reactions that they are experiencing and understanding that these reactions are normal and expectable. Some important considerations in the process of educating survivors about their reactions include:

• Build any discussion around their individual reactions.
• Take care to avoid pathologizing survivor responses; don’t use terms like “symptoms.”

Review Common Psychological Reactions to Traumatic Experiences and Losses

Especially for individuals who have had significant exposure to trauma and have sustained significant losses, provide basic psycho-education about common distress reactions. The Psychological First Aid provider can review these, again emphasizing that such reactions are understandable and expectable. Inform survivors that if these reactions continue to interfere with their ability to function adequately for over a month, psychological services should be considered.

Many individuals who have had traumatic experiences suffer from ongoing reactions that are distressing and can lead to difficulties in daily life.

There are three types of posttraumatic stress reactions:

Intrusive reactions are ways in which the traumatic experience comes back to mind. These reactions include distressing thoughts or images of the event (e.g., picturing what one saw), or dreams about what happened. Among children, bad dreams can occur that may not be specifically about the disaster. Intrusive reactions also include upsetting emotional or physical reactions to reminders of the experience. Some people may act like one of their worst experiences is happening all over again. This is called “a flashback.”

Avoidance and withdrawal reactions are ways people use to keep away from, or protect against, intrusive reactions. These reactions include efforts to avoid talking, thinking and having feelings about the traumatic event, and to avoid any reminders of the event, including places and people connected to what happened. Emotions can become restricted, even numb, to protect against distress. Feelings of detachment and estrangement from others may lead to social withdrawal. There may be a loss of interest in usually pleasurable activities.

Physical arousal reactions are physical changes that make the body react as if danger is still present. These reactions include constantly being "on the lookout" for danger, startling easily or being jumpy, irritability or experiencing outbursts of anger, difficulty falling or staying asleep, and difficulty concentrating or paying attention.

It is also useful to discuss the role of trauma reminders, loss reminders and hardships in contributing to distress.

Trauma Reminders can be sights, sounds, places, smells, specific people, times of the day, situations or even feelings, like being afraid or anxious. Trauma reminders can evoke upsetting thoughts and feelings about what happened. Examples include the sound of wind, rain, helicopters, screaming or shouting and specific people who were present at the time. Reminders are related to a specific type of event, such as hurricane, earthquake, flood, tornado or fire. Over time, avoidance of reminders can make it hard for people to do what they normally do or need to do.

Loss Reminders can also be sights, sounds, places, smells, specific people, the time of day, situations or feelings. Loss reminders bring to mind the absence of a loved one. Missing the deceased can bring up strong feelings, like sadness, feeling nervous, feeling uncertain about what life will be without them, feeling angry, feeling alone or abandoned or feeling hopeless. Examples include seeing a picture of a lost loved one or seeing their belongings. Loss reminders can also lead to avoiding things that people want to do or need to do.

Change Reminderscan be things (people, places, things, activities or hardships) that remind us of how our lives have changed from what they used to be as the result of a disaster. This can be something as simple as waking up in a different bed in the morning, or going to a different school, or being in a different place. Even nice things can remind us of how things have changed and make us miss what we had before.

Hardships often follow in the wake of disasters and can make it more difficult to recover. Hardships place additional strains on children and families and can contribute to feelings of anxiety, depression, irritability, uncertainty, and mental and physical exhaustion. Examples of hardships include: loss of home or possessions, lack of money, shortages of food or water, separations from friends and family, medical or physical health problems, the process of obtaining compensation for losses, school closures, being moved to a new area and lack of fun things for children to do.

Other kinds of reactions include grief reactions, depression and physical reactions.

Grief Reactions will be prevalent among those who survived the disaster but have suffered many types of losses including loss of loved ones, home, possessions, pets, schools and community. Loss may lead to feelings of sadness and anger, guilt or regret over the loss, missing or longing for the deceased, and dreams of seeing the person again. These grief reactions are normal, vary from person to person and can last for many years after the loss. There is no single “correct” course of grieving.  Importantly, personal, family, religious and cultural factors affect the course of grief.  Although grief reactions may be painful to experience, especially at first, they are healthy reactions and reflect the ongoing significance of the loss. Over time, grief reactions tend to include more pleasant thoughts and activities, such as positive reminiscing or finding positive ways to memorialize or remember a loved one.

Traumatic Grief occurs when children and adults have suffered the traumatic loss of a loved one and often makes grieving more difficult. In traumatic death, there is a tendency for the mind stay focused on the circumstances of the death, including preoccupations with how the loss could have been prevented, what the last moments were like and issues of accountability. Traumatic grief reactions include intrusive, disturbing images of the manner of death that interfere with positive remembering and reminiscing, delay in the onset of healthy grief reactions, retreat from close relationships with family and friends, and avoidance of usual activities because they are reminders of the traumatic loss. Traumatic grief changes the course of mourning, putting individuals on a different time course than may be expected by other family members. Often, traumatic grief reactions can clash with the timing of religious rituals and other cultural expressions of mourning.

Depression can be an additional major concern. Depression is associated with prolonged grief reactions and strongly related to the accumulation of post-disaster adversities. Reactions include: persistent depressed or irritable mood; loss of appetite; sleep disturbance, often early morning awakening; greatly diminished interest or pleasure in life activities; fatigue or loss of energy; feelings of worthlessness or guilt; feelings of hopelessness; and sometimes thoughts about suicide. Demoralization is a common response to unfulfilled expectations about improvement in post-disaster adversities, and resignation to adverse changes in life circumstances.

Physical Reactions may be commonly experienced, even in the absence of any underlying physical injury or illness. These reactions can include headaches;, dizziness, stomachaches, muscle aches, rapid heart beating, tightness in the chest, loss of appetite and bowel problems. 

Provide Basic Information on Ways of Coping

It may also be appropriate and helpful to discuss various ways of coping.

Adaptive coping actions are those that help to reduce anxiety, lessen other distressing reactions and improve the situation. In general, coping methods that are likely to be helpful include:

• Talking to another person for support
• Getting adequate rest, diet, exercise
• Engaging in positive distracting activities (sports, hobbies, reading)
• Trying to maintain a normal schedule to the extent possible
• Scheduling pleasant activities
• Eating healthy meals
• Taking breaks
• Spending time with others
• Participating in a support group
• Using relaxation methods
• Using calming self-talk
• Exercising in moderation
• Seeking counseling
• Keeping a journal

Maladaptive coping actions tend to perpetuate problems. Such actions include:

• Using alcohol or drugs to cope
• Withdrawing from activities
• Withdrawing from family or friends
• Working too many hours
• Getting angry or violent
• Blaming others
• Overeating
• Watching too much TV or playing too many computer games
• Doing risky or dangerous things
• Not taking care of oneself (sleep, diet, exercise, etc.)

The aim of discussing positive and negative forms of coping is to:

• Help survivors consider coping options
• Identify and acknowledge their coping strengths
• Explore the negative consequences of maladaptive coping actions
• Encourage survivors to make conscious choices about how to cope
• Enhance a sense of control over coping and adjustment

Demonstrate Simple Relaxation Techniques

Breathing exercises help reduce feelings of over-arousal and physical tension. Simple exercises such as these can be taught in a brief period. Children and adolescents can use these techniques also and it may be helpful for parents to prompt their children (or vice versa) to use these techniques several times a day.

Assist with Anger Management

In post-disaster situations with stress and adversity, including difficulty sleeping, some individuals may be irritable and have difficulty managing their anger. When appropriate, the Psychological First Aid provider can discuss the following anger management issues. 

• Discuss how the anger is affecting the person’s life (e.g., relationship with family members and friends including effects on parenting).
• Normalize the experience of anger and discuss specifically how anger could increase conflict, push others away or lead to violence.
• Ask the person to identify changes he/she would like to make.

Some anger management skills that you can suggest include:

• Taking a “time out” or “cool down.”
• Reminding yourself that being angry will not help you achieve what you want and may harm important relationships.
• Increasing exercise or other tension-reducing activities.
• Talking to a friend about what’s angering you.
• Remembering that when you are feeling particularly angry or irritable, have another family member temporarily supervise your children’s activities.

If anger appears uncontrollable or leads to violence, seek immediate medical attention and contact security.

Address Highly Negative Emotions (e.g., guilt and shame)

In the aftermath of disasters, survivors may think about what caused the event, how they reacted and what the future holds. Some of these beliefs may add to their distress, especially attributing excessive blame to themselves. The Psychological First Aid provider should listen for such negative beliefs and help survivors to identify alternatives to the negative beliefs that are causing distress. Some questions that can facilitate this process are:

• How else could you look at the situation that would be less upsetting and more helpful? What’s another way of thinking about this?
• How might you respond if a good friend was talking to himself/herself like this?  What would you say to them? Can you say the same things to yourself?

It may be helpful for the individual to hear that just because he or she thinks she is at fault does not mean that this is true. If the individual is receptive, you can offer some alternative ways of looking at the situation. An important role for the Psychological First Aid provider in this effort is to attempt to clarify misunderstandings, rumors and distortions that exacerbate distress, unwarranted guilt or shame.

Help with Sleep Problems

Sleep difficulties are very common following a disaster or other trauma. Ask questions to assess the individual’s sleep routines and sleep-related habits. Problem-solve ways of improving sleep, including:

• Go to sleep at the same time and get up at the same time each day.
• Reduce alcohol consumption: alcohol disrupts sleep.
• Eliminate consumption of caffeinated beverages (e.g., coffee, soft drinks) in the afternoon or evening.
• Increase regular exercise, though not too close to bedtime.
• Relax before bedtime by doing something calming, like listening to soothing music, or praying.
• Limit daytime naps to 15 minutes and not napping later than 4 p.m.
• Discuss that worry over immediate concerns and exposure to daily reminders can make it more difficult to sleep and that being able to discuss these and get support from others can improve sleep over time.

Address Alcohol and Substance Use

When use of alcohol and other substances is a concern:

• Educate the individual regarding the tendency for many people who experience stress reactions to drink or use medications or drugs to reduce their bad feelings. 
• Ask the individual to identify what they see as the “pro’s and con’s” of using alcohol or drugs to cope. 
• Discuss and mutually agree on abstinence or a safe pattern of use.
• Discuss anticipated difficulties in making change.
• If appropriate and acceptable to the person, make a referral for substance abuse counseling.
• If the individual has previously received treatment for substance abuse, encourage him or her to once again seek treatment to get through the next few weeks and months.

Linkage with Collaborative Services

Provide Direct Link to Additional Needed Services

Providing information should be accompanied by a discussion about which of the survivor’s needs and current concerns require additional information or services. If the survivor is interested in additional services, do what is necessary to insure effective linkage with those services (e.g., walk the survivor over to an agency representative who can provide a service; set up a meeting with a community representative who may provide appropriate referrals).

When making a referral:

• First summarize your discussion with the person about their needs and concerns.
• Check for accuracy of your summary.
• Describe the option of referral, including how this may help and what will take place if the individual goes for further help.
• Ask about reaction to suggestion of referral.
• Give written referral information, or if possible, make an appointment then and there.

Promote Continuity in Helping Relationships

A secondary, but important concern for many affected persons is being able to keep in contact with helpers and other persons whom they feel have been or could be helpful as they continue to deal with the immediate situation.

In most cases, continuing contact between affected survivors and you will not be possible because the affected persons will leave triage sites or family assistance centers and go to other sites for continuing services. However, contacts made during the acute aftermath of disasters can lead to a sense of abandonment or rejection if the Psychological First Aid provider seems to just “vanish.” Therefore, Psychological First Aid should include the use of strategies for creating a psychological sense of continuity of care, such as:

• Give the name(s) and contact information for the local public health and public mental health service providers in the community, especially the counseling and health centers on campus. There may also be other local providers or recognized agencies who have volunteered to provide post-disaster follow up services for the community. (Be wary of referring to unknown volunteer providers.) Such information may not be known for several hours or days, but once available, it can be considerably helpful to disaster survivors.
• Introduce the survivor to other mental health, healthcare, family service or relief workers so that they know several helpers by name rather than only you.

Sometimes, survivors feel as if they are meeting a never-ending succession of helpers and that they have to go on explaining their situation and telling their story to each one in turn. To the extent possible, this should be minimized. If you are leaving a response site, it is important to let the survivor know this and to ensure a direct “hand-off” to another provider, and if possible, one who will be in a position to maintain an ongoing helping relationship with the person. Orient the new provider to what he or she needs to know about the person and provide an introduction if at all possible.