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Article Excerpt
Psychological First Aid (PFA) consists of a systematic set of helping actions aimed at reducing initial post-trauma distress and supporting short- and long-term adaptive functioning. Designed as an initial component of a comprehensive disaster/trauma response, PFA is constructed around eight core actions: contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connection with social supports, information on coping support, and linkage with collaborative services. PFA for children and adolescents focuses on these same core actions, with modifications to make them developmentally appropriate. Formal evaluation of the effectiveness of PFA is needed and it is hoped that development of a PFA Field Operations Guide will facilitate such evaluation.
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Exposure to disaster and other traumatic experiences confronts survivors with immediate challenges and, for some, leads to development of enduring problems. Most psychological responses to trauma are relatively immediate, mild, and transient (Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002), but significant percentages of traumatized individuals experience more intense stress reactions and some develop post-traumatic stress disorder and other mental health problems. Given the capacity of traumatic events to produce great immediate distress and sometimes overwhelm immediate coping abilities, disaster response encompasses efforts to support survivors in the immediate aftermath of disaster and to respond to their psychological needs.
Despite a widely recognized need to provide immediate help for trauma survivors, little is known about how best to assist individuals during the first hours and days after their experiences. In an effort to improve and promote formal evaluation of immediate care for survivors, the National Center for PTSD and the National Child Traumatic Stress Network recently collaborated to design a systematic set of helping actions called Psychological First Aid (PFA) intended for use by disaster mental health responders and others, including mental health counselors, who may be called upon to provide immediate support for trauma survivors. PFA is aimed at reducing initial post-trauma distress and supporting short- and long-term adaptive functioning. It is designed for delivery anywhere that trauma survivors can be found. Following a disaster, it can be offered in shelters, schools, hospitals, homes, staging areas, feeding locations, family assistance centers, and other community settings. The principles can also be applied immediately following traumatization in many non-disaster settings, including hospital trauma centers, rape crisis centers, and warzones. PFA is designed for simple and practical administration in field settings. The complete PFA manual can be downloaded at http://www.ncptsd.va.gov/pfa/PFA.html or http://www.nctsnet.org/nccts/ nav.do?pid=typ_terr_resources_pfa. In this paper, we briefly review previous work on early intervention, describe the focus on evidence-informed intervention principles within PFA, outline the basic principles and practices of PFA, discuss adaptation of PFA for children and adolescents, identify key considerations in the evaluation of PFA, and indicate some future directions in development of this approach.
EARLY POST-TRAUMA INTERVENTION
To date, there are few published randomized controlled trials of interventions initiated in the first 14 days following disaster, mass violence, or other trauma. Difficulties in obtaining empirical support as well as lack of a conceptual framework have impeded the development of definitive recommendations. The current literature on the effects of disasters on mental health functioning suggests that: (a) people's reactions should not necessarily be regarded as pathological responses or even as precursors of subsequent disorder; (b) many people will have transient stress reactions in the aftermath of mass violence, and such reactions may occur, occasionally, even years later; (c) rather than traditional diagnosis and clinical treatment, most people are likely to need support and provision of resources to ease the transition to normalcy; and (d) some survivors may experience great distress and require community and at times clinical intervention (Galea et al., 2003).
A number of reviews of the post-trauma intervention literature have concluded that there is no evidence that Critical Incident Stress Debriefing (CISD), a structured group model designed to explore facts, thoughts, reactions, and coping strategies following trauma, prevents long-term negative outcomes (Litz et al., 2002; Bisson, 2003; McNally, Bryant, & Ehlers, 2003; Watson et al., 2003). For example, in a recent large-scale randomized controlled trial (RCT) of a group debriefing intervention with active duty personnel, Litz and colleagues (2002) found that while soldiers rated their satisfaction with CISD as high and mental health outcomes at follow-up did not worsen as a result of CISD, there were no differences among the CISD, stress education, and survey-only conditions on any behavioral health outcome, including PTSD, depression, general well-being, aggressive behavior, marital satisfaction, perceived organizational support, or morale. Heart rate and blood pressure readings before and after the sessions did not indicate a change in physiological stress, and subjective ratings of distress did not change pre to post-session. There have been two randomized controlled trials (RCTs) of CISD that reported a higher incidence of negative outcomes in those who received CISD compared with those who did not receive an intervention (Bisson ; Mayou, Ehlers, & Hobbs, 2000).
While many of the CISD studies, particularly those showing negative outcomes, have methodological flaws, there are many possible theoretical explanations for both neutral and negative findings. For example, it is possible that CISD interventions with primary civilian survivors of disaster are too brief to allow for adequate emotional processing, that they increase arousal and anxiety levels, or that they inadvertently decrease the likelihood that individuals will pursue more intensive interventions. It is possible that future research will demonstrate that CISD may be useful for some populations, or has more subtle positive effects (e.g., increasing perceived social support). In the meantime, numerous reviews of the best-controlled studies have concluded that it cannot be endorsed as an intervention which prevents long-term distress or psychopathology, given the current state of the research (McNally, Bryant, & Ehlers, 2003; Rose, Bisson & Wessely, 2003; Gray, Maquen & Litz, 2004). Given the negative findings associated with CISD, as well as preliminary evidence that increased arousal in the immediate phases post-trauma is linked to long-term pathology (e.g., Shalev, Sahar, Freedman, Peri, Glick, Brandes, Orr, & Pitman, 1998), there is concern that any intervention that focuses on emotional processing during this period may be contra-indicated. It has, therefore, been recommended that any one-session interventions that require emotional processing be more fully researched prior to recommending their routine practice post-disaster (Watson, 2004). In fact, there are particularly strong recommendations against their use in post-disaster settings involving mass trauma, due to the chaotic post-incident environment, need for attention to pragmatic material needs, possible cultural and bereavement issues, and multiple recovery trajectories based on complex variables (Watson et al., 2002).
While most empirical support for prevention of psychopathology and distress comes from short-term (4-5 session) cognitive-behavioral interventions (i.e., education, anxiety management training, imaginal exposure therapy, in vivo exposure, and cognitive restructuring) delivered within a month of trauma, cognitive-behavioral therapy (CBT) has not been empirically examined in the immediate aftermath (0-14 days) of trauma. Recent work with injury and accident victims has sought to evaluate services in the acute post-incident phase, but the interventions have generally been delivered more than 14 days post-trauma (Bisson, 2003, Bisson et al., 2004; Zatzick & Roy-Byrne, 2003; Zatzick et al., 2004).
The brief CBT model may have elements that can be applied to immediate intervention, as research suggests that it results in prevention of PTSD and in decreased depressive symptoms when compared to repeated assessment, self-help, and education and support, and that benefits in psychological functioning are maintained nine months to four years later (Bryant, Moulds, & Nixon, 2003; et al., 2003). A number of RCTs have been conducted with individual survivors of motor vehicle accidents (including those with acute injuries), industrial accidents, and non-sexual assault who have been diagnosed with acute stress disorder (Bryant et al., 1998; Bryant et al., 1999; Bisson et al., 2004; Ehlers et al., 2003; Zatzick et al., 2004).
One of the difficulties of applying the brief CBT model to disasters and mass violence settings is that victims of accidents, assault, or injuries do not experience the disruption in the physical and social environment that is typical of mass trauma. Therefore further research is needed to determine whether the early provision of CBT-influenced interventions following mass violence or disaster is indicated earlier than 2 weeks posttrauma. Members of recent consensus efforts (Watson, 2004) agreed that the chaotic and stressful post-event environment may reduce the energy and effort needed to participate in CBT treatments (i.e., homework, emotional, and time investment). They suggest that structured cognitive-behavioral interventions not be implemented until secondary stressors in the environment are under sufficient control to allow the individual to focus on the intervention (usually not sooner than three weeks post-incident) (Watson, 2004).
Recent efforts in acute intervention following disasters utilize cognitive-behavioral principles in community-based programs, such as the post-traumatic stress management (PTSM) program implemented following community stressors (i.e., suicide cluster, bus accident; Macy et al., 2004). The model is put into place within 24 hours, and involves a series of individual and group interventions designed to help people orient, stabilize, and improve coping skills (i.e., identification of access to support and resources, nonverbal and verbal processing of the trauma narrative, psychoeducation regarding the neurophysiology of traumatic stress and its impact on psychosocial functioning, and planning, problem-solving, and self-care). While this model has not been studied in a RCT, survey information indicates that the most useful parts of the program were providing direction to help communities heal and helping the communities come together to handle the crisis. Program creators recommend that this program can be overlaid on existing human services programs until a trained resource network is in place and stable.
Creative implementation strategies for CBT-based interventions include brief telephone (Greist et al., 2000; Mohr et al., 2000; Somer et al., 2004) and Internet interventions (Gega, Marks, & Mataix-Cols, 2004), which have proven helpful with a variety of mental health problems. One study employing a cognitive-behavioral telephone hotline intervention (e.g., relaxation breathing and challenging maladaptive thoughts) in Israel before the most recent American invasion of Iraq (see Somer et al., 2005) indicated decreased anxiety on several measures post-intervention. Similarly, a study by Gidron et al. (2001) reported reductions in PTSD symptoms at 3-4 month follow-up utilizing a CBT-based telephone intervention within the first 48 hours post-incident. Finally, Litz et al. (2004) have designed a cognitive-behavioral therapist-assisted Internet-based intervention designed to enable the treatment of large numbers of traumatized individuals, that uses a form of stress inoculation training for both secondary prevention of PTSD and treatment of the chronic disorder.
Because of the difficulty in applying the current literature base to interventions following disasters and mass trauma, a number of experts in the fields of trauma and disasters have identified the following five empirically-supported intervention principles to guide intervention practices following disaster and mass violence at the early to mid-term stages. These principles are (a) promoting sense of safety, (b) promoting calming, (c) promoting sense of self- and community-efficacy, (d) promoting connectedness, and (e) instilling hope (Hobfoll et al., manuscript under review).
Promotion of a psychological sense of safety can reduce biological aspects of post-traumatic stress reactions (Bryant, 2006; McEwen, 1998; Friedman & McEwen 2004; Anotonovsky, 1979; Charney, 2004), and can positively affect cognitive processes that inhibit recovery, including a belief that "the world is completely dangerous" and exaggeration of future risk (Foa & Rothbaum, 1998; Ehlers, Mayou, & Bryant, 1998; Smith & Bryant, 2000; Warda & Bryant, 1998). Interventions include imaginal exposure and real-world, in-vivo exposure, which interrupt the process that links harmless images, people, and things to dangerous stimuli associated with the original traumatic threat (Bryant et al., 1998; Foa & Rothbaum, 1998; Gersons et al., 2000; Resick et al., 2002), "grounding techniques" such as reality reminders, to bring individuals to the relative safety of the present time, and instruction in contextual discrimination in the face of trauma and loss triggers (Hien et al., 2004; Najavits, 2002; Najavitz et al., 1998; Resick & Schnicke,...
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