essay about psychological first aid

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What Is Psychological First Aid?

Disaster Response to Promote Safety and Stability

When Is It Used?

Who does it, how it works.

After someone experiences a traumatic event, their early responses can lead to distress that can interfere with coping. Psychological first aid (PFA) is a disaster relief technique developed by the National Child Traumatic Stress Network and National Center for PTSD ( post-traumatic stress disorder ).

The goal of the intervention is to provide safety, stability, and resources to people in the immediate aftermath of a traumatic event to increase survivors’ abilities to cope. This article explains how PFA is used, who does it, and its outcomes. 

Photo Talk / Getty Images

PFA is not on-site therapy . Instead, it connects with people in the aftermath of a disaster with resources and support for their immediate needs. 

PFA includes eight core components, which include:

• Making initial contact 
• Ensuring people are safe and comfortable
• Calming and orienting people
• Identifying people's immediate needs
• Offering practical assistance
• Connecting people with resources
• Providing coping strategies
• Linking people to collaborative services

PFA is not professional mental health care . In fact, laypeople (people without professional credentials) often perform it. However, certain understandings about people's coping needs guide PFA, including:

• The need to feel safe, connected, and hopeful
• The need for access to support
• The need for self-reliance

Since 9/11, mental health experts have widely endorsed and advocated PFA as an early intervention for disaster survivors.

As a concept, PSA was introduced in the mid-20th century. However, it gained traction as a disaster response in the post-9/11 era.

In 2001, in response to mass shootings in schools, the workplace, and terrorist attacks, the National Institute of Mental Health brought 60 mental health experts together to discuss the psychological interventions to mass violence. Since then, PFA has become an integral early intervention disaster response.

"Psychological first aid" is the most widely used term to describe immediate emotional support following a crisis. However, other terms are also used, including:

• Community-based psycho-social support
• Disaster behavioral health first aid
• Mental health first aid
• Stress first aid

PFA benefits anyone who has survived or witnessed a traumatic event, including people of any age and gender. The World Health Organization (WHO) identifies the following as crisis events that could benefit from PFA:

• Natural disasters
• Terrorist attacks
• Disease outbreaks
• Displacement 

In the aftermath of a disaster, people have common stress reactions. By reducing people’s immediate stress through PFA, people may have a better ability to cope long-term. Common stress reactions include:

• Hopelessness

Anyone can be trained in psychological first aid. However, since certain people are more likely to be present following a disaster, PFA is commonly used by the following:

• First responders
• Healthcare workers
• School crisis response teams
• Disaster relief organizations

Providing PFA may look different from crisis to crisis and even from person to person in the same predicament. That’s because each situation is unique. In addition, while there are common reactions to disasters, each person has an individual response, and their immediate needs vary. 

People trained in PFA learn how to promote the following:

• Safety : Responders help people locate food, shelter, and medical attention.
• Calm : Responders listen to people’s stories and feelings.
• Connection : Responders help people locate friends and family and keep families together.
• Hope : Responders remind people that help is coming and tell them about resources available to them.
• Self-efficacy : Responders give suggestions on how people can help themselves.

What It Is Not

PFA is not therapy, mental health treatment, or debriefing. Responders avoid forcing interactions, giving simple reassurances, or telling people how they should feel or what they should do.

The Evidence for PFA

Despite its widespread use and promotion, there is little scientific evidence to support the effectiveness of PFA following disasters. However, the practice is still considered an evidence-informed practice (using current best practices in making decisions regarding care of an individual).

Evidence-Informed Practices

Evidence-informed practices, or evidence-based practices, are considered the gold standard of care. That’s because they are based on proven scientific evidence. However, in the absence of sufficient scientific support, evidence-informed practices are enriched by evidence but not necessarily limited by it.

PFA is based on well-established concepts of human resilience . In addition, mental health and disaster research and response organizations developed PFA. Therefore, the practice is based on existing knowledge and research.

Psychological first aid (PFA) is a disaster relief response that supports people in the immediate aftermath of a crisis. The goal is to reduce people's primary stress by connecting them with resources, reuniting them with family and friends, and offering hope to have a better ability to cope long term.

A Word From Verywell

PFA is an essential skill that nearly anyone can learn. However, it is crucial for first responders, medical workers, and disaster relief workers. Several organizations offer PFA training. If you are interested in training, the American Psychological Association has a list of the training provided by various organizations.

National Child Traumatic Stress Network. About PFA . 

American Psychological Association. What is psychological first aid? .

World Health Organization. Psychological first aid for all ,

Shultz JM, Forbes D. Psychological first aid: Rapid proliferation and the search for evidence . Disaster Health . 2014;2(1):3-12. doi:10.4161/dish.26006

Minnesota Department of Health. Psychological first aid (PFA) .

Department of Veteran’s Affairs. Psychological first aid (PFA) manual . 

New York City Department of Health and Mental Hygiene. Providing psychological first aid (PFA) .

Dieltjens T, Moonens I, Van Praet K, De Buck E, Vandekerckhove P. A systematic literature search on psychological first aid: Lack of evidence to develop guidelines . Matsuoka Y, ed. PLoS ONE . 2014;9(12):e114714. doi:10.1371/journal.pone.0114714.

Kumah EA, McSherry R, Bettany Saltikov J, et al. PROTOCOL: Evidence‐informed practice versus evidence‐based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: A comprehensive systematic review of undergraduate students . Campbell Systematic Reviews . 2019;15(1-2). doi:10.1002/cl2.1015

By Kathi Valeii Valeii is a Michigan-based freelance writer with a bachelor's degree in communication from Purdue Global.

• Introduction and Overview

What is Psychological First Aid?

Psychological First Aid is an evidence-informed [1] modular approach to help 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:

• Consistent with research evidence on risk and resilience following trauma
• Applicable and practical in field settings
• Appropriate for developmental levels across the lifespan
• Culturally informed and delivered in a flexible manner

Psychological First Aid does not assume that all survivors will develop severe mental health problems or long-term difficulties in recovery. Instead, it is based on an understanding that disaster survivors and others affected by such events will experience a broad range of early reactions (for example, physical, psychological, behavioral, spiritual). Some of these reactions will cause enough distress to interfere with adaptive coping, and recovery may be helped by support from compassionate and caring disaster responders.

Who is Psychological First Aid For?

Psychological First Aid intervention strategies are intended for use with children, adolescents, parents/caretakers, families, and adults exposed to disaster or terrorism. Psychological First Aid can also be provided to first responders and other disaster relief workers.

Who Delivers Psychological First Aid?

Psychological First Aid is designed for delivery by mental health and other disaster response workers who provide early assistance to affected children, families, and adults as part of an organized disaster response effort. These providers may be imbedded in a variety of response units, including first responder teams, incident command systems, primary and emergency health care, school crisis response teams, faith-based organizations, Community Emergency Response Teams (CERT), Medical Reserve Corps, the Citizens Corps, and other disaster relief organizations. [1]

When Should Psychological First Aid Be Used?

Psychological First Aid is a supportive intervention for use in the immediate aftermath of disasters and terrorism.

Where Should Psychological First Aid Be Used?

Psychological First Aid is designed for delivery in diverse settings. Mental health and other disaster response workers may be called upon to provide Psychological First Aid in general population shelters, special needs shelters, field hospitals and medical triage areas, acute care facilities (for example, Emergency Departments), staging areas or respite centers for first responders or other relief workers, emergency operations centers, crisis hotlines or phone banks, feeding locations, disaster assistance service centers, family reception and assistance centers, homes, businesses, and other community settings. For more information on the challenges of providing Psychological First Aid in various service settings, see Appendix B .

Strengths of Psychological First Aid

• Psychological First Aid includes basic information-gathering techniques to help providers make rapid assessments of survivors’ immediate concerns and needs, and 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 handouts that provide important information for youth, adults, and families for their use over the course of recovery.

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 tell you specifically what their immediate needs and concerns are, 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 adaptive 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 cope effectively with the psychological impact of disasters.
• Be clear about your availability, and (when appropriate) link the survivor to another member of a disaster response team or to local recovery systems, mental health services, public-sector services, and organizations.

Delivering Psychological First Aid

Professional behavior.

• Operate only within the framework of an authorized disaster response system.
• Model healthy 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 survivor.
• Be knowledgeable and sensitive to issues of culture and diversity.
• Pay attention to your own emotional and physical reactions, and practice self-care.

Guidelines for Delivering Psychological First Aid

• Politely observe first; don’t intrude. Then ask simple respectful questions to determine how you may help.
• Often, the best way to make contact is to provide practical assistance (food, water, blankets).
• Initiate contact only after you have observed the situation and the person or family, and have determined that contact is not likely to be intrusive or disruptive.
• Be prepared that survivors will either avoid you or flood you with contact.
• Speak calmly. Be patient, responsive, and sensitive.
• Speak slowly, in simple concrete terms; don’t use acronyms or jargon.
• If survivors want to talk, be prepared to listen. When you listen, focus on hearing what they want to tell you, and how you can be of help.
• Acknowledge the positive features of what the survivor has done to keep safe.
• Give information that directly addresses the survivor’s immediate goals and clarify answers repeatedly as needed.
• Give information that is accurate and age-appropriate for your audience.
• When communicating through a translator or interpreter, look at and talk to the person you are addressing, not at the translator or interpreter.
• Remember that the goal of Psychological First Aid is to reduce distress, assist with current needs, and promote adaptive functioning, not to elicit details of traumatic experiences and losses.

Some Behaviors to Avoid

• Do not make assumptions about what survivors are experiencing or what they have been through.
• Do not assume that everyone exposed to a disaster will be traumatized.
• Do not pathologize. Most acute reactions are understandable and expectable given what people exposed to the disaster have experienced. Do not label reactions as “symptoms,” or speak in terms of “diagnoses,” “conditions,” “pathologies,” or “disorders.”
• Do not talk down to or patronize the survivor, or focus on his/her helplessness, weaknesses, mistakes, or disability. Focus instead on what the person has done that is effective or may have contributed to helping others in need, both during the disaster and in the present setting.
• Do not assume that all survivors want to talk or need to talk to you. Often, being physically present in a supportive and calm way helps affected people feel safer and more able to cope.
• Do not “debrief” by asking for details of what happened.
• Do not speculate or offer possibly inaccurate information. If you cannot answer a survivor’s question, do your best to learn the facts.

Working With Children and Adolescents

• For young children, sit or crouch at the child’s eye level.
• Help school-age children verbalize their feelings, concerns and questions; provide simple labels for common emotional reactions (for example, mad, sad, scared, worried). Do not use extreme words like “terrified” or “horrified” because this may increase their distress.
• Listen carefully and check in with the child to make sure you understand him/her.
• Be aware that children may show developmental regression in their behavior and use of language.
• Match your language to the child’s developmental level. Younger children typically have less understanding of abstract concepts like “death.” Use direct and simple language as much as possible.
• Talk to adolescents “adult-to-adult,” so you give the message that you respect their feelings, concerns, and questions.
• Reinforce these techniques with the child’s parents/caregivers to help them provide appropriate emotional support to their child.

Working with Older Adults

• Older adults have strengths as well as vulnerabilities. Many older adults have acquired effective coping skills over a lifetime of dealing with adversities.
• For those who may have a hearing difficulty, speak clearly and in a low pitch.
• Don’t make assumptions based only on physical appearance or age, for example, that a confused elder has irreversible problems with memory, reasoning, or judgment. Reasons for apparent confusion may include: disaster-related disorientation due to change in surroundings; poor vision or hearing; poor nutrition or dehydration; sleep deprivation; a medical condition or problems with medications; social isolation; and feeling helpless or vulnerable.
• An older adult with a mental health disability may be more upset or confused in unfamiliar surroundings. If you identify such an individual, help to make arrangements for a mental health consultation or referral.

Working With Survivors with Disabilities

• When needed, try to provide assistance in an area with little noise or other stimulation.
• Address the person directly, rather than the caretaker, unless direct communication is difficult.
• If communication (hearing, memory, speech) seems impaired, speak simply and slowly.
• Take the word of a person who claims to have a disability–even if the disability is not obvious or familiar to you.
• When you are unsure of how to help, ask, “What can I do to help?” and trust what the person tells you.
• When possible, enable the person to be self-sufficient.
• Offer a blind or visually impaired person your arm to help him/her move about in unfamiliar surroundings.
• If needed, offer to write down information and make arrangements for the person to receive written announcements.
• Keep essential aids (such as medications, oxygen tank, respiratory equipment, and wheelchair) with the person.
• Preparing to Deliver Psychological First Aid
• Contact and Engagement
• Safety and Comfort
• Stabilization (if needed)
• Information Gathering : Needs and Current Concerns
• Practical Assistance
• Connection with Social Supports
• Information on Coping
• Linkage with Collaborative Services
• Psychological First Aid is supported by disaster mental health experts as the “acute intervention of choice” when responding to the psychosocial needs of children, adults and families affected by disaster and terrorism. At the time of this writing, this model requires systematic empirical support; however, because many of the components have been guided by research, there is consensus among experts that these components provide effective ways to help survivors manage post-disaster distress and adversities, and to identify those who may require additional services.

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• Publications

Applications of Psychological First Aid around the world: summary of a five-year retrospective

1. provide an updated overview of the mhpss field that clarifies the place of pfa within the broader spectrum of support, 2. keep attention to pfa as a foundational component of mhpss approaches and tend to its applications in practice, 3. continue to develop innovative pfa resources and technologies, 4. promote fidelity to the model with support to capacity-building initiatives and dialogue among communities of practice, 5. develop common approaches and tools for monitoring and evaluation of and research on pfa.

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When terrible things happen, we want to reach out a helping hand to those who have been affected. Psychological First Aid is … an approach to help people recover by responding to their basic needs and showing them concern and care, in a way that respects their wishes, culture, dignity and capabilities. – Psychological First Aid Brief, WHO for World Mental Health Day, 2016

I n 2011, on World Humanitarian Day, the World Health Organisation (WHO) and partners launched guidance in Psychological First Aid (PFA) in a simply worded format designed for professionals and non-professionals alike. World Health Organisation, War Trauma Foundation and World Vision International, Psychological First Aid: Guide for Field Workers (Geneva: WHO, 2011). To be as accessible as possible, the guidance was made freely available online, with content that was easy to translate and adapt for different languages and cultures. Sixty international peer reviewers from various countries, cultures and crisis contexts provided input into the guidance over the two-year period of its development, and 24 UN and NGO agencies endorsed the final product. A facilitation manual followed in 2013, and in 2014 revisions to both documents were developed to meet the particular needs of field staff working in the Ebola virus disease outbreak in West Africa.

PFA is not new: the concept and term were coined in the 1940s as a way to help Merchant Marines suffering from ‘war stress’. Today, several formulations of PFA exist, but the WHO guide appeared to fill an unmet need for practical guidance in non-technical language for people meeting or working with individuals in distress. This includes, but is not limited to, people affected by humanitarian emergencies, or in lower-resource settings. PFA has become a widely used, frontline approach to mental health and psychosocial support (MHPSS) for people affected by crisis events large and small. As part of humanitarian emergency preparedness and response, large-scale national and regional PFA capacity-building efforts have been undertaken by various entities, including the Japanese government, the Pan American Health Organization (PAHO) and NGO consortia in Asia, the Middle East and Africa. Many aid organisations orient staff and volunteers as standard practice in humanitarian emergencies, including the Nepal earthquake and the European refugee influx.

The guidance quickly became the second-highest selling publication in the WHO bookstore, and there are now over 20 language translations around the world. That the guidance was so rapidly taken up is likely due to its simplicity. Illustrated with engaging cartoons depicting different cultural contexts, it promotes concrete skills that anyone can learn in order to assist in practical, humane ways. Helpers – from firefighters, police and community volunteers to health and mental health staff – could grasp the guidance and apply it to their particular roles in helping distressed people, and often to their daily lives. It appeared to make abstract concepts, such as psychosocial support, more practical, defined and understandable for nonmental health humanitarian responders.

As the MHPSS field evolved, with a growing evidence base and a variety of innovative intervention strategies undergoing field testing, the time was right to critically reflect on PFA and its place within the spectrum of MHPSS approaches. The Church of Sweden, with advisory support from World Vision International (both Reference Group members), commissioned a five-year retrospective (2011–16) to understand how the WHO PFA guidance has been perceived and applied since its launch. Church of Sweden, Peace in Practice and World Vision International, Psychological First Aid: Five Year Retrospective (2011–2016), Church of Sweden, 2018 ( https://www.svenskakyrkan.se/internationelltarbete/reports-policydocuments–and-positions-on-church-of-swedens-international-work ) Utilising a desk review, online survey, case studies and interviews, the retrospective looked at:

• translation and adaptation processes;
• applications (and misapplications) in different crisis contexts;
• use by different types of helpers, from lay people to professionals;
• the place of PFA in the larger field of MHPSS in emergency response; and
• recommendations for the future.

The retrospective provides a rich overview of respondents’ experiences with the materials (including adaptation and translation), with PFA orientation and training-of-trainers, and their perceptions of PFA, including the name itself, how it is understood and its key strengths and risks. The case studies provide further analysis on how PFA has been applied, from large capacity-building efforts to applications in particular settings such as the Ebola crisis, in staff and team care and in emergency response coordination and advocacy for MHPSS in general.

Five key recommendations summarise the priorities that emerged from these varied perspectives, and provide a roadmap for next steps for practitioners, the authors of the guide and stakeholders in the global MHPSS community:

According to respondents, the simplicity and accessibility of PFA was both its greatest strength and its greatest potential danger. In the experience of some practitioners and donors, ‘PFA’ became synonymous with ‘MHPSS’, and so the full range of multi-layered, integrated MHPSS support and interventions in emergencies tended to be overlooked (and sometimes underfunded) in favour of this one, useful yet insufficient approach. Asking respondents to locate PFA on the Inter-Agency Standing Committee (IASC)’s MHPSS intervention pyramid also highlighted the lack of clarity and consensus about where PFA fits on the spectrum of MHPSS actions and interventions.

The MHPSS field is evolving rapidly as new, accessible resources are developed and tested and the evidence base expands. It would be timely to update the MHPSS field with an overview of the range of resources in the repertoire of MHPSS practitioners, when and how they should be used, and how they complement each other in a coordinated system of support. PFA can then be situated more appropriately within the larger sphere of psychosocial approaches and mental health interventions.

Respondents recognised the value of ensuring that PFA guidance is widely accessible and freely available, and recommended promoting it further within disaster preparedness initiatives. Many noted that PFA helped to raise the profile of MHPSS in emergencies, reached across cultures and contexts through the translations and opened the door to mainstreaming MHPSS within other sectors. However, despite guidance on facilitating orientations little is known about how PFA has actually been applied or orientations have been conducted, and the ethical principles of safety, dignity and rights that underpin PFA sometimes got lost. One concrete recommendation was to acknowledge that PFA provides core guidance on basic psychosocial support skills, and to focus attention on how it is incorporated within ongoing and new initiatives – including as an integral component of new scalable mental health care interventions.

Few respondents in the survey were aware that an e-learning course for PFA exists on the website of one international NGO, Plan International, See Plan International Plan Academy website: http://www.plan-academy.org/enrol/index.php?id=31 . or that there is an online forum linking practitioners on MHPSS.net. See the PFA Adaptation and Training Group on MHPSS.net . Respondents were very interested in these types of resources and technologies, as a complement to face-to-face orientations, to broaden the reach of PFA in lower-resource settings and to help clarify its use. Apps, online forums and e-learning utilising video clips and simulation demonstrations would be highly valued and would help in future applications of PFA.

Respondents generally felt the content of the PFA guidance had held up over time, and asked that the original guidance be kept intact. What they felt would be helpful at this stage is more information on how best to adapt and apply PFA in different contexts, including a compilation of case scenarios and orientation approaches from crisis situations. There are successful examples of national and regional capacity-building efforts that have led to the formation of communities of practice offering peer support for the application of PFA, improved attention to the care of staff and other helpers in crisis response, more coordinated advocacy for MHPSS in general and improved preparedness. A reinvigoration of existing online forums (e.g. the MHPSS.net PFA group) could be a good place to start, along with innovative technologies that could further develop communities of practice.

One question that has come increasingly to the fore as PFA has gained popularity is: what is the evidence that it works? PFA as articulated in the WHO guide is purportedly ‘evidenceinformed’ and ‘consensus-based’. The evidence informing PFA comes from disaster research focused on risk and the resilience of individuals and communities and, in particular, findings around the importance of social support in recovery from crisis events. Through the Look, Listen, Link actions of PFA, it is designed to improve the ability of responders to appropriately make contact with survivors, listen supportively and help affected people connect with services and their natural sources of support. PFA is also consistent with the literature promoting the factors known to support individuals in their recovery from crisis events, namely hope, safety, calming, self and community efficacy and (again) social support.

However, ‘evidence-informed’ is not ‘evidence-based’, and calls to evaluate the efficacy of PFA have increasingly revealed challenges and diverging points of view. PFA is not a discrete ‘intervention’ with one, agreed definition, and it is used flexibly according to the needs of affected people and the skills and roles of different helpers. Some liken PFA to a set of good communication and helping skills or a good bedside manner, and do not see it as an intervention at all. Indeed, as PFA has been increasingly utilised by helpers outside of the MHPSS field, it more clearly emerges as guidance for any helper to communicate better, be aware of safety considerations and other support and services, and minimise further harm to a survivor by poorly chosen words or actions. Furthermore, the WHO PFA guidance explicitly distances itself from the notion that offering PFA as a brief, supportive approach can prevent later mental disorder or distress, or that it can be used to reliably identify people at risk of developing longer-term mental health problems. Thus, clinical evaluation methods and outcomes defined by mental health symptoms would not be appropriate for evaluating the efficacy of PFA.

Opinions on the importance of establishing an evidence base for PFA varied widely among respondents in the retrospective study. Some emphasised that it was critical to evaluate PFA, while others believed an evidence base for common-sense, basic helping skills is unnecessary. However, respondents generally agreed on the need to develop a common, practical approach to monitoring and evaluating PFA – including developing relevant indicators and simple tools that could be used to collect data on its application during crisis response. Focus areas recommended for evaluation and research included fidelity to the model described in the guidance and the impact of orientation on helpers themselves. In addition, based on the influence of PFA in general MHPSS approaches, a systems-level perspective for evaluation and research may be warranted.

In conclusion, the PFA retrospective study allowed us the chance to Look at the progression of the WHO PFA guidance, Listen carefully to people’s experiences and perceptions and hopefully now Link PFA within holistic, comprehensive MHPSS responses in emergencies. Just as medical first aid does not constitute a comprehensive health response, so PFA is not a panacea for all the mental health needs of people affected by crisis events – it must be integrated as a component of wider MHPSS frameworks and services to most effectively ‘reach out a helping hand’. It is the hope of the authors of the retrospective study that these findings can help to guide future applications of this widely used resource in ways that will benefit the larger MHPSS field, and to provide a clear picture of the wealth of MHPSS resources and knowledge now available to field practitioners.

Leslie Snider is an independent consultant and the founder of Peace in Practice. Alison Schafer is MHPSS Technical Advisor at World Vision International. They were involved in the development of the original PFA guide in 2011. Carina Hjelmstam Winberg is with the humanitarian team of Church of Sweden, which commissioned the PFA retrospective.

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We need to build the evidence: A systematic review of psychological first aid on mental health and well-being

Sabrina hermosilla.

1 Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA

2 Columbia University Irving Medical Center, New York, New York, USA

Sarah Forthal

Karolina sadowska, elizabeth b. magill.

3 Icahn School of Medicine at Mount Sinai, New York, New York, USA

Patricia Watson

4 National Center for Posttraumatic Stress Disorder, Washington, D.C., USA

Kathleen M. Pike

Associated data.

Ensuring effective mental health and psychosocial support is crucial following exposure to a potentially traumatic event and can have long-term consequences for individuals, families, and communities. Psychological first aid (PFA) has become a widespread intervention of choice following exposure to conflict or disaster; however, its impact is unknown. This systematic review assessed PFA efficacy in improving the mental health and psychosocial well-being of individuals exposed to potentially traumatic events. We searched PubMed, PsycINFO, PTSDpubs, and EMBASE for peer reviewed studies evaluating programmatic outcomes of PFA, or an adapted intervention, published in English before March 9, 2021. Studies evaluating training outcomes or program feasibility were excluded. The primary outcomes were reported measures of participant mental health and psychosocial well-being, with narrative results presented for each. The Cochrane Risk of Bias tool was applied. Of 9,048 potentially eligible citations, 12 studies with a total of 1,437 participants met the inclusion criteria. Only one study was a randomized controlled trial. The findings from all studies suggest a positive impact of PFA, with most reporting reduced symptoms of anxiety, depression, posttraumatic stress, and distress, as well as improved ratings of mood, the experience of safety, connectedness, and a sense of control, among youth and adults. Risk of bias was generally high. Inconsistent intervention components, insufficient evaluation methodologies, and a high risk of bias within the reviewed studies present challenges in assessing PFA efficacy, and an imbalance between popular support for PFA and scant evidence of outcome data exists. Further research is needed to justify the proliferation of PFA.

Exposure to potentially traumatic events (PTEs), defined in the Diagnostic and Statistical Manual of Mental Disorders (fifth ed.; DSM-5 ; American Psychiatric Association [APA], 2013 ) as those involving “actual or threatened death, severe injury, or sexual violence,” can have long-term consequences on individuals, families, and communities ( Bonanno et al., 2010 ; Norris, 1992 ; Overstreet et al., 2017 ). With few exceptions ( Di Nota et al., 2021 ), prior efforts to respond to and improve mental health and well-being in communities affected by PTEs have too often not only failed to demonstrate their goals ( Papola et al., 2020 ) but, at times, have harmed the individuals they sought to help ( Rose et al., 2002 ). Intervention efforts have, thus, prioritized implementation supported by international guidelines (APA; Inter-Agency Standing Committee [IASC], 2007 ) that support the cost-effective use of finite resources. Regrettably, the data are controversial and sparse.

First introduced during World War II, psychological first aid (PFA) is the widespread intervention of choice following PTE exposure ( Brymer et al., 2006 ). PFA is a manualized approach to providing psychosocial support to individuals in the immediate aftermath of a stressful event (The National Child Traumatic Stress Network [NCTSN]), designed to reduce immediate distress and mitigate psychopathology risk ( Vernberg et al., 2008 ). Although there are different PFA models, all involve a needs assessment, nonjudgmental listening and engagement, and service referral when indicated ( Supplementary Table S1 ). PFA was originally designed for humanitarian settings, does not require specialist training, and can be delivered by non–mental health care workers ( IASC, 2007 ). Interest in PFA has grown in recent years, and many organizations offer training ( NCTSN, ) or have published PFA information (APA; Substance Abuse and Mental Health Services Administration [SAMHSA], 2005 ; World Health Organization [WHO] et al., 2011 ). Standard implementation guidelines developed by the WHO are widely endorsed ( WHO et al., 2011 ). Although the WHO guide for PFA is unique in that it has been translated into more than 20 languages, PFA frameworks have been developed by organizations or for specific populations as well. This has resulted in significant heterogeneity of the PFA models ( Supplementary Table S1 ).

Public mental health communities promote PFA implementation as a gold standard and assume effectiveness ( Van Ommeren & Saxena, 2016 ) despite over a decade of calls to build the evidence base ( Bisson & Lewis, 2009 ; Dieltjens et al., 2014 ; Fox et al., 2012 ; Shultz & Forbes, 2014 ; Tol et al., 2012 ). Previous reviews have demonstrated insufficient evidence to evaluate efficacy ( Bisson & Lewis, 2009 ; Dieltjens et al., 2014 ; Fox et al., 2012 ). With the most recent review in 2014 and funding and support for PFA implementation high, we conducted this systematic review of PFA to assess the efficacy of PFA in improving mental health and psychosocial well-being among individuals exposed to PTEs, identify best practices based on the extant data, and recommend research priorities that will produce the much-needed evidence base to guide similar interventions in humanitarian, postdisaster, and crisis settings.

We conducted this systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement ( Page et al., 2021 ; Supplementary Tables S2 and S3 ). Because previous systematic reviews ( Bisson & Lewis, 2009 ; Dieltjens et al., 2014 ; Fox et al., 2012 ) and a preliminary review of recent literature suggest insufficient evidence to quantitatively synthesize PFA programmatic effect (i.e., through meta-analysis), this review was not submitted to PROSPERO, as it is ineligible.

Search strategy and selection criteria

We searched the PubMed, PsycINFO, PTSDpubs, and EMBASE electronic databases using the search terms: “psychological first aid” or “mental health first aid” or “psychological crisis intervention” or “mental health crisis intervention” for English-language, peer reviewed papers published before March 9, 2021 (see Supplementary Materials ).

Only published, peer reviewed studies evaluating a PFA programmatic outcome, irrespective of design required to evaluate efficacy (i.e., related to mental health or psychosocial well-being), or an adapted intervention were included. A programmatic outcome is the assessment of a PFA-based action taken to improve the mental health or psychosocial well-being of participants. Studies evaluating training outcomes or program feasibility were excluded, as they do not speak to the overall intervention efficacy, as were commentaries, opinion pieces, protocols, and reviews. There were no restrictions on study setting or population, and both qualitative and quantitative studies were considered.

After removing duplicate records, the remaining titles and abstracts were reviewed, and studies were selected for inclusion by three independent authors (SF, KS, EM) based on the predetermined inclusion and exclusion criteria (see Supplementary Materials ). To ensure quality, a second author (SF, KS, EM) randomly reviewed 15% of titles and 10% of abstracts. The full texts of eligible studies were reviewed for inclusion independently by two authors (SF, KS), and a third author (SH) settled all conflicts.

Data analysis

Study-level data on setting, details, participant characteristics, facilitator characteristics, study design, and the programmatic outcomes evaluated were extracted. All programmatic outcome results were extracted. Risk of bias was assessed using the Cochrane Risk of Bias tool, which rates studies as having a low, high, or unclear risk of bias in the following domains: random sequence generation, allocation concealment, participants and personnel blinding, outcome assessment blinding, incomplete outcome data, selective reporting, and other sources of bias ( Higgins & Green, 2011 ). Two authors independently assessed risk of bias for each study using the tool’s criteria ( Higgins & Green, 2011 ) and settled disagreements among themselves.

Results for each study are presented narratively, by outcome, using the effect sizes and precision measures reported in the studies. Tables were structured by study, outcome, and intervention components.

The search identified 9,855 articles potentially eligible for study inclusion ( Figure 1 ). After the removal of 1,093 duplicates, 8,762 titles were screened for eligibility based on title and abstract. This eliminated 8,613 studies, leaving 149 for full-text screening. Most studies were excluded because the intervention tested was not PFA (59.9%) or the study did not analyze a programmatic outcome (19.7%). Other reasons for exclusion were that the paper was unavailable due to insufficient access privileges (researchers used the [Columbia University Library, which offers access to over 163,000,000 articles), did not reflect not original research, was not a peer reviewed journal article, or was not published in English. Papers were also excluded if PFA was an unevaluated intervention component. In total, 12 studies were included in the systematic review.

Note: PFA = psychological first aid.

Table 1 briefly describes the studies and presents relevant effect sizes and results. The 12 included studies reported individual outcomes from a PFA or a PFA-based intervention; no studies reported community outcomes. Five studies were randomized control trials ( Despeaux et al., 2019 ; Everly et al., 2016 ; McCart et al., 2020 ; Meir et al., 2012 ) or randomized trials ( Ironson et al., 2020 ); study assignment was not randomized for most: One study was a pilot quasi-experiment ( Ramirez et al., 2013 ), two were convenience sample pretest–posttest group designs ( Cain et al., 2010 ; Kameno et al., 2021 ), one was a convenience sample uncontrolled longitudinal design ( Blake et al., 2020 ), one was a qualitative comparative analysis ( Schafer et al., 2016 ), and two were qualitative thematic analyses ( Bakes-Denman et al., 2021 ; De Freitas Girardi et al., 2020 ). Four studies had control groups ( Despeaux et al., 2019 ; Everly et al., 2016 ; McCart et al., 2020 ; Meir et al., 2012 ), and five included randomization with regard to the intervention condition ( Despeaux et al., 2019 ; Everly et al., 2016 ; Ironson et al., 2020 ; McCart et al., 2020 ; Meir et al., 2012 ). Most studies did not include power calculations ( Despeaux et al., 2019 ; Everly et al., 2016 ; McCart et al., 2020 ), and only one reported having sufficient power to detect medium effects for differences between the intervention and control groups ( Meir et al., 2012 ). Eight studies included a pre–post analysis ( Cain et al., 2010 ; Despeaux et al., 2019 ; Everly et al., 2016 ; Ironson et al., 2020 ; Kameno et al., 2021 ; McCart et al., 2020 ; Meir et al., 2012 ; Ramirez et al., 2013 ), and nine studies included postintervention follow-up ( Bakes-Denman et al., 2021 ; Despeaux et al., 2019 ; Everly et al., 2016 ; Ironson et al., 2020 ; Kameno et al., 2021 ; McCart et al., 2020 ; Meir et al., 2012 ; Ramirez et al., 2013 ; Schafer et al., 2016 ), which ranged from 30 min ( Despeaux et al., 2019 ; Everly et al., 2016 ) to 6 months ( Ironson et al., 2020 ). None of the included studies were examined in previous PFA systematic reviews.

Study characteristics and major outcomes

Note: PTE = potentially traumatic event; EMDR = eye movement desensitization and reprocessing; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms; M = mean score.

Studies were primarily conducted in the United States ( Cain et al., 2010 ; Despeaux et al., 2019 ; Everly et al., 2016 ; Ironson et al., 2020 ; McCart et al., 2020 ; Ramirez et al., 2013 ). Interventions were conducted in school or university facilities ( Cain et al., 2010 ; Despeaux et al., 2019 ; Everly et al., 2016 ; Meir et al., 2012 ; Ramirez et al., 2013 ), hospitals or other health care settings ( Bakes-Denman et al., 2021 ; Blake et al., 2020 ; Kameno et al., 2021 ), designated child-friendly spaces ( Schafer et al., 2016 ), community settings ( Ironson et al., 2020 ; McCart et al., 2020 ), or during home visits ( Cain et al., 2010 ; De Freitas Girardi et al., 2020 ; Schafer et al., 2016 ). The target populations were adults ( Bakes-Denman et al., 2021 ; Blake et al., 2020 ; Everly et al., 2016 ; Ironson et al., 2020 ; Kameno et al., 2021 ; Schafer et al., 2016 ), undergraduate college students ( Despeaux et al., 2019 ), adolescents ( Ramirez et al., 2013 ; Schafer et al., 2016 ), and children ( Cain et al., 2010 ; De Freitas Girardi et al., 2020 ; Meir et al., 2012 ). All interventions except one ( Despeaux et al., 2019 ) were conducted among individuals who reported PTE exposure. Study sample sizes ranged from 13 ( Bakes-Denman et al., 2021 ) to 260 participants ( Blake et al., 2020 ).

PFA intervention components varied across studies ( Table 2 ). Four PFA interventions were conducted with individuals ( Bakes-Denman et al., 2021 ; Everly et al., 2016 ; Kameno et al., 2021 ; Ramirez et al., 2013 ), and eight were conducted in group settings ( Blake et al., 2020 ; Cain et al., 2010 ; De Freitas Girardi et al., 2020 ; Despeaux et al., 2019 ; Ironson et al., 2020 ; McCart et al., 2020 ; Meir et al., 2012 ; Schafer et al., 2016 ). Intervention components included promoting safety, calming, self- and community efficacy, connectedness, hope, reflective listening, knowledge, self-worth, and self-awareness. In six studies, PFA interventions were facilitated by mental health professionals ( Bakes-Denman et al., 2021 ; Everly et al., 2016 ; Ironson et al., 2020 ; Kameno et al., 2021 ; Meir et al., 2012 ; Schafer et al., 2016 ), whereas six studies used PFA facilitators with non–mental health or nonspecified backgrounds ( Blake et al., 2020 ; Cain et al., 2010 ; De Freitas Girardi et al., 2020 ; Despeaux et al., 2019 ; McCart et al., 2020 ; Ramirez et al., 2013 ). Intervention sessions ranged from a single, 10-min session ( Despeaux et al., 2019 ; Everly et al., 2016 ) to multiple sessions across 6 ( Cain et al., 2010 ) to 17 ( Blake et al., 2020 ) weeks. All interventions were conducted in person.

Psychological first aid (PFA) intervention components

Note: NS = nonspecified.

All studies reported improvement in mental health outcomes. Outcome measurements varied across studies ( Supplementary Table S4 ). In total, 26 measures were used to assess 17 outcomes. Four studies found reductions in anxiety ( Despeaux et al., 2019 ; Everly et al., 2016 ; McCart et al., 2020 ; Meir et al., 2012 ) and depressive symptoms ( Ironson et al., 2020 ; McCart et al., 2020 ; Meir et al., 2012 ; Ramirez et al., 2013 ). Symptoms of posttraumatic stress disorder (PTSD) were also measured in four studies ( Cain et al., 2010 ; Ironson et al., 2020 ; McCart et al., 2020 ; Ramirez et al., 2013 ), with all but one ( Ramirez et al., 2013 ) reporting a statistically significant reduction in PTSD symptoms. Two studies evaluated mood scores, with nonstatistically significant improvement reported in one ( Everly et al., 2016 ) and statistically significant increases in the other ( Despeaux et al., 2019 ). Among qualitative studies, PFA was found to contribute to safety, reduce distress, foster connectedness, provide a greater sense of control among youth and adults, and improve the normalization of emotions ( Bakes-Denman et al., 2021 ; De Freitas Girardi et al., 2020 ; Schafer et al., 2016 ).

Informed by the Cochrane Risk of Bias tool, the literature had an overall extremely high risk of bias, with only one study assessed as having a low risk across all categories ( McCart et al., 2020 ; Table 3 ). Studies consistently failed to address bias across all measured domains, with several lacking random allocation to an intervention arm ( Bakes-Denman et al., 2021 ; Blake et al., 2020 ; Cain et al., 2010 ; De Freitas Girardi et al., 2020 ; Kameno et al., 2021 ; Ramirez et al., 2013 ; Schafer et al., 2016 ), treatment group concealment ( Cain et al., 2010 ; De Freitas Girardi et al., 2020 ; Despeaux et al., 2019 ; Meir et al., 2012 ; Ramirez et al., 2013 ; Schafer et al., 2016 ), and/or the blinding of participants and evaluators to treatment arm ( Bakes-Denman et al., 2021 ; Blake et al., 2020 ; Cain et al., 2010 ; De Freitas Girardi et al., 2020 ; Despeaux et al., 2019 ; Ironson et al., 2020 ; Kameno et al., 2021 ; Ramirez et al., 2013 ; Schafer et al., 2016 ). Often, studies had very small sample sizes, making it difficult to distinguish between selective reporting and an inability to report ( Bakes-Denman et al., 2021 ; De Freitas Girardi et al., 2020 ; Everly et al., 2016 ; Ironson et al., 2020 ; Kameno et al., 2021 ; Ramirez et al., 2013 ; Schafer et al., 2016 ), and researchers frequently did not perform subanalyses or sensitivity analyses ( Bakes-Denman et al., 2021 ; Blake et al., 2020 ; Cain et al., 2010 ; De Freitas Girardi et al., 2020 ; Everly et al., 2016 ; Ironson et al., 2020 ; Kameno et al., 2021 ; Meir et al., 2012 ; Ramirez et al., 2013 ; Schafer et al., 2016 ).

Cochrane risk of bias ratings from each study included in the systematic review

Note: RSG = random sequence generation; AC = allocation concealment; B = blinding of participants and personnel; OA = outcome assessment; IOD = incomplete outcome data; SR = selective reporting; O = other sources of bias.

This systematic review explored the programmatic effect of PFA and identified only 12 studies from over 9,000 reviewed citations. Although the results of these studies suggest that PFA may improve mental health and psychosocial well-being among individuals exposed to PTEs, inconsistent intervention components, insufficient evaluation methodologies, and high risks of bias within the included studies challenged our ability to evaluate PFA’s programmatic effect.

Heterogeneous PFA programmatic specification (i.e, activity type and duration) is a primary challenge to its systematic implementation and evaluation ( Dieltjens et al., 2014 ; Forbes et al., 2011 ; Shultz & Forbes, 2014 ). The interventions described in the included studies varied with regard to timing, duration, mode of delivery, previous experience of trainers and trainees, and key intervention principles. For example, the Wellbeing Centres described by Blake et al. (2020) delivered a 17-week program, whereas RAPID PFA ( Despeaux et al., 2019 ; Everly et al., 2016 ) is delivered in a single session. Although all “five essential elements” of PFA ( Shultz & Forbes, 2014 ) are represented across the included studies, only the promotion of safety was included in all studies. A framework approach to programming ( Forbes et al., 2011 ) could address this, providing a structure for standardized localization and adaptation to support program fidelity and evaluation.

Even accounting for programmatic heterogeneity, the existing study designs are largely inappropriate to test PFA efficacy. Consistent with previous reviews of the PFA literature ( Bisson & Lewis, 2009 ; Dieltjens et al., 2014 ; Forbes et al., 2011 ; Fox et al., 2012 ), of the reviewed articles, the methodology was inconsistent, often lacked rigor, and included studies that had an overall high risk of bias. PFA is, thus, evidence-informed but not evidence-based ( Brymer et al., 2006 ). Given the dearth of programmatic evidence, and its near nonexistent increase, since previous systematic literature reviews ( Dieltjens et al., 2014 ; Fox et al., 2012 ), now is the time to build the evidence base. To address complicating factors of core implementation, these evaluations should apply program evaluation best practices and, where possible, standardize rigorous measurement methods to allow for cross-context comparisons. As PFA intends to serve a diverse population of survivors, future studies should consider evaluating the roles of demographic moderators such as gender, age, ethnicity, and race.

The widespread support and use of PFA in an environment absent rigorous evaluations reflects a failure to fund, document, or disseminate rigorous PFA evaluations. The imprecise nature of “evidence-informed” as opposed to “evidence-based” could dampen downstream donor agency funding, as many consider PFA efficacy already “established.” Given the complexity of conducting program evaluation research in emergency settings, donor agencies should clearly identify program evaluation as a key funding priority, such as Elrha’s (n.d.) urgent appeal for COVID-19–related studies rather than including language that explicitly discourages research and is unclear about programmatic evaluations (Centers for Disease Control and Prevention, 2020).

The dearth of rigorous PFA evaluations could stem from methodological challenges inherent to conducting program evaluations in complex emergency settings. PFA is a flexible model that recommends efficiently adapting actions depending on the affected individual’s needs. Standard manualized protocols and objective documentation of the intervention are not only difficult but also potentially contraindicated. Flexible designs that consider the overall PFA framework yet allow for individual-level heterogeneity of activities and outcomes are required. Evaluators can look to other fields, such as reproductive health ( Casey, 2015 ) and child protection ( Ager et al., 2011 ; Hermosilla et al., 2019 ), and increasingly, other mental health interventions ( Bolton et al., 2007 ) for examples on how to deal with this complexity.

Conducting research within chaotic postdisaster contexts is challenging, specifically with respect to securing rapid research funding and institutional review board approvals, mobilizing research, obtaining informed consent and assessment information, ensuring model fidelity, and developing randomization and control group designs. Although staff capacity is improving, it is often insufficient to adequately document and evaluate programmatic outcomes ( Madfis et al., 2010 ).

Supporting innovative and rigorous study designs and measurement will address these challenges. Future PFA evaluations should include randomization, control groups, long-term follow-up periods, and sophisticated analytic designs and methods—in short, building the efficacy data that can inform future effectiveness studies. A growing body of literature documents how such practices, applied in humanitarian crises ( Bolton et al., 2014 ; Brown et al., 2018 ; Charlson et al., 2019 ; Hermosilla et al., 2019 ; Rahman et al., 2016 ; World Health Organization, 2015 ), can lead to improved programming and response efforts.

When considering which tools to use to evaluate PFA, researchers should focus on both outcome measurement and process indicators. Although identifying locally valid instruments that map onto standardized nosological frameworks within the constraints of humanitarian response is challenging ( Mollica et al., 2004 ), researchers should rely on and help build the growing body of psychometric research ( Bell et al., 2015 ). Distress measures and trauma coping scales could be applied and tested ( Bovin et al., 2018 ; Kessler et al., 2002 ). When examining PFA, researchers could employ phased evaluation approaches ( Forbes et al., 2011 ), theoretical domains frameworks ( Birken et al., 2017 ), adaptive study designs ( Kilbourne et al., 2014 ), and optimized strategies ( Collins et al., 2007 ).

These systematic review results must be understood within the context of their limitations. First, all included studies were in English, and it is possible that some studies were missed. Second, this evaluation focused explicitly on PFA efficacy rather than intermediate indicators, such as training, which could, with a larger sample of included studies, begin to disentangle varied programmatic effects across studies. Third, although some studies included information exploring potential subpopulation trends and impacts of complementary interventions and treatments, their risks of bias were too high to extend analyses to these topics.

While acknowledging unique challenges that exist in these settings, a growing body of rigorous, ethical research tasks humanitarian actors to adapt and adhere to the highest standards not despite challenges presented in humanitarian settings but because of them. Exemplars demonstrating that researchers and clinicians can apply the highest standards of research to the most complex emergency settings exist ( Bolton et al., 2014 ; Brown et al., 2018 ; Charlson et al., 2019 ; Hermosilla et al., 2019 ; Rahman et al., 2016 ; World Health Organization, 2015 ). People in distress everywhere have a right to evidence-based practices that do no harm, and researchers today have the skills and expertise to develop this evidence. The time to fund the work is now.

There is scant evidence on the programmatic effect of PFA. Inconsistent intervention components, insufficient evaluation methodologies, and high risks of bias within the studies reviewed challenge our ability to evaluate PFA’s programmatic effect. Large crises, such as the current COVID-19 global pandemic, provide unique opportunities to focus responders, leverage new funding, and build an evidence base to guide response efforts. Future studies must effectively evaluate PFA.

OPEN PRACTICES STATEMENT

Our research protocol adhered to PROSPERO guidelines, and protocol data are available from the corresponding author.

Supplementary Material

Acknowledgments.

This work was supported by the National Institute of Mental Health (R01-MH110872) and program funding for the Columbia–WHO Center for Global Mental Health.

The funders had no role in the study design, data collection, analysis, interpretation, or writing of this article. The authors report no financial relationships with commercial interests.

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Psychological First Aid Essays

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Psychological first aid

Facilitator’s manual for orienting field workers

This manual is designed to orient helpers to offer psychological first aid (PFA) to people following a serious crisis event. PFA involves humane, supportive and practical assistance for people who are distressed, in ways that respect their dignity, culture and abilities. This facilitator’s manual is to be used together with the Psychological first aid: Guide for field workers (World Health Organization, War Trauma Foundation, World Vision International, 2011).

The manual is structured in three parts:

1) Overview of the manual

This section provides general information about how to use this manual, how to prepare for giving an orientation, and tips for facilitators.

2) Step-by-step orientation

This section provides a half-day orientation agenda and a step-by-step description of each module, including learning objectives, narrative and tips for the facilitator, accompanying slides, and instructions for group exercises and discussion.

3) Supporting materials

This section of annexes provides supporting materials to print as handouts for participants.

Psychological First Aid to Children Research Paper

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The condition of people having no dwelling places is referred to as homelessness. Homelessness can be brought about by many factors including poverty, unemployment, government abuse, war, natural disasters, as well as domestic violence. Most of these victims, especially the youth who either are rendered homeless through natural disasters or through any other way, experience some sought of trauma. They, therefore, need psychological first aid from professional therapists or trained personnel (Ruzek et al, 2007). Every day children are exposed to danger and some of these events can threaten a person’s physical and emotional well-being leading to traumatic events (Lennquist, 2011).

Children show common behavioral and emotional responses to these traumatic and natural disasters. Nevertheless, some may be indirectly exposed to such events. There are primary goals that are used to respond to mental health disasters, which include. Normalizing the victim’s feelings by assuring them that the upsetting and strange feelings they are going through are quite normal given the situation at hand and the other goal is assisting the victims to get appropriate ways of coping with the stress around them (Barbanel, 2006).

There are several stages of grief though they may not come in order and they include; shock, which is the first reaction by the victims, which is associated with physical and emotional pain. Another thing would be denial, which makes them act as if nothing has occurred. In addition to that, they suffer from depression – a feeling of loneliness, despair, and pain. Some also undergo guilty feelings that are self-blame for the people they have lost and anxiety comes along as reality sets in. They can become aggressive mostly towards those they think might have been in a position to prevent the loss but if this anger is expressed it might be of great use to their recovery.

Four major areas need immediate attention and enhanced implementation, which are; transition concerns from an individual engagement perspective and mental health help the enrollment of families and students and adding the new staff, which is a way of establishing interventions to ease their stay in the new schools. It also addresses any problems of adjustments in schools. Besides that, the new students who needed help even before the disaster need special assistance especially those with IEPs to avoid them from dropping out of school as well as the teachers so that they can be able to help the students. Finally, there is a need to identify and give special assistance to those students who are much more traumatized and need psychological aid (Barbanel, 2006).

The process of giving psychological first aid has some core values which should be installed to the victims among which are; contacting and engaging the victims so as not to feel left out, offering them comfort and safety to be free to share what it is they feel and this fastens their healing process. Connecting with social supports services to give them professional help as well as linking with collaborative service. During times like this, people tend to seek support and solace. Social support and supportive relationships are critical in stress management since they offer emotional support and allow them to express their difficult emotions (Lennquist, 2011).

Teachers, parents, and other adults who care can help the youth, children manage their stressful moments by encouraging them to get used to the normal routines or even new ones, and this makes them feel safe even when they are not focused on the sad events. They also help them maintain a proper social connection and engage in social activities that help them normalize and adjust. Their level of sadness exposure should be minimal to help them heal completely. They should be encouraged to eat healthy foods and keep fit to cope with stress and getting enough sleep.

Victims of such disasters should be engaged in discussions about the event through the discussions that should be made optional for the students who feel courageous enough to speak of the happenings of that event. They should be allowed to express their feelings without any interruptions though some of the students prefer engaging themselves with creative activities, drawing or writing to express their feelings. The children should also be reassured of their safety by the school officials to respond well knowing that someone is looking out for them. The routine and structure of the school should resume for the children to function better knowing what to expect regarding the daily school activities (Lennquist, 2011).

Finally, to be prepared for this kind of event, school professionals and teachers should be in a position to get all valuable information concerning the people to contact in cases of emergency, especially their parents. They should also incorporate the school community members and plan on how to house the parents who might want to be with their children during these events. The staff should limit the media coverage of such live events especially to those who were victims of the events because emotions are a common thing and so they should expect such during commemorations even when the victims had started adjusting.

Reference List

Barbanel, L. (2006). Psychological interventions in times of crisis . New York: Springer.

Lennquist, Sten. (2011). Medical Response to Major Incidents and Disasters: A Practical Guide for All Medical Staff . Springer Verlag.

Ruzek, J. et al. (2007). Psychological First Aid. Journal of Mental Health Counseling , 29(1), 17-49. Web.

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IvyPanda. (2020, July 14). Psychological First Aid to Children. https://ivypanda.com/essays/psychological-first-aid/

"Psychological First Aid to Children." IvyPanda , 14 July 2020, ivypanda.com/essays/psychological-first-aid/.

IvyPanda . (2020) 'Psychological First Aid to Children'. 14 July.

IvyPanda . 2020. "Psychological First Aid to Children." July 14, 2020. https://ivypanda.com/essays/psychological-first-aid/.

1. IvyPanda . "Psychological First Aid to Children." July 14, 2020. https://ivypanda.com/essays/psychological-first-aid/.

Bibliography

IvyPanda . "Psychological First Aid to Children." July 14, 2020. https://ivypanda.com/essays/psychological-first-aid/.

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Psychological First Aid Intervention after Exposure to a Traumatic Event at Work among Emergency Medical Services Workers

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Marine Tessier, Josianne Lamothe, Steve Geoffrion, Psychological First Aid Intervention after Exposure to a Traumatic Event at Work among Emergency Medical Services Workers, Annals of Work Exposures and Health , Volume 66, Issue 7, August 2022, Pages 946–959, https://doi.org/10.1093/annweh/wxac013

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Psychological First Aid (PFA) is a promising early intervention for managing mental health symptoms and providing psychosocial support after exposure to a traumatic event (TE) among high-risk organizations such as Emergency Medical Service (EMS). However, recipients’ experience with PFA remains understudied. This study aimed to explore the perception of EMS workers ( n = 13) who received PFA administered by a peer helper using a qualitative inductive approach. Findings from a thematic analysis indicated that the PFA intervention addresses EMS workers’ immediate needs in congruence with Hobfoll’s five essential principles to enhance coping and recovery after a TE. Specific components of the intervention, such as its time-sensitive nature and the closeness with peers, were especially appreciated by EMS workers. The PFA intervention appeared to have a beneficial impact on recipients, regarding the reduction of stigma, the increase of help-seeking behaviors, and the decrease of organizational difficulties. In conclusion, the PFA intervention offered by peer helpers is appreciated by recipients and is a beneficial first step toward supporting EMS workers in the aftermath of workplace trauma. These qualitative findings contribute to the current literature by informing further research about PFA intervention in other high-risk organizations and quantitative studies aiming to test PFA’s efficacy in such settings.

First responders, including emergency medical services (EMS) workers, experience traumatic events (TEs), which can lead to mental health disorders. This study found that a Psychological First Aid (PFA) intervention delivered by peer helpers in the EMS context helped to decrease immediate distress as well as to facilitate adaptation over time. The PFA intervention may be tailored to different organizational contexts and facilitate return to work after a TE, as well as reduce mental health stigma.

First responders (i.e., police, firefighters, emergency medical service [EMS] workers) are frequently exposed to Traumatic Events (TEs) at work ( Carleton et al. , 2019 ). Trauma-related mental health disorders usually include acute stress disorder, post-traumatic stress disorder (PTSD), anxiety, depression, and substance abuse ( Berger et al. , 2012 ; Carleton et al. , 2019 ). Among those high-risk workers, EMS workers appeared worldwide to be at higher risk of developing trauma-related mental health disorders according to two meta-analyses with estimated prevalence rates of around 11 or 15% for PTSD ( Berger et al. , 2012 ; Petrie, Milligan-Saville et al. , 2018 ). These mental health problems also lead to physical health problems (i.e., greater levels of gastrointestinal and cardiorespiratory symptoms— Milligan-Saville et al. , 2017 ; Sommer et al. , 2020 ) and to negative repercussions at the organizational level (i.e., occupational stress, less operational performance, more days off work) for EMS organizations ( Wild et al. , 2016 ; Rankin, 2019 ).

Unfortunately, international trauma guidelines currently do not recommend any early post-traumatic intervention for individuals exposed to a TE. Current findings suggest that the evidence supporting early intervention is too weak to make official recommendations, except for active monitoring in the weeks following the TE ( NICE, 2018a ). A recent systematic review and meta-analysis ( Roberts et al. , 2019 ) reviewed over 60 studies evaluating several early post-traumatic interventions. Results indicated that for individuals who had not been pre-screened for traumatic stress symptoms, there were no clinically important differences between early post-traumatic interventions and usual care. Further research is therefore needed to determine how to intervene with individuals who have recently experienced a TE.

Also, a significant proportion of first responders endure mental health stigma and face barriers to mental health care ( Haugen et al. , 2017 ). Emergency response organizations tend to enable a professional culture that devalues emotional vulnerability, emphasizes tough-mindedness, and stigmatizes mental health problems. These cultural-induced stigmas are often reported as a significant barrier to seeking help ( Richins et al. , 2020 ). International guidelines suggest investing in the protective role of peer support following a TE in first responders’ organizations to help reduce this stigma ( Creamer et al. , 2012 ; NICE, 2018b ). Peer support refers to the supportive relationship between people who have a shared experience ( Mental Health Commission of Canada, 2021 ). Peer support may have an important role to play in managing TE. Recovery was identified as more likely when emergency responders supported one another ( Donnelly et al. , 2016 ; Richins et al. , 2020 ). Shakespeare-Finch and Daley (2017) also demonstrated that EMS workers receiving general organizational support reported decreased post-traumatic symptoms and higher post-traumatic growth as it enhances a sense of workplace belongingness. Gouweloos-Trines and colleagues (2017) conducted a study on the relationship between perceived support at work after TE and psychological distress among prehospital providers (e.g., emergency medical technician, paramedic); they concluded that formal peer support may reduce prehospital providers’ distress by increasing their sense of support from colleagues.

More studies are needed to demonstrate the effectiveness of peer helpers regarding the management of post-traumatic stress symptoms and the offering of psychosocial support in the aftermath of a TE ( Creamer et al. , 2012 ; Petri, Joyce et al. , 2018 ) and specifically among EMS ( Beshai and Carleton, 2016 ). Some researchers have proposed selecting peer support as an intervention modality in the implementation of Psychological First Aid (PFA— Brymer et al. , 2006 ; Ruzek et al. , 2007 ) in high-risk organizations ( Forbes et al. , 2011 ; Lewis et al. , 2014 ). PFA ( Brymer et al. , 2006 ; Ruzek et al. , 2007 ) was originally developed to help survivors exposed to disasters and terrorism. It is an interesting early intervention approach for managing mental health symptoms and providing psychosocial support ( WHO, 2013 ; Shah et al. , 2020 ). PFA can be provided by people trained in the PFA intervention even if they are not mental health professionals ( Ruzek et al. , 2007 ). Therefore, it may be relevant to use colleagues as providers, using the peer support model. Moreover, in contrast to psychological debriefing, PFA does not encourage first responders to disclose their emotional experience or give detailed description of the TE. PFA focuses on teaching recipients how to reduce acute arousal, identify immediate needs, adopt healthy coping strategies, and provide referral information if needed. Participation in PFA is also voluntary. Therefore, PFA tries to avoid the pitfalls of re-exposing first responders to the TE ( Bryant, 2021b ). Although the essential elements of PFA are documented in the trauma literature ( Hobfoll et al. , 2007 ), PFA as an intervention in and of itself is not part of any official recommendations ( NICE, 2018a ). As an evidence-informed approach, PFA aims to reduce the initial distress caused by a TE and foster short- and long-term adaptive functioning ( Ruzek et al. , 2007 ). The focus of PFA is on promoting safety, calmness, self- and collective efficacy, connectedness, and hope; together they form the five essential elements of immediate trauma intervention, according to experts ( Hobfoll et al. , 2007 ). PFA targets those who wish to receive support and allows for the early identification of those who will subsequently require further specialized help ( Ruzek et al. , 2007 ). It is now recommended to add a period of watchful waiting: actively monitoring a person who has been exposed to a TE to check for symptoms’ development or persistence ( NICE, 2018c ). The core actions of PFA, both in the immediate phase and post-immediate phase (active monitoring), are flexible and can be used only when needed. Even though PFA is a promising intervention, very few studies have examined its effectiveness in reducing post-traumatic stress symptoms, given the challenges of conducting studies in a traumatic context ( Fox et al. , 2012 ; Dieltjens et al. , 2014 ). To our knowledge, only two studies provided preliminary results indicating that PFA did not outperform the usual care but could provide a reasonable alternative ( McCart et al. , 2020 ; Ironson et al. , 2021 ).

Therefore, evidence on the effectiveness of PFA is still lacking, despite various frameworks and specific models being in the developmental stages for targeted populations ( Forbes et al. , 2011 ; Lewis et al. , 2014 ). For example, Forbes and colleagues (2011) proposed a stepwise PFA model for high-risk organizations. They provided a framework for implementing PFA calling for future research to experiment and evaluate their phased PFA model in high-risk organizational settings. Following this, Lewis and al. (2014) investigated the effectiveness of PFA training (using Forbes’s model) for managers and peer helpers in a high-risk organization regarding changes in knowledge about TE, PFA actions and self-reported skills and confidence to respond appropriately to a TE affecting colleagues. Results indicated that PFA training had the intended immediate effects of improving manager and peer helper knowledge and skills related to TE and PFA ( Lewis et al. , 2014 ). Results further suggest that the training improved participants’ self-perceived capacity to deliver PFA ( Lewis et al. , 2014 ). Some studies have also investigated PFA trainings in other emergency contexts, showing that PFA is a promising approach to improving providers’ confidence and competency in addressing post-traumatic needs ( Semlitz et al. , 2013 ; Chandra et al. , 2014 ; Akoury-Dirani et al. , 2015 ; Sijbrandij et al. , 2020 ).

In parallel with the necessity to examine the effectiveness of PFA through quantitative experimental studies ( Dieltjens et al. , 2014 ), it remains essential to explore the subjective experience of PFA recipients; especially regarding its perceived impacts and contributing characteristics as suggested by the original creators of PFA ( Ruzek et al. , 2007 ). These various queries on PFA intervention remain unexplored and would be best answered with qualitative studies. Researchers suggest new studies to include outcomes from the recipients’ perspective, by studying their experiences of receiving PFA ( Forbes et al. , 2011 ; Lewis et al. , 2014 ; Sijbrandij et al. , 2020 ). To our knowledge, only one study conducted an exploration of recipients’ experience with PFA in a humanitarian crisis context ( Schafer et al. , 2015 ). They found that recipients believed PFA provided the needed psychosocial support and assistance to foster coping and recovery after crisis events. The authors also highlighted the need for similar research in other contexts ( Schafer et al. , 2015 ). On this last point, interviews with recipients could shed light on the perceived short- and long-term effects of PFA but also the components make PFA a well-liked and beneficial intervention.

For the current study, we conducted semi-structured interviews with EMS workers who had recently received PFA after a TE exposure at work. Our objective was to explore with an inductive approach what was the perception of EMS recipients of the intervention. After an initial analysis of the participants’ transcriptions, we divided this objective into three research questions and reanalyzed interviews on this premise. As a result, we divided the overarching objectives into three specific objectives:

To determine what immediate needs of EMS workers exposed to a TE does PFA meet.

To identity the components that make PFA a valued and beneficial intervention.

To explore the perceived outcomes of their participation in the PFA intervention.

Participants

Participants were EMS workers (paramedics and emergency medical dispatchers) recruited from a Montreal’s EMS organization. Their organization had recently implemented a PFA program beginning in July 2018 ( Brymer et al. , 2006 ; Forbes et al. , 2011 ). The organization chose to use selected and trained colleagues to administer PFA (i.e., peer helpers). After exposure to a TE, EMS workers may individually receive PFA intervention in the next few hours or days. PFA program was implemented across the entire eligible worker population (paramedics and emergency medical dispatchers) in the organization. Each worker was free to request PFA or accept its offer. The inclusion criteria were to be fluent in French, to be currently at work, and to have received PFA 4 to 12 months prior the research interview (to reduce the risk of perspective bias and recall bias). All participants received PFA intervention prior to the COVID-19 outbreak. Participants were recruited on a voluntary basis. Even if this study was conducted with an opportunistic sampling, researchers tried to recruit a sample representative of workers in terms of gender, age, and type of job ( Paillé and Mucchielli, 2016 ).

All EMS workers who received PFA after a TE in the selected period were contacted by the occupational health and safety advisor to inform them of the study ( n = 39). The research team contacted only those who had previously agreed to share their contact information with the research team. The final sample comprised of 13 participants (see Table 1 ). They received the PFA intervention no later than 5 days after exposure to a TE at work and 11 to 5 months before the research interviews. The researchers ensured that participants had received PFA from different peer helpers in the organization to increase the representability of the PFA intervention (e.g., 11 different peer helpers have provided PFA interventions to our participants). Based on the concept of information power ( Malterud et al. , 2016 ), the quality of the information was considered sufficient after 13 participants. Information power dictates that the more information the sample holds, the fewer participants are needed.

Participant demographic and professional information.

Qualitative interview protocol

The purpose of the study, consent form, and confidentiality were explained to participants before to interviews. A short sociodemographic questionnaire was also filled. The individual semi-structured interviews took place from July to October 2020 and lasted between 45 and 60 min. They were conducted over the phone by the first author. Participants were asked to be in a quiet and confidential setting outside of their working hours. Researchers opted for telephone interviews as their data collecting method for practical reasons, especially regarding participant availability outside of work hours. Current evidence shows that telephone interviews do not produce lower quality data than face-to-face interviews ( Novick, 2008 ). All interviews were audio-recorded and later transcribed for analysis. Several strategies were used to enhance the reliability of the study: only one interviewer conducted all interviews, content saturation and sample diversity were employed as strategies to allow better transferability of the results ( Flick, 2014 ; Paillé and Muchielli, 2016 ). The interview schedule was developed based on open-ended questions about EMS workers’ general perception of PFA, the context, their expectations, the perceived impacts, and potential harm or default.

Data were analyzed using a thematic analysis. This type of analysis is commonly used in psychology and especially useful in descriptive qualitative studies ( Braun and Clarke, 2006 ). We applied an inductive thematic analysis perspective. This type of analysis allows an exploratory approach and to report on elements as perceived by the participants. We conducted inductive coding to identify emerging themes from the sample. We followed the six phases of thematic analysis for each research question: Familiarizing with the data—Generating preliminary codes—Searching for potential themes—Reviewing themes—Defining and naming themes—Producing the report ( Braun and Clarke, 2006 ; Nowell et al. , 2017 ). We performed a vertical analysis of each interview to identify the themes, followed by a horizontal analysis across the sample to identify the common themes and the differences between each interview. The three objectives were inductively inspired by the first analysis of the material. Indeed, first analysis revealed three main themes in participants’ interviews. To analyze the content of each theme in greater depth, given the rich content of the interviews, we decided to address these themes as three specific research questions. A second analysis was then conducted to identify subsequent themes and subthemes for each of these research questions. All transcripts were coded in a systematic manner by the first author. The last author reviewed the suggested themes; disagreements led to a reexamination of the data until agreement was reached. For the second analysis, the second author performed double coding. Cohen’s kappa was chosen to measure the intercoder reliability of themes as it is a strict measure ( Cohen, 1960 ). Coders suggested 22 subthemes using a random selection of 31% of the interview material ( McPhail et al. , 2016 ). The global Cohen’s Kappa was κ = 0.81 (SD = 0.1691). Kappa values between 0.40 and 0.60 are commonly considered satisfactory agreement, and values above 0.80 suggest perfect agreement ( Burla et al. , 2008 ). Our intercoder reliability is therefore considered highly sufficient to continue data interpretation. We used the QSR-NVivo V.12 software package for qualitative analysis and intercoder reliability.

The immediate needs met through PFA intervention

All participants were pleased with the intervention. They described a straightforward, suitable, and appropriate intervention that they would highly recommend to colleagues exposed to a TE. Researchers identified five recurrent themes describing specific immediate needs met by PFA intervention.

Recipients felt listened to and respected through PFA intervention

All participants highlighted that they felt listened to by PFA peer helpers. They were able to express their concerns, feelings, and apprehensions about the future freely. For example, several participants shared how feeling heard made them feel respected in their own experience of the TE.

The peer helper really took the time to listen to me. He was a non-judgmental person, which really helped me. (P6)

Recipients felt surrounded and supported through PFA intervention

All participants agreed that PFA allowed them to feel surrounded, supported, and accompanied after the TE exposure. They indicated that the intervention had enhanced their sense of belonging, which was described as an important element promoting resilience.

I felt supported. I remember when one of my colleagues called for a peer helper, they said: “There is no problem he can come now”. I really felt supported by my organization like we were not just numbers. I really felt like I was someone important. I really appreciated that. (P3)

Recipients felt understood through PFA intervention

Most participants indicated they were able to share common meanings of their experiences with PFA peer helpers. They appreciated the perception that what they had experienced during and after the TE was easily understood by the peer helper.

I think everybody can listen to someone, or give references, but this kind of understanding to say: “I hear you and I understand why you react like this, because it’s not easy to live such high levels of stress and adrenaline.” […]. Someone who is here to listen to you and to understand. We have some difficulties when we meet with a psychologist who is not from the same work environment. He can’t understand or put himself in our place. And it is annoying when you hear his reaction “oh my god, you shouldn’t have to go through this”, but for us it is our normal life. (P9)

Recipients felt calmed and reassured through PFA intervention

Most of the participants indicated that the PFA intervention helped them return to a calmer state and manage their stress reactions and concerns. PFA providers generated calmer state by being present, responsive, and normalizing.

It was really reassuring, especially because I felt that I could be 100% honest. It was really reassuring to be able to say to her “well today I am fine for real, I’m still a little scared but I’m less scared, I feel more comfortable”. For me it went well but if I put myself in the mental state I was in the day before, if I had had the same crisis the next day? It would have been reassuring to have someone checking up on me, to be sure that I was OK, to either wait for me to be able to talk together again as he had suggested or to take a day off and call each other on the phone. So, it is still very reassuring. (P9)

Recipients felt equipped through PFA intervention

Most of the participants reported feeling better equipped to deal with the outcomes of the TE. They described a better understanding of their stress reactions, feeling better able to handle future symptoms and to take action to enhance their mental health.

We explored some solutions. For me the next day was a day off. He told me “what are you going to do tomorrow?”. He gave me lots of solutions. He wanted to make sure I was OK emotionally […]. He also walked me through how I might feel both physically and mentally and to be alert of these signs. That’s good because we often miss out on those signs. […]. So we open our eyes on things we don’t often talk about. We can have a more careful look on what is happening around us. It is about educating ourselves. We are always in action mode but it’s important to know when something is wrong. (P10)

The components that make PFA a valued and beneficial intervention

Various components of the PFA intervention were identified by participants as valuable and beneficial to them. We categorized those specific components into characteristics of the provider and characteristics of the intervention itself. See Fig. 1 .

Themes and subthemes of the second research question.

Characteristics of the provider

Closeness between the recipient and the PFA peer helper

Almost all the participants addressed how closeness with the PFA provider was a significant factor promoting trust and engagement. For some of them, it was crucial they knew the peer helper beforehand (i.e., had worked with him, had heard of him). But for most of them, simply meeting with another EMS was enough. This shared knowledge about the job (i.e., technical terms, responsibilities, challenges, concerns, expectations) eased the partnership and enhanced trust and openness during the PFA intervention. For many participants, asking for help appeared to be more natural and less threatening with a peer than having to reach for a superior or a mental health professional.

The fact that they are our colleagues, they understand the what we work with. That is essential. The bond wouldn’t be the same if it was someone from the outside […]. There are lots of people in the work environment who are too proud. They appear like they never lose their temper. We are inhibited to show it when we are upset. When it’s people from the outside, the filter is still there. When we meet someone in an office, we have the time to regroup ourselves and show this person that it was not difficult and it is going to be OK […]. Someone who understands the work of EMS and knows how intense it can be... You know that you can trust this person when he gives you advise, because he’s sharing his lived experience. (P12)

Few participants issued a warning regarding the potential negative aspects of this same closeness. Some EMS workers feared adding to the workload or mental burden to their peer helpers colleagues, which may inhibit help-seeking behavior (e.g., asking to receive PFA).

When I knew he was a paramedic, I said to myself “s*%!. He has also lived through some things. I hope I won’t hurt him” […]. I thought, “will I awaken memories he had, interventions that look like mine, I don’t know”. […] It is conflicting because he understands my situation, but I am also afraid to affect him. (P3) PFA peer helpers have interpersonal qualities and competency to intervene

Most participants shared the perception that peer helpers are competent to provide PFA intervention and have the interpersonal qualities needed to that facilitate the relationship. Those characteristics particularly helped recipients to be trustworthy toward PFA intervention. They acknowledged the fact that peer helpers were selected and trained by a mental health professional, which increases their confidence in provider’s abilities. Participants also highlighted that, among interpersonal qualities, PFA peer helpers were generally well intentioned, calm, open, respectful, invested, patient, and empathetic. These qualities are portrayed as essential by recipients.

I think any peer helper could be good. They all have the same training. They are friendly and have tools to make us feel comfortable. They are here to listen to us, we can cry if we need to. They are really open and accessible It is really helpful. (P10) His ability to listen was very important for me and his openness, kindness and attention were sincere, I think. […] This is someone who is truly calm and attentive. You constantly see that he is there to help you. This is someone who looks at you with a benevolent eye and you feel his presence. His presence is here at 100%. (P3)

Characteristics of the intervention

Several components attached to the structure or content of the PFA intervention were described by participants as beneficial to them. We identified nine of them, organized in three different categories.

Components facilitating willingness to participate in PFA intervention PFA is easy to access

All of the participants affirmed that ease-of-access of PFA was an important factor in encouraging participation. This is reflected in the availability of PFA providers immediately after the TE, the visibility of PFA providers (e.g., wearing a distinctive sign from other EMS workers), or even in advertising by the organization.

Seeing that this person is available for you to talk to, decreases the stress that “I am going to bother someone that I don’t know to tell him I’m not OK”. This stress is not here anymore. At the same time, we can identify the peer helpers easily, it is written on the huge TV that there are PFA peer helpers in the central station. (P2) It is a really good point, they are easy to identify, we can turn to them at any time, any hour, and anywhere. (P13) Recipients don’t need to ask for assistance, just to accept it

Most of the participants highlighted that they appreciated not having to ask for PFA intervention. Stigma, pride, or lack of knowledge related to mental health was reported as inhibiting or delaying help-seeking. The fact that the PFA intervention was initiated or suggested by a manager or the PFA provider directly fostered acceptance and therefore participation according to participants.

The fact that it is often them who offer the help, it decreases the question of pride, it makes it feel OK to be shaken sometime in this job […]. I find it is a good thing that they take the lead, because it can happen. Especially in the beginning for the newcomers, we will all fall at least once […]. We all have a big sense of pride. We are trained and paid not to look stressed out. So when we live some stress that is not easy, sometimes it is like we don’t know how to handle this stress. […] We all know that PFA peer helpers exist, but I never see my colleagues say “I feel like talking to a peer helper right now”. If the peer helper hadn’t come and reached out to us, I think that all the problems would have remained buried inside us (P12) Privacy is assured

Most of the participants indicated that confidentiality and privacy during PFA intervention encourage participation and openness and genuineness with the PFA provider. The opportunity to have a secluded interaction from colleagues or managers was a crucial element of engagement for most participants.

Confidentiality from the employer is very important. Because those interventions stir up personal issues and you don’t want the employer to know about it. But with the peer helper you know that it’s going to stay between the two of you. You know that you are free to open up, and the employer isn’t going to know about it. (P10) PFA is flexible and tailored to the situation and participant needs

Most of the participants highlighted the fact that the PFA intervention was adaptable in terms of location (i.e., dedicated room, garage, hospital, ambulance). They also appreciated being able to address more personal issues, beyond the TE. They felt PFA was adapted to their needs and the realities of their work, which encouraged them to contact a PFA provider again if needed.

The first contact, I would say, was very informal. We were in the garage of the hospital, a little bit out of the way if you will, but it was in an informal setting. (P1) I was able to tell him where I was in my personal life, that for some time it had been building up and I was falling back on drugs and other problems. So, he offered me some resources to help me, and he encouraged me to go talk to a doctor. (P4) Valued types of assistance PFA allows to normalize elements related to the traumatic event

Most participants described PFA as a helpful intervention because it helped them normalize the situation. They talked about PFA providers normalizing their actions during the event, their stress reactions, their feelings, and normalizing their help-seeking behaviors. Normalization helped participants to reduce guilt after the TE. For example, they could put aside the issue of potential professional error and focus on the psychological recovery process from the TE.

We talked about my experience, about what happened, how I feel now. He reassured me about the fact that it is normal to feel like that, especially in those big interventions, that was my first day alone on the road […]. He reassures me about that, just having someone who talks to you about the “wall” (e.g., breaking point) we all experience. […] It is a wall we all hit, normally it is after a few months in your carreer, for me it was after my first day alone. But he explained to me that it was normal, that we often see that among paramedics. It is always the first wall that is the most difficult. He supported me, normalizing those things and reassuring me to accept what happened, that I don’t have to be ashamed. (p9) Practical help is offered in PFA intervention

Participants found helpful that PFA providers could also address some immediate needs and concerns such as filling out a document concerning the TE, call the psychologist for an appointment, inform the manager of their sick leave, or collect their personal belongings for them to return home.

What is also really good is that, at least with me, he managed everything after I left my post. […] I couldn’t do my shift anymore […]. The PFA peer helper handled the situation with the manager and took my stuff at headquarters, so I didn’t have to go back there for my bag and my headphone. The peer helper did all that. That was really helpful at the moment. It is really nice to have someone who can do this for you […] I didn’t have to go back there and explain everything by myself. It is helpful. (P11) Importance of timing and duration of PFA intervention PFA intervention is offered early on

The majority of the participants highlighted that the rapid deployment of the intervention was a key element in their participation and openness. Regarding the occupational culture, they reported that if the offer of PFA intervention had been delayed (e.g., several hours, next days), most EMS workers would be probably less psychologically available to talk about the aftermath of the TE.

I thought it was important to talk about it right now. Waiting would have only increased my worries, but the fact that I talked to him there, it reassured me for the next calls to know: ‘‘OK even if something happens, there is someone who has my back”. (P3)

However, one participant shared that an intervention proposed too early after the TE may decrease the chance for some EMS workers to identify traumatic consequences and to benefit fully from the intervention.

At that moment you don’t know what it is, you are so emotional. You don’t know what it is. After that, with hindsight, you say to yourself, “OK yes, maybe I would have liked to talk with a peer helper”, but maybe not there. As if in the moment you had to live your emotion and then the peer helper can come, without you really asking for him. You have no choice but to speak, but you were still confused, your ideas are not clear in your head [...]. They should say that in the next 24 hours a PFA peer helper will contact you if you want. […] Sometimes it seems like everything happens too fast. Which is good at the same time because some people need the support right away but maybe in my situation it’s like everything happened too fast. (P8) Follow-up is provided by PFA intervention

Regarding the follow-up, most participants saw value in the monitoring symptoms beyond one session, during the following days. They named that stress reactions evolved over time, perception regarding their own situation sometimes changed and that they felt reassured to know a follow-up was scheduled. Some asked for a longer follow-up period to the PFA peer helper (n.b., a phone call is scheduled after 48 h in the studied organization).

I think this is good. It is a validating follow-up 48 hours later. But it would take a second follow-up a little later or even do a third one. Let’s say a week later, but the follow-ups are something constructive that should not be canceled. [...] That TE took me three or four days to really decompress, to move on. I was really in a state where, let’s admit it, my girlfriend was trying to talk to me, but I found it heavy to be asked how things were going and this and that... (p13)

The outcomes of participating in PFA intervention

Longer-term outcomes of participating in PFA intervention were also described by participants. Beyond immediate impacts, such as needs fulfilled by PFA intervention, participants indicate three types of outcomes for the days or months to follow, related to their participation in PFA intervention.

PFA fosters demand for and access to psychosocial resources

All participants agreed that participating in the PFA intervention encouraged and guided participants toward further help-seeking. Some used psychosocial resources to deal with the consequences of the TE or to take care of general psychosocial issues usually ignored. Some participants saw a psychologist or a doctor, contacted their employee assistance program, or used mental health apps. They were also likely to ask to see a PFA provider again if needed or even encouraging colleagues to ask for PFA intervention after a TE.

It’s the peer helpers who pushed me to consult the psychologist because it’s the same thing, when you don’t know someone, I said to myself “well, maybe she’s busy with other things”. You don’t want to disturb her and then you say to yourself “well, it’s not that serious, there are others with more important problems”. The PFA peer helpers here, they were the ones who pushed me to say “no, you will see, she will listen to you, and if you don’t like it, well you don’t like it. At that point, you don’t have to see her again, but try because you will see, she may have some things to help”. They were the ones who pushed me to see the psychologist at [organization’s name]. The PFA peer helper followed up with me and it was a real breakthrough in the sense that after that I went to see the psychologist. This is something that my work partner could not have done. (P8)

PFA improves destigmatization of mental health issues

Regarding perceptions of mental health issues, most of the participants indicated that the PFA intervention helped them destigmatize post-traumatic stress reactions or more general mental health concerns. They reported that EMS workers may tend to dismiss or be critical of mental health issues and that PFA intervention led them to be more considerate and less judgmental about personal or a colleague’s mental health issues.

For me, everything about mental health is important, and I see a lot of changes. A lot of paramedics are comfortable talking about it now too. Mainly because there are people among us who help us, who guide us. As far as I’m concerned, it’s something that should be implemented in all emergency professions. Because I think it provides a different kind of psychological support. (P9)

PFA enables faster and more efficient return to work

Most of the participants highlighted that the PFA intervention enabled them to make a faster and more efficient return to work. They described being able to go through the aftermath of the TE more easily. They also reported that not receiving the PFA intervention would have likely increased their worries related to the event as well as their abilities to be a competent EMS worker again, making them more at risk for post-traumatic reactions in subsequent work interventions. Two of them reported that PFA intervention had probably prevented them from leaving their job.

I went into the manager’s office and was on my way to resign. The stress was way too much for me [after a TE]. I was wondering if I really wanted to do this for the rest of my life, being stressed out like this. That’s when the peer helper was called. From that moment on, I realized that I was having a panic attack, and under the effect of the shock and the first time a patient had a cardiorespiratory arrest in front of me. So, it was more about talking about all that and normalizing it in the context of our work [...]. For me, the experience that I had with him, it probably made it so that I still have my job today, and that I love my job so much. (P9)

The aim of this study was to explore the perception of EMS recipients on PFA interventions. Using inductive thematic analysis, the focus was on answering three research questions: to determine what immediate needs of EMS workers exposed to a TE does PFA meet: to identity the components that make PFA a valued and beneficial intervention; to explore the perceived outcomes of their participation in the PFA intervention. Results indicated that PFA intervention was appreciated by and perceived as beneficial to EMS workers in the short and longer term. Specific components enhanced the positive perception of the PFA intervention when it tailored to the needs of workers.

Immediate needs met through PFA intervention are consistent with early interventions principles

Participants reported that the PFA intervention addressed some of their needs just after exposure to a TE. These results are in line with the only field research aiming to identify the benefits of PFA using qualitative analyses in a humanitarian crisis context ( Schafer et al. , 2015 ). Their results showed, congruently with the present study, that PFA could promote safety, enable calming strategies, improve social connections, and give a greater sense of control and hope to recipients.

Moreover, these needs described by our participants are congruent with early intervention principles suggested by the disaster literature to promote coping and recovery after a TE ( Hobfoll et al. , 2007 ). There is overlap between Hobfoll’s five principles and the needs identified by our participants. The feeling of being listened to and respected may be linked with the sense of safety proposed by Hobfoll. Recipients felt safe and able to talk about the event. Their unique and individual experience was respected during the PFA intervention, they did not feel judged or inadequate. The feeling of being surrounded and supported echoes the concepts of connectedness and the collective efficacy named by Hobfoll. Indeed, participants felt that the PFA intervention enhanced social support perceptions and minimized isolation. PFA intervention informs recipients of resources available, making them feel supported. The feeling of being understood is related to connectedness also. Participants felt they were talking to someone who shared their experience. The feeling of being calm and reassured through PFA intervention is more directly linked to the sense of calming identified by Hobfoll. Finally, the feeling of being equipped can be associated with Hobfoll’s concept of self-efficacy and hope. Participants reported feeling able to cope and to take action. In this manner, the PFA intervention appears to have enhanced their perceived control and encouraged their positive coping behaviors.

As suggested by researchers ( Hobfoll et al. , 2007 ; Shultz et al. , 2014 ; Schafer et al. , 2015 ), it is important to assess if the PFA intervention addresses Hobfoll’s five essential principles to ensure that this intervention is suitable as an early post-traumatic intervention. The immediate needs described by our participants suggest that the PFA intervention is a good way to operationalize these core principles (see Fig. 2 ).

Matching between Hobfoll’s early intervention principles and the immediate needs met through PFA intervention in this study.

Recommendations for implementation in high-risk organizations based on the elements that make PFA a valued and beneficial intervention

Several papers about PFA intervention or early post-traumatic interventions in general encourage new studies to identify key components of each intervention to make recommendations for future implementation and adaptation in various contexts ( Hobfoll et al. , 2007 ; Ruzek et al. , 2007 ; Shultz et al. , 2014 ; Richins et al. , 2020 ). Collecting the perceptions of recipients is a good way to unravel specific elements in PFA intervention that are particularly appreciated, fostering acceptability, and participation ( Ruzek et al. , 2007 ).

Some components were related to characteristics of the provider. Participants placed a lot of importance on PFA providers being co-workers (paramedics and emergency medical dispatchers). Sharing experience of the job eased the partnership and enhanced trust and openness. This finding is consistent with the literature about peer support in high-risk organizations ( Creamer et al. , 2012 ; Lewis et al. , 2014 ; Richins et al. , 2020 ). Peer helpers are considered ideally placed to provide post-traumatic support as an initial point of contact within the organization ( Creamer et al. , 2012 ; Lewis et al. , 2014 ; NICE, 2018c ). The use of peer helpers is recently acknowledged as one of the recommendations for optimal effectiveness of early post-traumatic intervention in emergency response organizations ( Richins et al. , 2020 ). However, our participants also highlighted that some EMS workers may be particularly mindful to their colleague’s distress and may feel compelled to restrain from asking for help as to know awaken their traumatic memories. This finding is in accordance with literature that advises how important it is to look after the peer helpers to avoid heavy workload or mental burden ( Creamer et al. , 2012 ). The other component directly related to peer helpers is the importance of competency to intervene and interpersonal qualities. Participants described those characteristics as significant elements allowing to invest and be trustworthy toward PFA intervention. The result echoes Creamer and colleagues’ (2012) recommendations about selection, training, and accreditation of peer helpers to enhance peer support in improving psychosocial outcomes.

Some components were related to characteristics of PFA intervention itself. Participants described components that increased their willingness to participate in the PFA intervention: easy to access, no need to ask for assistance, assure privacy as well making efforts to render the intervention flexible and tailored. These subthemes are a reminder of the vulnerability of help-seeking behaviors for EMS workers. They highlight the essential need to facilitate the help-seeking process to minimize stigma ( Haugen et al. , 2017 ). These results offer us a first glance as how to improve participation; our participants asked for an easy-to-access, flexible, and tailored intervention, initiated by PFA provider, where confidentiality and privacy are offered. These directions are congruent with findings from the larger literature that recommend psychosocial intervention to be culturally tailored to first responders’ needs and concerns ( Lanza et al. , 2018 ; Richins et al. , 2020 ). Furthermore, being visible and available, initiating contact after observation, being careful about confidentiality, ensuring a flexible delivery, as well as being culturally informed are elements included in original Brymer’s guidelines for delivering PFA ( Brymer et al. , 2006 ). Those recommendations appear therefore to be empirically validated by our participants.

Results showed some valued types of assistance received by our participants. Normalization and practical help emerge spontaneously as two valuable and beneficial types of assistance according to PFA recipients’ perceptions. Rumination and catastrophizing are frequent after exposure to a TE ( Ehlers and Clark, 2000 ). It may also appear for EMS workers, rumination about their professional skills during the TE and their ability to continue working ( Haugen et al. , 2017 ). Therefore, normalization trough psychoeducation and shared experiences is highly appreciated by EMS workers, and reduces affiliated stigma ( Haugen et al. , 2017 ). Normalization is also linked to an enhanced sense of calm, connectedness, and hope after a TE ( Hobfoll et al. , 2007 ; Ruzek et al. , 2007 ). To offer practical assistance is one of the core actions in PFA intervention ( Brymer et al. , 2006 ). Furthermore, being in an organizational context, exposed EMS workers have a lot of obligations following a TE (i.e., complete their shift, inform their manager, fill paperwork). This may explain why practical help is appreciated since it lets them focus on their mental health and relieves them of their professional obligations. This tangible and action-oriented type of assistance is also attuned with EMS culture ( Halpern et al. , 2009 ; Donnelly et al. , 2015 ) and creates a sense of connectedness after a TE ( Hobfoll et al. , 2007 ).

Finally, timing and duration of the PFA intervention were also reported as important, valuable, and beneficial components. Most participants appreciated that the PFA intervention was offered early (e.g., first hours) after the TE. They indicated that the period of psychological availability is rather short as EMS work requires setting aside negative emotions while performing their job. Regarding when to intervene, no specific timing was given by PFA guidelines ( Brymer et al. , 2006 ; Ruzek et al. , 2007 ) and there are opposing views in the trauma literature ( Roberts et al. , 2019 ; Bryant, 2021a ). Therefore, we may recommend working with participants’ needs and their organizational culture (i.e., culture of emergency) and adapt PFA intervention accordingly. This recommendation is consistent with PFA guidelines ( Ruzek et al. , 2007 ) that state that PFA was designed to be culturally informed. It is also in line with a recent scoping review of early post-traumatic interventions in high-risk organizations ( Richins et al. , 2020 ) that encourages early interventions to be tailored to the needs of the population to support emergency responders following a TE exposure. Regarding follow-up calls, participants valued this safety net over time and considered it beneficial for their recovery. Indeed, more and more authors recognize the importance of multiple sessions or at least active monitoring over time for early post-traumatic interventions, as previous reviews have found that single session interventions have not always been effective at preventing PTSD ( NICE, 2018c ; Roberts et al. , 2019 ). Knowing that support is available over time provides a protective factor and facilitates recovery ( Prati and Pietrantoni, 2010 ) as well as it maintains the sense of connectedness ( Hobfoll et al. , 2007 ).

Benefits over time as outcomes to participation in PFA intervention

Three perceived impacts were described by our participants. It appears that PFA fosters demand for and access to psychosocial resources according to all participants. Recipients’ positive experiences and the recommendations for future resources made by PFA providers had a positive impact on their willingness to seek help. This finding indicates that PFA may help to reduce the stigma associated with mental health and therefore to lower the barriers to help-seeking behaviors among EMS workers ( Haugen et al. , 2017 ).

Most of our participants described how the PFA intervention helped to destigmatize post-traumatic stress reactions and more general mental health concerns. The PFA intervention helped to reduce systemic and internalized stigma regarding mental health issues and seeking-help behaviors as it is expected from a mental health intervention among first responders ( Lanza et al. , 2018 ; Szeto et al. , 2019 ; Wild et al. , 2020 ). PFA fosters sensitivity and understanding among EMS workers regarding mental illness.

The third outcome reported by some recipients was how PFA intervention enabled faster and more efficient return to work, according to them. Beyond reducing distress, early post-traumatic intervention, in an organizational context, is expected to help respond to more organizational needs such as reducing levels of sick leave and turnover and improving workplace performances ( Forbes et al. , 2011 ; Richins et al. , 2020 ). By responding to EMS workers needs early on after the TE, our findings suggest that PFA intervention may have organizational benefits (e.g., faster and more efficient return to work), which is a favorable argument for its development in high-risk organizations.

The matter of the medium- to long-term impacts of PFA is a topical one. As a psychosocial intervention, the goal of PFA is not specifically a reduction in terms of symptoms, unlike psychological debriefing (which is now recognized in research as something to be avoided following a TE— van Emmerik et al. , 2002 ; Petri, Joyce et al. , 2018 ). The goal of PFA is to reduce initial distress and facilitate adaptation over time, for example, through practical assistance, focusing on meeting needs, and adaptative coping strategies ( Ruzek et al. , 2007 ). Interviews shedding light on the perceived impacts of PFA may help to detail the actual benefits of this intervention and to better understand what to measure in future quantitative studies regarding effectiveness of PFA ( Schafer et al. , 2015 ).

These three research questions helped to answer the general objective of this study regarding EMS recipients’ perception of PFA intervention delivered by peer helpers. Largely positive perceptions were described by participants indicating that EMS workers are eager for early intervention to help them through the TE exposures. As suggested by the creators of PFA ( Ruzek et al. , 2007 ), it appears that the PFA intervention delivered by peer helpers in EMS context helps to decrease immediate distress as well as to facilitate adaptation over time. This is especially true when the intervention is flexible and tailored to the needs of the targeted population. PFA also appears to have positive organizational outcomes. The PFA intervention may be tailored to the specificity of the organizational context (i.e., easy, and timely access).

This study also has limitations. First, the opportunistic sampling strategy and its small size may lead to limited diversity of the population under study. The objective of qualitative research is not the generalizability of its results. Given this, researchers aimed for a reflective exploration of recipients’ experience of receiving PFA. Second, the self-report method is susceptible to lead to social desirability effects that may influence perceptions. Similarly, self-selection may have led those who benefited most from PFA to participate, thereby excluding those who did not recognize a beneficial effect or who perceived negative effects from PFA. We believe that voluntary exploration of negative cases could have enhanced the quality of our results, leading to more diverse perceptions of the PFA intervention, although obtaining voluntary participants who did not appreciate the intervention is challenging in an organizational context. Finally, the organization under study has decided to offer PFA intervention using a peer support system; therefore, our results are to be considered only when those two elements are combined.

Using qualitative analysis, this study aimed to capture recipients’ experiences of receiving PFA after exposure to a TE at work. These findings may help to better understand the benefits of implementing PFA interventions within high-risk organizations, selecting a peer support model. While PFA should take place on a larger continuum of services, it appears to be an appreciated and beneficial first step for supporting EMS workers. Not considered as a treatment for PTSD, the results suggested that it fulfilled post-traumatic needs and fostered adaptive functioning ( Brymer et al. , 2006 ; Ruzek et al. , 2007 ). Future studies should consider and assess PFA as part of a larger mental health offering (i.e., with psychological, social, organizational impacts) and refrain to focus only on PTSD symptoms reduction. These qualitative findings may contribute to inform further research about PFA in other high-risk settings. It may also inform quantitative studies aiming to test PFA’s efficacy.

The project has ethical approval (CER-CEMTL 2019-1884) from the ethics committee of Integrated University Health and Social Services Centre for the East Island of Montreal. Participants were informed of the process and intentions of the research, provided free, and informed consent, and were administered with personal codes for anonymity.

This research was funded by the Canadian Institutes of Health Research, Catalyst Grant: Post-Traumatic Stress Injuries among Public Safety Personnel/Subvention, grant number: PPS-162535. The first author received a scholarship from the Fonds de Recherche du Québec - Société et Culture (FRQSC), grant number: B2Z-299287. This study was also funded by a career grant awarded to the last author by the Fonds de recherche du Québec–Institut Robert-Sauvé en Santé et Sécurité au Travail, grant number: 268274. The APC was funded by Canadian Institutes of Health Research.

The authors declared no potential conflicts of interest with respect to the research, authorship, or publication of this article. There were no sources of funding that could have influenced the outcome of the submitted work.

The data underlying this article cannot be shared publicly to protect the confidentiality of participant information, the University Institute of Mental Health of Montreal will not allow the authors to make data publicly available. The data will be shared on reasonable request to the corresponding author.

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The Use of Psychological First Aid in Children Exposed to Mass Trauma

• Child and Family Disaster Psychiatry (B Pfefferbaum, Section Editor)
• Published: 07 July 2021
• Volume 23 , article number  53 , ( 2021 )

Cite this article

• Renee Gilbert 1 ,
• Madelaine R. Abel 1 ,
• Eric M. Vernberg 1 &
• Anne K. Jacobs 2  

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Purpose of Review

Psychological first aid (PFA) has been widely disseminated and promoted as an intervention to support short-term coping and long-term functioning after disasters. Despite its popularity, earlier reviews cite a startling lack of empirical outcome studies. The current review explores recent studies of PFA, especially pertaining to its use with children.

Recent Findings

Initial studies of PFA show that it is well received by youth, families, and providers as well as being linked to decreases in depressive and posttraumatic stress symptoms, improved self-efficacy, increased knowledge about disaster preparedness and recovery, and enhanced feelings of safety and connection. The flexibility of the modular style of PFA and cultural adaptations emerged as significant themes.

Although the studies reviewed cast a favorable light on PFA, more research is needed regarding its use and outcomes. This review describes the challenges to conducting these studies as well as suggestions for paths forward.

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Gilbert, R., Abel, M.R., Vernberg, E.M. et al. The Use of Psychological First Aid in Children Exposed to Mass Trauma. Curr Psychiatry Rep 23 , 53 (2021). https://doi.org/10.1007/s11920-021-01270-8

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Accepted : 27 May 2021

Published : 07 July 2021

DOI : https://doi.org/10.1007/s11920-021-01270-8

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