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This Psychological First Aid Field Operations Guide has been under development by the Terrorism Disaster Branch of the National Child Traumatic Stress Network and the National Center for PTSD. Although not a final document, the present version is being released to meet the need for guidelines and strategies for early assistance to so many affected by Hurricane Katrina. Members of the National Child Traumatic Stress Network and the National Center for PTSD, as well as other individuals involved in coordinating and participating in disaster response, have contributed to the current document.
The principal authors (in alphabetical order) included: Melissa Brymer, Chris Layne, Robert Pynoos, Josef Ruzek, Alan Steinberg, Eric Vernberg, and Patricia Watson. Special contributors included: Steve Berkowitz, Jessica Hamblen, Julian Ford, Laura Gibson, Robin Gurwitch, Anne Jacobs, Robert Macy, William Saltzman, Janine Shelby, Merritt Schreiber, Betty Pfefferbaum, Cynthia Whitham, Bonita Wirth, and Bruce Young.
A SAMHSA-supported expert review panel was convened on March 31-April 1, 2005. Participants made invaluable contributions. Those attending included: Miksha Brown, Cecilia Revera-Casale, Kerry Crawford, Rosemary Creeden, Daniel Dodgen, Darrin Donato, William Eisenberg, Mary Fetchet, Ellen Gerrity, Richard Gist, Ian Gordon, Susan Hamilton, Seth Hassett, Jack Herrmann, Stevan Hobfoll, Stacia Jepson, Sandra Kaplan, Susan Ko, Linda Ligenza, Steven Marans, Christina Mosser, April Naturale, Elana Newman, Bonnie O'neill, Dory Reissman, Gilbert Reyes, and Robert Ursano.
For citation: National Child Traumatic Stress Network and National Center for PTSD, Psychological First Aid: Field Operations Guide, September, 2005.
If you use these guidelines to provide assistance to hurricane survivors, please notify Melissa Brymer at the National Center for Child Traumatic Stress or Patricia Watson at the National Center for PTSD.
For more information and resources on the hurricane recovery, please go to the websites of the National Child Traumatic Stress Network (NCTSN.org ) and the National Center for PTSD (NCPTSD.va.gov )
Psychological First Aid
Table of Contents
Introduction and Overview
Preparing to Deliver Psychological First Aid
Core Actions
Introduction and Overview of Psychological First Aid
What is Psychological First Aid?
Psychological First Aid is an evidence-informed modular approach for assisting 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. Principles and techniques of Psychological First Aid meet four basic standards. They are: (1) consistent with research evidence on risk and resilience following trauma; (2) applicable and practical in field settings; (3) appropriate to developmental level across the lifespan; and (4) culturally informed and adaptable.
Who is Psychological First Aid For?
Psychological First Aid intervention strategies are intended for use with children, adolescents, parents/caretakers, families, and adults.
Who Delivers Psychological First Aid?
Psychological First Aid is designed for delivery by mental health specialists who provide acute assistance to affected children and families as part of an organized disaster response effort. These specialists may be imbedded in a variety of response units, including first responder teams, incident command systems, primary and emergency health care providers, school crisis response teams, faith-based organizations, Community Emergency Response Teams (CERT), Medical Reserve Corps, the Citizens Corps, and disaster relief organizations.
When Should Psychological First Aid Be Used?
Psychological First Aid provides a guide for mental health specialists in the immediate wake of disasters. Where Should Psychological First Aid Be Used? Psychological First Aid is designed for delivery in diverse settings. Sites may include shelters, schools, hospitals, homes, staging areas, feeding locations, family assistance centers, and other community settings. Following weapons of mass destruction (WMD) events, Psychological First Aid may be delivered in mass casualty collection points, hospitals, and in field decontamination and mass prophylaxis locations.
Strengths of Psychological First Aid
Basic Objectives of Psychological First Aid
Delivering Psychological First Aid Professional Behavior
Guidelines for Delivering Psychological First Aid
Working With Children and Adolescents
Some Behaviors to Avoid
Preparing to Deliver Psychological First Aid
In order to be of assistance to disaster-affected communities, the provider must be knowledgeable about the nature of the event, the post-event circumstances, and the type and availability of relief and support services.
Entering the Setting
Psychological First Aid begins when a disaster mental health specialist enters an emergency management setting in the aftermath of a disaster. Successful entry involves working within the framework of an authorized Incident Command System (ICS) in which roles and decision-making are clearly defined. It is essential to establish communication and coordinate all activities with authorized personnel or organizations that are managing the setting. Effective entry also involves orienting yourself to the setting (e.g., leadership, organization, policies and procedures, security, psychiatric support) and available services. As you provide Psychological First Aid, you need to have accurate information about what is going to happen, what services are available, and where services can be found. This information needs to be gathered as soon as possible, given that providing such information is often critical to reducing distress and promoting adaptive coping.
Providing Services
In some settings, Psychological First Aid may be provided in designated areas. In other settings, Psychological First Aid providers may circulate around the facility to identify those to be approached for assistance. Focus your attention on how people are reacting and interacting in the setting. Individuals who may need assistance include those showing signs of acute distress. This includes individuals who are:
Decide who may need assistance or would benefit most from contact with you, and plan for how to contact them within the time and constraints of the setting.
Maintain a Calm Presence
People take their cue from how others are reacting. By demonstrating calmness and clear thinking, you can help survivors feel that they can rely on you. Others may follow your lead in remaining focused, even if they do not feel calm, safe, effective, or even hopeful. Psychological First Aid providers often model the sense of hope that affected persons cannot always feel while they are still attempting to deal with what happened and current pressing concerns.
Be Sensitive to Culture and Diversity
Sensitivity to culture and ethnic, religious, racial, and language diversity is central to providing Psychological First Aid. It is critical to both outreach efforts and service provision. Providers should be aware of their own values and prejudices, and how these may coincide or differ with those of the community being served. Helping to maintain or reestablish customs, traditions, rituals, family structure, gender roles, and social bonds is important to helping survivors cope with the impact of a disaster. Information about the community being served, including how emotions and other psychological reactions are expressed, attitudes towards governmental agencies, and receptivity to counseling, should be gathered with the assistance of community cultural leaders who represent and best understand local cultural groups.
Be Aware of At-Risk Populations
Individuals that are at special risk after a disaster include:
The prevalence of exposure to pre-disaster trauma may be higher among economically disadvantaged populations. As a consequence, minority and marginalized communities may have higher rates of pre-disaster trauma-related mental health problems, and are at greater risk for developing problems following disaster. Mistrust, stigma, fear (e.g., fear of deportation), and lack of knowledge about disaster relief services are important barriers to seeking, providing, and receiving services for these populations. Those living in disaster-prone regions are more likely to have had prior disaster experiences, although having dealt well with a disaster in the past may be helpful in the current situation.
Psychological First Aid Core Actions
These core goals of Psychological First Aid constitute the basic objectives of providing early assistance (e.g., within days or weeks following an event). These objectives will need to be addressed in a flexible way, using strategies that meet the specific needs of children, families and adults. The amount of time spent on each goal will vary from person to person, and with different circumstances according to need.
Goal: To respond to contacts initiated by affected persons, or initiate contacts in a non-intrusive, compassionate, and helpful manner.
The first contact with a survivor is important. If managed in a respectful and compassionate way, it can help establish an effective helping relationship and increase the person's receptiveness to further help. Your first priority should be to manage contacts with persons who seek you out, especially if a number of people approach you simultaneously. Make contact with as many individuals as you can. Often this will be very brief, but even a brief look of interest and calm concern from another person can be grounding and helpful to people who are feeling detached or overwhelmed.
Culture Alert: The type of physical or personal contact that is appropriate may vary from person to person and across cultures and social groups, for example, how close to stand to someone, how much eye contact to make or how acceptable it is to touch someone. You should look for clues to a survivor's need for "personal space," and be informed about cultural norms through community cultural leaders who best understand local customs.
Others will not seek your help but may benefit from assistance. When you identify such persons, timing is important. Do not interrupt conversations. You may try to make nonverbal contact first (e.g., by returning eye contact). Do not assume that people will respond to your assistance with immediate positive reactions. It may take time for some survivors or bereaved persons to feel some degree of safety, confidence and trust. If an individual declines your offer of help, respect his/her decision and indicate when and where Psychological First Aid providers will be available later on.
Introduce Yourself/Ask about Immediate Needs
Introduce yourself with your name and title, and describe your role. Ask for permission to talk to them, and explain your objective of finding out whether there is anything you can do to make things easier, or helping with ways to help themselves feel better. Unless given permission to do otherwise, address adult survivors using last names. Invite the person to sit, try to ensure some level of privacy for the conversation, and give the person your full attention. Speak softly and calmly. Refrain from looking around or being distracted. Find out whether there is any pressing problem that needs immediate attention. Immediate medical concerns have the utmost priority.
| Adult/ Caregiver | Hello. My name is ___________. I work with __________. We're checking in with people to see how they are doing, and to see if we can help in dealing with the current situation. Is it okay that we speak? May I ask your name? Mrs. Williams, before we talk, is there something right now that you need, like some water or fruit juice? |
| Adolescent/ Child | And is this your daughter? (Get on child's eye level, smile and greet the child, using her/his name and speaking softly.) Hi Lisa, I'm ___________ and I'm here to try to help you and your family. Is there anything you need right now? There is some water and juice over there, and we have a few blankets and toys in those boxes. |
When making contact with children or adolescents, it is good practice to make a connection with a parent or accompanying adult to explain your role and seek permission. When speaking with a child in distress when no adult is present, it is important to find a parent or caregiver to let them know about your conversation.
Goal: Enhance immediate and ongoing safety, and provide physical and emotional comfort.
Restoration of a sense of safety is an important goal in the immediate aftermath of disaster. Comfort and a sense of safety can be supported in many ways. Some strategies to accomplish this include:
Ensure Immediate Physical Safety
Make sure that individuals and families are physically safe to the extent possible in the situation at hand. If necessary, re-organize the immediate environment to increase physical and emotional safety. For example:
If there are medical concerns requiring urgent attention, contact the appropriate unit leader or medical support immediately. Remain with the affected person or find someone to stay with the affected person until help can be obtained. Other safety concerns involve:
Enhance Sense of Predictability, Control, Comfort, and Safety
Information can help to re-orient and comfort children and families, and can include information about:
In providing information:
Provide Simple Information about Disaster Response Activities and Services
Ask survivors if they have any questions about what is going to happen, and give simple accurate information about what they can expect. Be sure to ask about concerns regarding current danger and safety in their new situation. Try to connect survivors with information that addresses these concerns. If you do not have specific information, do not guess or invent information in order to provide reassurance. Instead, develop a plan with the person for ways you and he/she can gather the needed information. Examples of what you might say include:
| Adult/ Caregiver /Adolescent | From what I understand, we will start transporting people to the shelter at West High School in about an hour. There will be food, clean clothing, and a place to rest. Stay in this area. A member of the team will look for you here when we are ready to go. |
| Child | Here's what's going to happen next. You and your mom are going to go together soon to a place called a shelter, which really is just a safe building with food, clean clothing, places to rest, and where you can play with toys if you want to. Stay here close to your mom until people are ready to go. |
Do not reassure people that they are safe unless you have definite factual information that this is the case. For example, you may say:
| Adult/ Caregiver | Mrs. Williams, I want to assure you that you are in good hands. The fire has been contained, and you and your family are not in danger from the fire. Do you have any concerns about your family's safety right now? |
| Adolescent | We're working hard to make you and your family safe. Do you have any questions about what happened, or what is going to be done to keep everyone safe? |
| Child | Your mom and dad are here, and many people are all working hard together so that you and your family will be safe. Do you have any questions about what we're doing to keep you safe? |
Attend to Physical Comfort
Look for simple ways to make the physical environment more comfortable. If possible, consider things like temperature, lighting, air quality, access to furniture, and how the furniture is arranged. In order to reduce feelings of helplessness or dependency, encourage affected persons to participate in getting things needed for comfort (e.g., offer to walk over to the supply area with the person rather than fetching supplies for them). Help them regain or exercise their ability to soothe and comfort themselves and others around them. For children, toys like soft Teddy Bears that they can hold and take care of, can help them to soothe themselves. You can help them learn how to take care of themselves by explaining how they can "care" for their toy, (e.g., "Remember that she needs to drink lots of water and eat three meals a day - and you can do that too."
Promote Social Engagement
Facilitate proximity to other people as appropriate. It is generally soothing and reassuring to be near other people who seem to be coping adequately with the situation. On the other hand, it is upsetting being near others who appear very agitated and emotionally overwhelmed. If they have heard worrying information from others or circulating rumors, help to clarify these and correct misinformation.
Children, and to some extent adolescents, are particularly likely to look to adults for cues about safety and appropriate behavior. When possible, place children near adults or peers who appear relatively calm given the circumstances, and shield them from close proximity to highly distressed individuals. Offer brief explanations to children and adolescents who have observed extreme reactions in other survivors.
| Child/ Adolescent | "That man is so upset that he can't calm down yet. Someone from our team is trying to help him calm down." |
As appropriate, encourage people who are coping adequately to talk with others who are currently distressed or not coping as well. Those coping adequately may have concerns about being burdened by others' fears and anger. However, you can reassure them that talking to people, especially if the conversation focuses on things that people hold in common (for example, coming from nearby neighborhoods or sharing new information), can help them support one another. This often reduces a sense of isolation and helplessness in both parties. If feasible, provide access to age-appropriate materials that foster soothing activities. For children, encourage social activities like reading out loud, doing a joint art activity, and playing cards, board games, or sports.
Attend to Children Who Are Separated from their Parents
Parents play a crucial role in children's perceived sense of safety following disasters. In the event that children are separated from their parents, helping them reconnect quickly is a priority. Try to help create a sense of security for children while their parents are being located or during periods of time where parents may become emotionally overwhelmed and are thus not emotionally accessible to their children.
For children separated from parents, help to create a designated child-friendly space. This can be a corner or room, ideally separate from rescue activities, warm, and with one door to control those who come in and out. Pre-prepared kits with toys, paper and markers, books, etc. are helpful. Examples of calming, soothing, reassuring activities that have been found to be useful are playing with Legos or other basic building materials, using play dough, doing cut-outs or other simple art projects that keep the hands busy, and working on coloring books (containing neutral scenes of flowers, rainbows, trees, or cute animals). Arrange for this space to be staffed with providers who are known and respected, who can help supervise activities that foster engagement, active interaction, and education at the appropriate developmental level. That person should be able to promote calmness among those children. Older children may be engaged as mentors/role models for younger children, as appropriate. Do not make any promises that you may not be able to keep, such as promising that they will be with their parents soon. Do provide accurate information in easy-to-understand terms so that the children will know who will be supervising them and what activities to expect next.
In addition to securing the children's physical safety, it is also important to protect them from exposure to additional traumatic stimuli including and sights, sounds, or smells that may be frightening. One psychologist working with a fire department described how responders would use their big yellow coats to help shield the child from traumatic sights while leading them to a safe place. The "big coat" analogy is an important one to keep in mind, as you will temporarily become that cover for the child. Use this time to find out the children's names, state your understanding of the situation, and reassure them that you are taking them to a safe place while adults work to connect them with their families.
In selecting a safe place for the children to rest while family members are located, think again about shielding them with a big coat. Try to find a place that is out of high-traffic areas. Even if you are positioned away from the injured and dead, children are likely to become distressed watching adults rush around in their rescue efforts. Finding rooms or structures to serve as walls can protect children from traumatic stimuli as well as help them focus on calming and reassuring activities.
Protect from Additional Traumatic Experiences and Trauma Reminders
Protect survivors from unnecessary exposure to additional trauma and trauma reminders (e.g., reduce exposure to the suffering of others). Psychological First Aid providers should look for ways to minimize additional distressing experiences. When necessary, try to shield survivors from reporters, other media professionals, onlookers or attorneys. Help protect their privacy.
If survivors have access to media coverage (e.g., television or radio broadcasts), point out that excessive viewing of such coverage can be highly upsetting, especially for children and adolescents. Encourage parents to monitor and limit their children's exposure to the media, and discuss their children's concerns after such viewing. Parents can let their children know that they are keeping track of information from the media, and that children can get this information from them so that they don't need to watch television. Remind parents to be careful about what they say in front of their children, and to clarify things that might have upset them.
| Adult/ Caregiver | "You've been through a lot, and it's a good idea to shield yourself and your children from further frightening or disturbing sights and sounds as much as possible. Even televised scenes of the disaster can be very disturbing to children. Sometimes children worry that the disaster is happening all over again. You may find that your children feel better if you limit their television viewing of the disaster. It doesn't hurt for adults to take a break from all the media coverage, too." |
| Child and Adolescent | "You've been through a lot already. People often want to watch TV or look for information on the internet after something like this, but this can be pretty scary. It's best to stay away from TV or radio programs that show this stuff. You can also tell your mom or dad if you see something that bothers you." |
Give Special Consideration for Acutely Bereaved Individuals
Culture Alert: The nature and course of grief is strongly influenced by family, cultural and religious beliefs and rituals related to mourning. You should inform yourself about cultural norms with the assistance of community cultural leaders who best understand local customs. Remember that it is important for families to decide from their own tradition of practices and rituals how to honor the death.
Someone who has lost a family member or close friend may want to express his/her feelings or talk about the loved one. Listen carefully and with sympathy for what they have experienced.
Do not probe. Use his/her name, rather than referring to the person as "the deceased."
Don't say:
If an affected person says any of the above things, you can respectfully acknowledge the feeling or thought (for example, "It's helpful for you to know that he didn't suffer, even though you really wish he could have survived."). Just don't initiate these statements yourself.
It is helpful to reassure grieving individuals that what they are experiencing is understandable and expectable. Let them know that if they continue to experience sadness, loneliness, anger, or long-term depression over the death, talking to a member of the clergy or to a counselor who specializes in grief may be advisable. They can ask medical providers for a referral to a counselor.
Children and Adolescents
The understanding of death changes as children and adolescents develop, and is strongly influenced by family, religious, and cultural values.
A loss can affect a young person in different ways. It is important when the caregiver of a toddler has died to provide consistent caretaking and consistency of their daily routine as best as possible. A school-age child loses not only a caretaker, but also continuing help with emotional regulation and support, and assistance with daily activities and mentoring. A teenager, who was becoming independent when a caregiver died, can be challenged by a conflict between taking up additional responsibilities within the family, and the wish for greater independence. This can be an important topic of discussion.
Goal: To calm and orient emotionally-overwhelmed or disoriented survivors.
Most individuals affected by a disaster or other traumatic incident will not require stabilization. Expressions of strong emotions, even muted emotions (e.g., numb, indifferent, spaced-out, or confused), are expectable reactions to disaster, and do not of themselves signal the need for additional intervention beyond ordinary supportive contact.
Stabilize Emotionally-Overwhelmed Survivors
Observe individuals for signs of being disorientated or overwhelmed. Signs include:
If the person is too upset, agitated, withdrawn, or disoriented to talk, or shows extreme anxiety, fear, or panic, the Psychological First Aid provider should consider:
For children or adolescents, consider:
Options for stabilizing distressed persons include:
Talking Points for Emotionally-Overwhelmed Survivors
Adults or Caregivers
Children and Adolescents
| Adolescent/ Child | "Is there anyone who helps you feel better when you talk to them? Maybe I can help you get hold of them." "You are doing a great job of letting grown-ups know what you need. It is important to keep letting people know how they can help you." |
If the person appears extremely agitated, shows a rush of speech, seems to be losing touch with the surroundings, or is experiencing ongoing intense crying, it may be helpful to:
A technique to help stabilize agitated children and adults called 'grounding' is the following. You can introduce grounding by saying:
After a frightening experience, you can sometimes find yourself overwhelmed with emotions or unable to stop thinking about or imagining what happened. You can use a method called "grounding" to feel less overwhelmed. Grounding works by turning your attention from your thoughts to the outside world. Here's what you do.
If none of these interventions aids in emotional stabilization, consultation with mental health colleagues and/or psychiatric consultation for medication may be indicated.
4. Information Gathering: Needs and Current Concerns
Goal: To identify immediate needs and concerns, gather additional information, and tailor Psychological First Aid interventions.
Gathering and clarifying information begins immediately after contact, and is ongoing throughout Psychological First Aid (as appropriate). As immediate needs and concerns are identified and addressed, it is useful to gather and clarify additional information. Remember that in most Psychological First Aid service delivery contexts, time, survivors' needs and priorities, and other factors will limit information gathering. However, although a formal assessment is not appropriate, the provider may ask pertinent questions to obtain and clarify a variety of issues that can inform decisions about:
It may be especially useful for the provider to ask some questions to clarify the following:
1. Nature and severity of experiences during the disaster
Children, adolescents and adults who have had the most serious forms of exposure to direct life-threat to self or loved ones, injury to self, or witnessing injury or death may likely experience more severe and prolonged distress. Those who felt extremely terrified and helpless may also have more difficulty in recovering.
Information about this may be elicited with questions like:
Start with: I know that you've been through a lot of difficult things. Would it be helpful to talk about any of what you have been through?
Where were you during the hurricane?
Did you get hurt?
Did you see anyone get hurt?
How afraid were you?
Provider Alert: In clarifying disaster-related traumatic experiences, the Psychological First Aid provider should avoid asking for in-depth description of traumatic experiences, as this may provoke unnecessary additional distress. It is especially important to follow the lead of the survivor in discussing what happened during the event. Individuals should not be pressed to disclose details of any trauma or loss. On the other hand, if individuals are anxious to talk about their experiences, let them know politely and respectfully that what would be most helpful now is to get some basic information to be able to help with what is currently needed and plan for future care. Let them know that the opportunity to discuss their experiences in a proper professional setting can be arranged for the future.
For people with these experiences, provide information about post-disaster reactions, information about coping, and offer a follow-up meeting.
2. Death of a family member or close friend
Loss of loved ones under traumatic circumstances is devastating, and over time can greatly complicate the grieving process.
Information about loss may be elicited with a question like:
Did someone close to you get hurt or die as a result of the hurricane? What happened?
For those with loss, provide emotional comfort, information about coping, information about social support, information on traumatic grief and offer a follow-up meeting.
3. Concerns about immediate post-disaster circumstances and ongoing threat
Especially in regard to complicated emergencies, concerns over immediate and ongoing danger can be a major source of distress.
Information about this may be elicited with questions like:
Do you need any information to help you better understand what has happened?
Do you need information about how to keep you and your family safe?
Do you need information about what is being done to protect the public?
For those with these concerns, help with obtaining risk-related information.
4. Separations from or concern about the safety of loved ones
Separation from loved ones, and concern over their safety, constitute additional sources of distress in the aftermath of disaster. If not earlier addressed, information may be elicited with questions like these:
Are you worried about anyone close to you right now? Do you know where they are?
Is there anyone especially important like a family member or friend who is missing?
For survivors with these concerns, provide practical assistance to help locate and reunite family members, or develop a strategy for seeking information about persons of concern.
5. Physical illness and need for medications
Pre-existing medical conditions and need for medications constitute additional sources of post-disaster distress and adversity. Immediate medical concerns need to be given a high priority.
Information about this may be elicited with questions like:
Do you have any physical or medical condition that needs attention?
Do you need any medications that you don't have?
Do you need to have a prescription filled?
For those with medical conditions, provide practical assistance in obtaining medical care and medication. Connect with additional services if needed.
6. Losses incurred as a result of the disaster (home, school, neighborhood, business, personal property, or pets)
Extensive material losses and their associated post-disaster adversities can significantly interfere with recovery, and are often be associated with feelings of depression, demoralization, and hopelessness over time.
Information about this may be elicited with questions like:
Was your home badly damaged or destroyed?
Did you lose other important personal property?
Did a pet die or get lost?
Was your business, school, or neighborhood badly damaged or destroyed?
For those with losses, provide emotional comfort, practical assistance to help link with available resources, information about coping, and information about social support.
7. Extreme feelings of guilt or shame
These extreme negative emotions can be very painful, difficult and challenging, especially for children and adolescents. Remember that children and adults may be ashamed to discuss these feelings. One approach would be to listen carefully for signs of these emotions in their comments, then make clarifying comments such as:
It sounds like you are being really hard on yourself about what happened.
It seems like you feel that you could have done more.
For those with these negative emotions, provide emotional comfort and information about coping.
8. Thoughts about causing harm to self or others
Disasters can evoke overwhelming feelings of grief, anxiety, depression, and anger. Getting a sense of whether an individual is having thoughts about causing harm to self or others should be handled sensitively.
Are there family members, friends, or community agencies that you can rely on for help in dealing with problems you are facing as a result of the disaster?
For those in this situation, provide linkage with available resources and services, information about coping, information about social support, and offer a follow-up meeting.
10. Prior alcohol or drug use
Provider Alert: In clarifying prior history of substance use, prior trauma and loss, and prior mental health problems (as in the sections below) the Psychological First Aid provider should be sensitive to the immediate needs of the survivor, avoid asking for a history if not appropriate, and avoid asking for in-depth description. It may be helpful to link the questions to clear reasons for asking (for example, "Sometimes events like this can remind individuals of previous bad times..." "Sometimes individuals who use alcohol to cope with stress will notice an increase in drinking following an event such as this.").
Exposure to trauma and post-disaster adversities can exacerbate ongoing substance use, cause relapse of past substance abuse, or lead to new abuse.
Information about this may be elicited with questions like:
Do you tend to use alcohol, prescription medications, or drugs as a way to cope with stress?
Have you had any problems in the past with alcohol or drug use?
For those with potential substance use problems, provide information about coping, information about social support, link to appropriate services and offer a follow-up meeting.
11. Prior exposure to trauma and loss
Those with a history of exposure to trauma or loss may experience more severe and prolonged post-disaster reactions, and a "rekindling" of prior trauma reactions.
Information about this may be elicited with questions like:
Sometimes events like this can remind individuals of previous bad times.
Have you ever been in a hurricane or other disaster before?
Has some other bad thing happened to you in the past?
Have you ever had someone close to you die?
For those with prior exposure, provide information about post-disaster reactions, information about coping, and offer a follow-up meeting.
12. Prior psychological problems
Those with a history of psychological problems may experience an exacerbation of these problems and more severe and prolonged post-disaster reactions.
Information about this may be elicited with a question like:
Sometimes events like this can make existing psychological problems worse. Have you ever had any treatment or taken medication for a mental health problem?
For those with prior psychological problems, provide information about post-disaster reactions, information about coping, information about social support, link with appropriate services, and offer a follow-up meeting.
13. Specific youth, adult, and family concerns over developmental impact
Interference with anticipated developmental activities and opportunities resulting from disaster and post-disaster circumstances may cause distress and concern.
Information about this may be elicited with questions like:
Were there any special things or events (birthday, graduation, beginning of the school year, vacation) coming up that were disrupted by the hurricane?
For those with developmental concerns, provide information about coping and link with appropriate services.
It is also useful to ask a general open-ended question to make sure that you have not missed any important information.
| Adult/ Caregiver/ Child | Is there anything else we have not talked about that is important for me to know? |
The Psychological First Aid provider will need to use judgment about how to gather this information, how much information to gather, and to what extent to ask questions, while remaining sensitive to the needs of the person. If the survivor identifies multiple concerns, summarize these and help to identify which issue is most pressing.
Goal: To offer practical help to the survivor in addressing immediate needs and concerns.
Assisting the survivor with current or anticipated problems is a central component of Psychological First Aid. Ongoing adversities and continuing problems resulting from a disaster can add significantly to the stress level of the survivor, distract from self-care, and help maintain distress reactions. Also, survivors may welcome a pragmatic focus on a current problem that is uppermost in their mind. Often, it is important to help them with problem-solving in regard to important problems.
Discussion of immediate needs occurs throughout a Psychological First Aid contact, and as much as possible, you should help the affected individual address those needs. Assistance may be helpful because problem-solving may be more difficult for the survivor under conditions of stress and adversity.
Identify the Most Immediate Need(s)
If several needs or current concerns have been mentioned by the survivor, it will be necessary to focus on them one at a time. For some needs there will be immediate solutions (e.g., getting something to eat, phoning a family member to reassure them that the survivor is ok). It will not be possible to rapidly solve other needs (e.g., locating a lost loved one, returning to previous routines, securing insurance for lost property, acquiring caregiving services for family members), but it may be possible to take concrete action steps that address the problem (e.g., completing a missing persons report or insurance form, applying for caregiving services).
As you collaborate with the survivor, help him or her to select issues requiring immediate help. For example you might say:
| Adult/ Caregiver | "I understand from what you're telling me, Mrs. Williams, that your main goal right now is to find your husband and make sure he's okay. Not knowing that he's safe and not being able to talk to him. We need to focus on helping you get in contact with him. In order to do that, let's make a plan on how to go about getting this information. |
Clarify the Need
Talk with the survivor to specify the problem. If the problem is understood and clarified, it will be easier to identify practical steps that can be taken to address it.
Discuss an Action Plan
Discuss what can be done to address the need or concern. The survivor may indicate what he or she would like to be done, or you can offer a suggestion. Knowing what services are available ahead of time will ensure that appropriate assistance can be provided about services related to obtaining food, clothing, shelter, medical and mental health services, financial assistance, help in determining the location of missing family members or friends, and volunteer opportunities for those who feel a need to contribute to relief efforts. Inform survivors about what they can realistically expect in terms of potential resources and support, qualification criteria, and application procedures.
Act to Address the Need
Follow through in making an active response. For example, help the person make contact or set an appointment with a needed service, or assist them in completing paperwork.
6. Connection with Social Supports
Goal: To help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources.
Enhance Access to Primary Support Persons (Family and Significant Others)
An immediate concern for most affected persons is being able to communicate with individuals with whom they have a primary relationship (e.g., spouse/partner, children, parents, other family members, close friends, clergy), and social support can play a strong role in recovery from trauma. Therefore, an important Psychological First Aid objective is to take practical steps to enable the person to make contact (in person, by phone, by e-mail) with individuals for whom the person feels the greatest concern (e.g., a child or frail elderly parent from whom the person has been separated) or the greatest need to be with right now.
Encourage Use of Immediately Available Support Persons
If individuals are disconnected from social support, encourage them to make use of immediately available sources of social support (i.e., yourself, other relief workers, other affected persons), while being respectful of individual preferences. For example, it can help to offer adults reading materials (e.g., magazines, fact sheets) and discuss the material with them. When people are in close proximity to each other, ask them, as a group, if they have questions or requests with which you can help. These group discussions can help provide a starting point for further conversations.
It can be helpful to bring similar-age children together in a shared activity - as long as they are not separated from their adult caregivers. Providing art materials, coloring books, or building materials can help younger children engage in soothing, familiar activities. Older children and adolescents can be helpful in encouraging the younger children to participate. Children may have suggestions of songs to sing or classroom games that they have played at school during recess. Several activities can be done with only paper and a pencil:
Discuss Support-Seeking and Giving
You can help survivors understand the value of social support, and how to be supportive to others. For instance, you can share that experts recommend that connection with others is an important factor in recovery from a disaster. Let them know that there are differences between normal stress and traumatic stress, which can cause people to want to avoid traumatic memories, or feel flooded by the memories. Let them know that, following trauma, some people choose not to talk about traumatic experiences at all, or not until a later time when they feel secure enough re-visit the experience. And when a person feels comfortable talking, they may need to discuss the event on numerous occasions. At times, just spending time with people one feels close to and accepted by, without having to talk, can feel best. For example, your message might be:
| Adult/ Caregiver | "When you're able to leave the Assistance Center you may just want to be with the people you feel close to. You may find that talking some about what each of you has been through can be helpful. You can decide when and what to talk about. You don't have to talk about everything that occurred; only what you choose to share with each person. It's good not to rush the talking, but also not to wait if it would help you or them to talk." |
| Adolescent | "When something really upsetting like this happens, even if you don't feel like talking, be sure to ask for what you need. Also, you might find that you will feel better if you try to help other people." |
| Child | "You are doing a great job of letting grown-ups know what you need. It is important to keep letting people know how they can help you."
"You're doing some great things to help the grown-ups too, like keeping an eye on your little brother and talking with these other kids who are scared." "The more help you get, the more you can make things better. Even grown-ups need help at times like this." |
As a helper, you can model positive supportive responses, such as:
If appropriate, distribute Handouts: Connecting with Others: Seeking Social Support and Giving Social Support. These handouts are intended for adults and older adolescents. Discuss the following points:
If an individual is reluctant to seek support, there may be many reasons, including:
In Handout: Connecting with Others - Seeking Social Support there are dos and don'ts of seeking support, such as:
Do …
Don't…
In Handout Connecting with Others - Giving Social Support there are dos and don'ts of giving social support, such as:
Do …
Don't…
When Support is Not Working:
You may need to inform individuals that if someone they care about is showing extreme social isolation or withdrawal, they can help the person choose specific ways to be involved with other people in a way that they feel will be helpful. A friend or loved one may need to also know that there are other people who can listen if more help is needed (i.e., primary care doctor, chaplain, support group, or counselor). Let them know that positive social support, in any way that is acceptable to them, is one of the most crucial factors in recovery from a disaster. They can enlist help from others in their social circle so that they all take part in supporting the person. They can also encourage their friend/loved one to get involved in a support group with others who have had similar experiences, or accompany them in seeking professional help.
Goal: To provide information (about stress reactions and coping) to reduce distress and promote adaptive functioning
Disasters can be disorienting, confusing, and overwhelming. Various types of information can help to re-orient children and adults to their situation. Such information includes:
In providing information, Psychological First Aid providers should use judgment as to when to present information, and provide the type of information that is most pertinent and useful. The most useful information provides assistance in addressing immediate needs, reducing distress, addressing current concerns, and supporting positive coping efforts.
Provide Basic Information about Stress Reactions
If appropriate, it may be useful to briefly discuss common stress reactions being experienced by the survivor. Stress reactions may be alarming for survivors. Some will be frightened or otherwise distressed by their own responses to an event; some may view their reactions in negative and distressing ways (e.g., my reactions mean "There's something wrong with me," or "I'm weak"). Therefore, individuals may benefit from explanations about reactions that they are experiencing, and understanding that these reactions are normal and expectable. Some important considerations in the process of educating survivors about their reactions include:
Provider Alert. While it may be helpful to describe common stress reactions and note that intense reactions are common but often diminish over time, it is also important to avoid providing "blanket" reassurance that stress reactions will disappear. This may set up unrealistic expectations, resulting in negative views of self if reactions persist.
Review Common Psychological Reactions to Traumatic Experiences and Losses
Especially for individuals who have had significant exposure to trauma and have sustained significant losses, provide basic psycho-education about common distress reactions. The Psychological First Aid provider can review these, again emphasizing that such reactions are understandable and expectable. Inform survivors that if these reactions continue to interfere with their ability to function adequately for over a month, psychological services should be considered.
Many individuals who have had traumatic experiences suffer from ongoing reactions that are distressing and can lead to difficulties in daily life.
The following basic information is presented as an overview for the Psychological First Aid provider so that issues arising from survivors' past experiences and post-disaster reactions can be selectively discussed as appropriate.
There are three types of posttraumatic stress reactions:
Intrusive reactions are ways in which the traumatic experience comes back to mind. These reactions include distressing thoughts or images of the event (e.g., picturing what one saw), or dreams about what happened. Among children, bad dreams can occur that may not be specifically about the disaster. Intrusive reactions also include upsetting emotional or physical reactions to reminders of the experience. Some people may act like one of their worst experiences is happening all over again. This is called "a flashback."
Avoidance and withdrawal reactions are ways people use to keep away from, or protect against, intrusive reactions. These reactions include efforts to avoid talking, thinking and having feelings about the traumatic event, and to avoid any reminders of the event, including places and people connected to what happened. Emotions can become restricted, even numb, to protect against distress. Feelings of detachment and estrangement from others may lead to social withdrawal. There may be a loss of interest in usually pleasurable activities.
Physical arousal reactions are physical changes that make the body react as if danger is still present. These reactions include constantly being "on the lookout" for danger, startling easily or being jumpy, irritability, or experiencing outbursts of anger, difficulty falling or staying asleep, and difficulty concentrating or paying attention.
It is also useful to discuss the role of trauma reminders, loss reminders, and hardships in contributing to distress.
Trauma Reminders can be sights, sounds, places, smells, specific people, times of the day, situations, or even feelings, like being afraid or anxious. Trauma reminders can evoke upsetting thoughts and feelings about what happened. Examples include the sound of wind, rain, helicopters, screaming or shouting, and specific people who were present at the time. Reminders are related to a specific type of event, such as hurricane, earthquake, flood, tornado or fire. Over time, avoidance of reminders can make it hard for people to do what they normally do or need to do.
Loss Reminders can also be sights, sounds, places, smells, specific people, the time of day, situations, or feelings. Loss reminders bring to mind the absence of a loved one. Missing the deceased can bring up strong feelings, like sadness, feeling nervous, feeling uncertain about what life will be without them, feeling angry, feeling alone or abandoned, or feeling hopeless. Examples include seeing a picture of a lost loved one, or seeing their belongings, like their clothes. Loss reminders can also lead to avoiding things that people want to do or need to do.
Change Reminders can be things (people, places, things, activities, or hardships) that remind us of how our lives have changed from what they used to be as the result of a disaster. This can be something as simple as waking up in a different bed in the morning, or going to a different school, or being in a different place. Even nice tings can remind us of how things have changed, and make us miss what we had before.
Hardships often follow in the wake of disasters, and can make it more difficult to recover. Hardships place additional strains on children and families, and can contribute to feelings of anxiety, depression, irritability, uncertainty, and mental and physical exhaustion. Examples of hardships include: loss of home or possessions, lack of money, shortages of food or water, separations from friends and family, medical or physical health problems, the process of obtaining compensation for losses, school closures, being moved to a new area, and lack of fun things for children to do.
Other kinds of reactions include grief reactions, depression and physical reactions.
Grief Reactions will be prevalent among those who survived the hurricane but have suffered many types of losses - including loss of loved ones, home, possessions, pets, schools, and community. Loss may lead to feelings of sadness and anger, guilt or regret over the loss, missing or longing for the deceased, and dreams of seeing the person again. These grief reactions are normal, vary from person to person, and can last for many years after the loss. There is no single "correct" course of grieving. Importantly, personal, family, religious and cultural factors affect the course of grief. Although grief reactions may be painful to experience, especially at first, they are healthy reactions and reflect the ongoing significance of the loss. Over time, grief reactions tend to include more pleasant thoughts and activities, such as positive reminiscing or finding positive ways to memorialize or remember a loved one.
Traumatic Grief occurs when children and adults have suffered the traumatic loss of a loved one, and often makes grieving more difficult. In traumatic death, there is a tendency for the mind stay focused on the circumstances of the death, including preoccupations with how the loss could have been prevented, what the last moments were like, and issues of accountability. Traumatic grief reactions include intrusive, disturbing images of the manner of death that interfere with positive remembering and reminiscing, delay in the onset of healthy grief reactions, retreat from close relationships with family and friends, and avoidance of usual activities because they are reminders of the traumatic loss. Traumatic grief changes the course of mourning, putting individuals on a different time course than may be expected by other family members. Often, traumatic grief reactions can clash with the timing of religious rituals and other cultural expressions of mourning.
Depression can be an additional major concern. Depression is associated with prolonged grief reactions and strongly related to the accumulation of post-hurricane adversities. Reactions include: persistent depressed or irritable mood; loss of appetite; sleep disturbance, often early morning awakening; greatly diminished interest or pleasure in life activities; fatigue or loss of energy; feelings of worthlessness or guilt; feelings of hopelessness; and sometimes thoughts about suicide. Demoralization is a common response to unfulfilled expectations about improvement in post-disaster adversities, and resignation to adverse changes in life circumstances.
Physical Reactions may be commonly experienced, even in the absence of any underlying physical injury or illness. These reactions include: headaches; dizziness; stomachaches; muscle aches; rapid heart beating; tightness in the chest; loss of appetite; and bowel problems.
Several handouts may be useful here.
Provide Basic Information on Ways of Coping
It may also be appropriate and helpful to discuss ways of coping. Positive coping actions are those that help to reduce anxiety, lessen other distressing reactions, and improve the situation. In general, coping methods that are likely to be helpful include:
Negative coping actions tend to perpetuate problems. Negative coping actions include:
The aim of discussing positive and negative forms of coping is to:
As noted above, Handout: When Terrible Things Happen reviews positive and negative coping for survivors in general.
Demonstrate Simple Relaxation Techniques
Breathing exercises help reduce feelings of over-arousal and physical tension. Simple exercises such as these can be taught in a brief period. Children and adolescents can use these techniques also, and it may be helpful for parents to prompt their children (or vice versa) to use these techniques several times a day. Handout: Basic Relaxation Exercises can be provided to reinforce the use of relaxation techniques.
| Adult/ Caregiver/ Adolescent | Inhale slowly (one-thousand one; one-thousand two; one-thousand three) through your nose and comfortably fill your lungs all the way down to your belly.
Silently and gently say to yourself, "My body is filling with calm." Exhale slowly (one-thousand one, one-thousand two, one-thousand three) through your mouth and comfortably empty your lungs all the way down to your abdomen. Silently and gently say to yourself, "My body is releasing tension." Repeat five times slowly and comfortably. |
| Child | Let's practice a different way of breathing that can help calm our bodies down. Put one hand on your stomach, like this [demonstrate]. Okay, we are going to breathe in through our noses. When we breathe in, we are going to fill up with a lot of air and our stomachs are going to stick out like this [demonstrate].
Then, we will breathe out through our mouths. When we breathe out, our stomachs are going to suck in and up like this [demonstrate]. We are going to breathe in really slowly while I count to three. I'm also going to count to three while we breathe out really slowly. Let's try it together. Great job! |
Engaging ways to practice deep breathing:
For Parents or Caregivers, Review Special Considerations for Children
For parents or caregivers, Handouts: Tips for Helping Preschool Children; Tips for Helping School Age Children; and Tips for Helping Adolescents provide specific information about age-related reactions, and strategies for addressing these to assist in children's recovery. They address children 5 years old and younger, children 6-12, and adolescents. These information sheets should be provided to parents or caretakers for their use over the next weeks and months.
Establishing family routines to the extent possible after a disaster is important for family recovery. It is especially important to encourage parents and caregivers to try to maintain family routines such as meal times, bedtime, wake up time, reading time, and play time. This can be done in a shelter or transitional housing.
Encourage youth and family members to pay special attention to taking care of their physical health. This includes getting enough sleep, proper nutrition (including fluid intake), proper exercise, good hygiene, and setting aside time for enjoyable activities.
It is especially important to assist family members in developing a mutual understanding of their different experiences, reactions and course of recovery, and to help develop a family plan for communicating about these differences. For example, a provider might say:
| Adult/ Caregiver | Often, due to differences in their experiences during and after a disaster, family members will have different reactions and different courses of recovery. These differences can be difficult for family members to deal with, and can lead to difficulties like not feeling understood, getting into arguments, or not supporting each other. For example, one family member may be more troubled by a trauma or loss reminder than other family members. |
The Psychological First Aid provider should encourage family members to be understanding, patient, and tolerant of differences in their reactions, and to talk about things that are bothering them so the others will know when and how to support them. People can support and help each other in a number of ways, like listening and trying to understand, comforting with a hug, doing something thoughtful like writing a note, or getting their mind off things by playing a game. Parents need to pay special attention to how their children may be troubled by reminders and hardships because they can strongly affect how their children appear and behave. For example, a child may look like he is having a temper tantrum when actually he has been reminded of a friend who was hurt or killed.
Assist with Developmental Issues
Children, adolescents, adults and families go through stages of physical, emotional, cognitive and social development. The many stresses and adversities in the aftermath of a disaster may result in key interruptions, delays or reversals in developmental progression. The loss of developmental opportunities or achievements can be experienced as a major consequence resulting from the disaster. Developmental progression is often measured by milestones.
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In responding to needs and concerns after a disaster, even though attention will be paid to those that are immediate, children and families should also be given an opportunity to attend to the disaster's impact on development. It can be useful to help children and families identify any of these issues by asking directly.
| Parent/ Caregiver | Are there any special events that the family was looking forward to? Was anyone looking forward to doing something important, like starting school, graduating from high school, or entering college? |
| Adult | Are there any goals you were working towards that this disaster has, or might, interfere with? |
| Child/ Adolescent | Were there things before the hurricane that you were looking forward to doing? Like a birthday, something fun at school, or going somewhere with a friend. |
The Psychological First Aid provider should try to increase appreciation of family members to these issues, so that they understand the challenge to each individual, as well as the whole family. Help find alternative ways for family members to handle the interruption or delay. In helping to develop a plan to help with these concerns, consider whether:
Assist with Anger Management
In post-disaster situations, with stress and adversity, including difficulty sleeping, some individuals may be irritable and have difficulty managing their anger. When appropriate, the Psychological First Aid provider can discuss the following anger management issues.
Some anger management skills that you can suggest include:
If anger appears uncontrollable, or leads to violence, seek immediate medical attention, and contact security.
Address Highly Negative Emotions (e.g., guilt and shame)
In the aftermath of disasters, survivors may think about what caused the event, how they reacted, and what the future holds. Some of these beliefs may add to their distress, especially attributing excessive blame to themselves. The Psychological First Aid provider should listen for such negative beliefs, and help survivors to identify alternatives to the negative beliefs that are causing distress. Some questions that can facilitate this process are:
It may be helpful for the individual to hear that just because he or she thinks she is at fault does not mean that this is true. If the individual is receptive, you can offer some alternative ways of looking at the situation. An important role for the Psychological First Aid provider in this effort is to attempt to clarify misunderstandings, rumors, and distortions that exacerbate distress, unwarranted guilt, or shame.
Help with Sleep Problems
Sleep difficulties are very common following a disaster or other trauma. Ask questions to assess the individual's sleep routines and sleep-related habits. Problem-solve ways of improving sleep, including:
Address Substance Abuse
When use of substances is a concern:
The Handout: Alcohol and Drug Use after Disasters gives an overview of this information, and is intended for adults and older adolescents who indicate concerns in this area.
8. Linkage with Collaborative Services
Goal: To link survivors with needed services, and inform them about available services that may be needed in the future.
Provide Direct Link to Additional Needed Services
Providing information should be accompanied by a discussion about which of the survivor's needs and current concerns require additional information or services. If the survivor is interested in additional services, do what is necessary to insure effective linkage with the services (e.g., walk the survivor over to an agency representative who can provide a service; set up a meeting with a community representative who may provide appropriate referrals)
When making a referral:
Promote Continuity in Helping Relationships
A secondary but important concern for many affected persons is being able to keep in contact with helpers and other persons whom they feel have been or could be helpful as they continue to deal with the immediate situation.
In most cases, continuing contact between affected survivors and you will not be possible because the affected persons will leave triage sites or family assistance centers and go to other sites for continuing services. However, contacts made during the acute aftermath of disasters can lead to a sense of abandonment or rejection if the Psychological First Aid provider seems to just "vanish." Therefore, Psychological First Aid should include the use of strategies for creating a psychological sense of continuity of care, such as:
Sometimes, survivors feel as if they are meeting a never-ending succession of helpers, and that they have to go on explaining their situation and telling their story to each one in turn. To the extent possible, this should be minimized. If you are leaving a response site, it is important to let the survivor know this and to ensure a direct "hand-off" to another provider, and if possible, one who will be in a position to maintain an ongoing helping relationship with the person. Orient the new provider to what he or she needs to know about the person, and provide an introduction if at all possible.
| Adult/ Caregiver/ Adolescent | "I'll be here tomorrow and for the rest of the week and will look for you - if you're here or want to stop by, would you look for me and let me know how you and your family/friends are doing?" |
| Child | "Thanks for staying with your brother, I know that's a big help to your parents while they're figuring out how to make sure you're all safe. I'll keep checking on you while I'm here, and if you have a chance and would like to make a drawing that I could keep to remember you, I'd really like that. I'll try to say goodbye if I have to go." |
This work was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Health and Human Services (HHS). The views, opinions, and content of this field operations guide are those of the authors, and do not necessarily reflect those of SAMHSA or HHS.