First, do no harm, Part 2: First aid for the mind

The second installment of this multi-part series on disaster psychology looks at the concepts behind psychological first aid for disaster settings.

First, do no harm, Part 1
First, do no harm, Part 3: First aid in disaster settings
Who needs help, of what sort, following a disaster?

Practitioners in all areas of crisis response have been hearing more and more about psychological first aid (PFA) as the next generation of immediate crisis assistance. The term itself conjures an image of immediate action to do things like stop bleeding, splint fractures, restore breathing and maintain circulation, a very attractive and affirming metaphor for what we’ve sought to do. The value of first aid is found in building an armamentarium of basic techniques to treat and stabilize at a very basic level, and especially in the ability of those various techniques to arrest the course of an injury without compounding the situation or causing additional harm.

Psychological first aid is a conceptual approach to providing immediate intervention and support after exposure to emotionally traumatic events, and is predicated on an analogy to first aid concepts in general medicine. As such, it is not itself a specific technique, but rather a collection of approaches intended to provide palliative care for cuts and scrapes, immediate “stop-gap” management of more pronounced illness and injury, and prompt disposition to definitive care where indicated. Perhaps even more than in other treatment efforts, there’s a strong emphasis on the Hippocratic caveat “Primum non nocere,” “First, do no harm.”

We all know, for example, that moving an injured person can add to their injuries if not done with proper care and procedures. Application of tourniquets to slow bleeding from extremities was once considered standard practice, but is now considered a risky “last-ditch” effort that may result in sacrifice of the limb.

Similarly, while CPR can be taught to anyone, it’s far from a simple procedure to apply, especially when never practiced between instruction and emergency use. And the protocols for CPR aren’t static. Indeed, they’ve just recently changed in response to accumulated evidence to concentrate more on chest compressions and less on rescue breathing.

PFA represents a very different set of notions and assumptions from those beneath the debriefing and CISM models that once dominated early intervention. Those approaches were very prescriptive, protocol-driven and relatively rigid. There were set rules for what would be said, by whom, in what order, sometimes even for such minute details as how chairs would be arranged and who should sit where. The techniques were rhetorically tied to presumptions of relatively high risk for PTSD and coupled to suggestions that these approaches could prevent its development.

PFA, on the other hand, specifically avoids the now well-known pitfalls of “one size sits all” intervention. It’s directed toward enhancing natural resilience rather than preventing PTSD, and it embraces a wide range of techniques and anticipates that methods will change as evidence develops. Its strength is in its flexibility.

The major limitation with PFA, though, is also a product of its flexibility. Absent standardization of definitions, objectives and techniques, just about anything might qualify as PFA. The National Child Traumatic Stress Network and the Substance Abuse and Mental Health Services Administration, working with the National Center for PTSD, commissioned a group of early intervention experts to draft a PFA Field Operations Guide. An expert consensus panel met to evaluate the draft and suggested a variety of refinements.

The result is an evidence-informed, modular approach for assistance in the aftermath of disaster and terrorism, built around four basic standards for actions and interventions:

1. Consistent with research evidence on risk and resilience following trauma;
2. Applicable and practical in a range of field settings;
3. Interventions geared to age, circumstance and situation; and
4. Culturally informed with respect to actions, intents and outcomes.

The Guide can be downloaded free at www.ncptsd.va.gov/ncmain/ncdocs/manuals/PFA_2ndEditionwithappendices.pdf.
While the current PFA Field Operations Guide is geared toward children, adolescents and families in disaster situations, its core principles are applicable to other early intervention targets and settings. The manual includes a range of handouts, provider guides and supporting materials. Other PFA handouts have been developed by the Center for the Study of Traumatic Stress at the Uniformed Services University of Health Sciences and are available on its Web site www.centerforthestudyoftraumaticstress.org.

Just as no one “owns” first aid, no one “owns” PFA. Techniques and recommendations in each evolve as more is learned in various areas of research and practice. The American Red Cross has offered basic first aid for decades, as have organizations such as the National Safety Council.

But a Google search for the phrase “first aid training” returns more than 1.5 million hits, including countless on-line and on-site courses available for enrollment. There are standards for specific components (such as CPR standards from the American Heart Association), and the federal Occupational Health and Safety Administration has standards for content of first-aid training programs in arenas under its jurisdiction. First aid itself, however, is a concept in which various techniques come and go as medical evidence regarding their effectiveness evolves over time. The same is intended to be true of PFA.

Early psychological intervention is just now evolving from an initial preoccupation with very specific techniques (such as debriefing) toward a conceptual model more akin to what we’ve come to know as first aid for physical injuries and illnesses. We can expect that, as this shift progresses, a number of our ideas regarding the techniques and approaches comprising PFA will need to evolve, just as our ideas about everything from tourniquets to chest compressions have had to change as new evidence brought progressively clearer pictures of both benefits and risks. We can also expect that, as a result, we will become progressively better equipped to meet the diverse needs of disaster victims, their supporters and their communities in safer and more effective ways.

One important final note: First aid was never envisioned as something to be delivered by doctors and nurses. It was designed to be the province of baseball coaches and babysitters, of those who are most likely to be in first contact with the ill or injured.

The intent in severe cases was to provide sufficient skills (the ABCs of Airway, Breathing and Circulation) to stabilize serious problems until definitive help could be secured, but just as important was to enable those folks to safely, effectively and confidently deal with minor injuries such as scrapes and bruises.

For PFA in disaster settings, the people most likely to make a difference are those who encounter victims as a part of response and relief duties. We’ll look more at how PFA integrates with other disaster relief functions in our next installment.