Psychological First Aid
Psychological First Aid refers to tools that can be used to help people in the aftermath following a disaster, terrorist attack, or other forms of traumatic exposure, to help reduce distress and maintain effectiveness. As a first responder, both you and your colleagues may encounter extremely distressing and traumatic events in the line of work. Making sure that you know how to offer assistance to those in distress will improve your effectiveness on the job.
The National Center for PTSD Guidelines for Psychological First Aid include 8 Core Actions:
Step One: Contact and Engagement
The goal of this action is to make contact with those in distress in a helpful, respectful, and compassionate manner. Introduce yourself and explain your role in the situation. Before offering help, ask whether the individual would like assistance. Recognize that some people will not wish to receive assistance, and be respectful of their decision.
As much as possible, give each individual your full attention, and speak softly and calmly when responding. Identify any urgent medical or safety concerns, and address these as quickly as possible. Be sure to respect privacy and confidentiality concerns.
Step Two: Enhancing Safety and Comfort
The goal of this core action is to restore and ensure safety, and to provide both physical and emotional comfort.
Ensuring physical safety can include removing broken glass or other sharp objects, and removing or cordoning off areas that are wet from spills or that create a tripping or falling hazard. If children are present, try to ensure a secure area in which they can play with supervision. Ask about health concerns, such as needed medications, hearing aids or glasses, insulin, canes, or other healthcare items they may need. Ask if they have a friend or relative that you could help them to contact.
You can enhance physical comfort by trying to ensure, if possible, a comfortable temperature comfortable seating, and adequate lighting. Feelings of helplessness can be reduced by encouraging survivors to be engaged in helping themselves or others, such as by having them walk with you to get supplies, and encouraging them to exert some control over arranging their environment.
If possible, encourage social engagement among survivors, as it tends to be comforting to be around others who are coping effectively. At the same time, interacting with a highly distressed fellow survivor may be more upsetting than reassuring, and so your best judgment should be used. Children who have been separated from their caregivers are especially vulnerable to distress, and priority should be given to locating caregivers or others who can care for them. Use simple language to explain the situation, including who will watch over them and what will happen next. Provide realistic reassurance and comfort, but avoid making optimistic promises that cannot be kept, such as that they will see their parents soon.
Remind survivors that overexposure to news about a traumatic event may cause worsening of emotional symptoms, especially in children and adolescents. Encourage them to thoughtfully monitor and reasonably limit the amount of time spent with such news. While updated information may be helpful or reassuring, constant replaying on news media of a traumatic situation is unhelpful. The National Center for PTSD guidelines recommend telling adults something like the following: “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. 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.” (p. 32).
Another source of comfort includes providing information about what is known about the situation, what they can do next, what is being done to help them, and services that they can access. At the same time, you will need to use your best judgment about what information should be disclosed at what time; some individuals may be particularly fragile at the moment, and would be better served by learning at a later time about deaths or other severe harm that may have occurred
When a loved one has died in a crisis situation, there is no single way of reacting to such news. The National Center for PTSD encourages sensitivity to the individual’s particular way of responding. They offer the following as an example of how to discuss grief with survivors:
“It is important to know that each family member may express their grief differently. Some may not cry, while others might cry a lot. Family members should not feel badly about this or think there is something wrong with them. What is most important is to respect the different ways each feels, and help each other in the days and weeks ahead.” (p. 35).
At the same time, avoid saying things that are often unhelpful, such as “I know how you feel,” “He is better off now,” or “Everything happens for a reason.”
Step Three: Stabilization (if needed)
The goal of stabilization is to calm and orient survivors who are disoriented or emotionally overwhelmed. This includes:
Stabilizing emotionally overwhelmed survivors
Orienting emotionally overwhelmed survivors
The role of medications in stabilization
Although disasters can be highly distressing, most people will not require stabilization. Stabilization may be necessary for those who are emotionally overwhelmed. Look for signs such as unresponsiveness to questions or directions; showing disorganized, aimless behaviors; persistent shaking or trembling; looking glassy-eyed; or frantic behaviors.
Stabilization measures include respecting the person’s privacy and offering time to recover before intervening; standing nearby while providing services to others, so the distressed person may seek you at his or her preference. You can also simply remain quiet and available instead of speaking directly to the person, giving time for the person to recover. If the person is willing to interact, you may suggest that he or she select specific distressing feelings or thoughts that they may be able to address and bring under control. If friends or family are available, ask for their involvement in reducing distress, if appropriate. It can also be reassuring to simply explain to the person how agency efforts are organized, what is available, what will happen next, and what choices he or she may be able to make.
If the distressed person is receptive, suggest that they try a calming exercise that can help them to reduce their distress. This can include a muscle relaxation exercise or deep breathing practice. This can include demonstrating for them the act of taking a deep breath, holding briefly, then releasing slowly, and repeating several times.
For intensely distressed persons, it can be useful to gently ask the person to look directly at you and to listen as you calmly ask if he or she can state where they are, and to describe the physical environment. You can also ask the person to ask if he or she understands what is happening. This can help to interrupt the sense of panic and alarm, and help to orient the person to the present moment. The National Center for PTSD provides the following script for a grounding exercise. “Grounding can help you feel less overwhelmed. It works by turning your attention from your thoughts back to the outside world. Here’s what you do…. Sit in a comfortable position with your legs and arms uncrossed. Breathe in and out slowly and deeply. Look around you and name five non-distressing objects that you can see. For example, you could say, ‘I see the floor, I see a shoe, I see a table, I see a chair, I see a person.’ Breathe in and out slowly and deeply. Next, name five non-distressing sounds you can hear. Breathe in and out slowly and deeply. Next, name five non-distressing things you can feel, such as ‘I can feel my toes inside my shoes, I can feel the blanket in my hands.’ Breathe in and out slowly and deeply.”
Step Four: Information Gathering: Current Needs and Concerns
In gathering information about what a survivor experienced, avoid questions about details that could increase their distress. Ask questions that will give you basic information about their current needs and what help they may need in the near future. If a loved one was injured or killed, offer emotional comfort, and when appropriate, provide information about support services they can receive. For survivors concerned about immediate safety, you may ask whether there is specific information they would like to understand about what has occurred, or how agencies are responding to keep them and others safe. Ask about any medical issues that should be addressed, such as medications they may need. This may include mental health conditions and psychiatric medications they may need to take regularly. Ask about family, friends, or community members they could rely on for support or help with recovering from the event. For those without social support, help them to identify the appropriate local agencies for their needs.
Step Five: Practical Assistance
Helping survivors to identify immediate needs and the steps they can take to address those needs can increase their optimism and help them regain a sense of control and predictability.
While they may be report many different needs, help them to focus one at a time on each need. Work with them to create a list of needs, identify highest priority needs, and plan what actions they can take. Some needs can be quickly met, such as getting access to food, or calling family members, while others may require several steps, such as filing insurance claims for damaged property.
In discussing their action plan, provide only accurate information and realistic expectations of what services or resources may be available for them, and how quickly these may be available. If needed, help the survivor to act on their plan, such as assisting while they make necessary appointments, or locate an appropriate agency.
Step Six: Connection with Social Supports
Social support is a powerful factor in helping survivors cope with disaster, and delayed or absent social support can hinder emotional well-being. An important first step for assisting most survivors is to help them contact family members, friends, or neighbors who can provide support. Religious organizations may also provide support services, if the survivor is affiliated or receptive to such groups. If needed, provide the survivor with phone or email access to make contact. If familiar social supports are not immediately available, encourage the survivor to rely on you, other personnel, or other survivors for social support. The social support can include attentive listening, helping them to clarify their concerns, providing coping information, and identifying practical solutions to immediate problems.
For survivors who may be reluctant to request social support, help them by asking them to consider what type of support would be most useful to them, what person could be asked for that help, and how they could request help.
Step Seven: Information on Coping
Traumatic experiences can cause survivors to feel overwhelmed, helpless, and confused. Providing information about what is known about the event that happened, what efforts are underway to help, where and when they can access needed services, and how to cope with their emotional responses can help the survivors to respond more effectively.
For some survivors, a brief and simple discussion of how people tend to react emotionally and physically to traumatic events can normalize their experience and help them make sense of their responses.
Physical reactions to traumatic events can include stomachache, headache, racing heart, and hyperventilation. It is also common to experience increased anxiety and watchfulness, withdrawal from activities; and intrusive reactions, such as repeated images of the event, or distressing dreams about what happened.
There are a number of helpful coping responses you can recommend to survivors that can help them manage the effects of the traumatic event. These can include talking to someone for support, and setting aside times for positive events, such as reading, or playing a sport. You can also encourage the survivor to be kind to himself or herself, and to not criticize themselves for the different kinds of emotional responses they may be experiencing. Setting a regular routine, including exercise as well as pleasurable activities, helps to restore predictability and enjoyment. As part of this, encourage them to follow a regular sleep schedule, going to bed and waking up at the same times each day.
Step Eight: Linkage with Collaborative Services
Finally, as you know better what the survivor needs, identify the appropriate types of services that may be needed, and do what is needed to help connect the survivor with those services. Acute medical needs, such as injuries from the trauma, should be a first priority. For those requiring medications, identify any missing medications and link the survivor with services that can provide any missing medications. Other considerations include services to provide counseling for psychological distress, and agencies to address alcohol or substance use concerns. Survivors who may have lost their housing or household materials may be connected with services that provide temporary shelter, food, or clothing.
Be sure that you provide accurate information about what is available, which agencies can provide which services, and how the survivor can reach these services. Because survivors are often somewhat disoriented and confused after a trauma, your help in providing information, support, and guidance in what to do next can be invaluable in getting them on track to returning to their normal life.
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