(For publication in the California Peer Support Association newsletter.)
Copying this article is permitted: Psychological First Aid – Clearing Confusion (PDF)
The name “psychological first aid” (PFA) has become a source of great confusion and controversy in emergency services. For 60 years, it has been a generic term for offering immediate support to people impacted by highly emotional events. Multiple PFA protocols have been developed, refined and studied for decades.
Confusion about PFA escalated 10 years ago, when the National Child Traumatic Stress Network (NCTSN) published a new PFA protocol, developed with the National Center for PTSD, and touted it as a “replacement” for Critical Incident Stress Management (CISM).
However, PFA has long been a component of CISM, so calling it a replacement is like saying a finger is a replacement for a hand, says Dr. George Everly, a Johns Hopkins psychologist and co-founder of the International Critical Incident Stress Foundation (ICISF), which establishes CISM standards. Everly has pioneered development and evaluation of both CISM and PFA protocols. He was a primary creator of the PFA protocol taught in CISM, the SAFER-R model.
Unfortunately, PFA confusion has led various organizations and agencies to recommend the NCTSN protocol as a “CISM replacement.” For example, a recent U.S. Department of Justice report, Preparing for the Unimaginable, which reviewed Sandy Hook and other mass casualty incidents, recommended NCTSN PFA as a “replacement” for CISM for law enforcement.
Concern over just one CISM component – debriefing – is at the root of the PFA muddle. The debriefing controversy began about 20 years ago when a small number of inconclusive studies of non-CISM debriefing techniques (none of which involved responders) were misinterpreted as suggesting that re-telling a traumatic story during debriefings could cause harm. However, over 35 years, no study has ever showed harm when ICISF protocols are used by trained people. Although much more research into the effectiveness of debriefings and other interventions is needed and welcome, the criticisms of CISM suggesting harm have been discredited.
Get trained, follow the ICISF protocols and rest assured that you are not going to do damage.
PFA’s Confusing Multiple Meanings
The existence of multiple PFA protocols has led to careless misrepresentation of support for the NCTSN protocol. For example, an Everly paper has been misquoted by multiple authors as saying NCTSN PFA is a “best practice” for first responders. However, the paper was actually about the Johns Hopkins RAPID-PFA protocol. (Everly et al., 2006). Reviewers should have noticed that the paper was written before NCTSN PFA was developed! In many other papers, the specific PFA protocol is not identified, casting doubt on whether NCTSN’s was used.
The NCTSN protocol was not developed with responders in mind. “[NCTSN] PFA is basic ‘grassroots’ psychological support provided for family, friends, neighbors and colleagues by members of the general population” (Barbanel and Sternberg, 2005). It was developed for children, schools and communities. The research literature reports that it has been used by faith communities to support their members in disasters, on school campuses, by community mental health, with disaster survivors, Syrian refugees, Greek refugees and domestic violence survivors. Applying it to responders has been an afterthought.
There has been one study of the NCTSN protocol in public safety. In Hong Kong, 900 responders were trained in the protocol in 2012. Early results were positive. (Chan, 2012,)
The NCTSN Protocol is for Individuals, Not Teams
The NCTSN PFA protocol only addresses interventions with individuals. There is no associated group process that would apply to responders, who have a strong sense of group cohesion and typically share trauma as a team. Applying it to a group is a round peg in a square hole.
The NCTSN Protocol’s Effectiveness Remains Unproven
The NCTSN protocol’s creators call it “evidence informed,” which means that it is based on research that identified potential, rather than actual benefits. Multiple expert reviewers say that there is almost no evidence for its effectiveness and further study is needed.
“The scientific literature on psychological first aid available to date, does not provide any evidence about the effectiveness of PFA interventions. Currently it is impossible to make evidence-based guidelines about which practices in psychosocial support are most effective to help disaster and trauma victims” (Dieltjens et al., 2014,).
“Despite popularity and promotion there remains a dearth of evidence for effectiveness and recent independent reviews of PFA have highlighted this important gap” (Shultz and Forbes, 2014).
“More evidenced-based research is still needed to prove the effectiveness of PFA.” (Zhang, Zhou, and Li, 2015).
The Red Cross, which has endorsed NCTSN PFA training for disaster workers, commissioned an independent review, which also found little evidence. “It was determined that adequate scientific evidence for psychological first aid is lacking but widely supported by expert opinion and rational conjecture. No controlled studies were found. There is insufficient evidence supporting a treatment standard or a treatment guideline” (Fox et al., 2012).
CISM is Helpful, not Harmful
The myth that researchers found that CISM is potentially harmful to responders was an odd conclusion of a review of several studies that gave “psychological debriefings” to victims of auto collisions, burns, dog bites and other accidents. In fact, the studies were inconclusive, but even if they actually had demonstrated potential harm, they are irrelevant to CISM and responders.
- The interventions were inconsistent; ICISF CISM protocols were not followed.
- No responders were involved – the care receivers were medical patients, victims of burns, accidents, etc.
- All of the interventions were with individuals, rather than groups.
Another myth is that debriefings (which are just one component of a CISM system) are intended reduce or prevent Post-Traumatic Stress Disorder. Although debriefings may contribute to that goal, they really are intended to help a team “bounce back” from a difficult incident. Their explicit goals are:
- Mitigation of the impact of a traumatic event.
- Facilitation of the normal recovery processes and a restoration of adaptive functions in psychologically healthy people who are distressed by an unusually disturbing event.
- A [debriefing] functions as a screening opportunity to identify group members who might benefit from additional support services or a referral for professional care.
Evidence of many benefits of CISM are documented in the scientific literature. Stress-related symptoms drop, such as depression, anger and anxiety. Alcohol consumption is reduced. Self-esteem and emotional well-being are higher. Recipients are more cooperative with treatment and care. Suicide rates are lower.
None of the scientific evidence could be properly described as making a strong case for CISM, which is undoubtedly one of the reasons for the “controversy” around it. More research is needed.
Isolation is Toxic
Protocols matter, but resistance and resilience to stress – chronic or acute – correlates most strongly to an individual’s social support. Social isolation, like physical isolation, puts people at high risk. So in the end, no matter our approach, demonstrating that we care for each other – that no one has to be alone – is the most important “protocol” of all.
ABPP, Laura Barbanel, EdD, and Robert J. Sternberg PhD. Psychological Interventions in Times of Crisis. Springer Publishing Company, 2005.
Chan, Emily Y. Y. “Preliminary Results of Psychological First Aid Capacity Building Program on Coping Strategies and Mental Health Measures Among Emergency Responders in Disaster: Results of 6-Month Follow-up of a Randomized Controlled Trial.” World Federation of Public Health Associations, 2012. https://wfpha.confex.com/wfpha/2012/webprogram/Paper10006.html.
Dieltjens, Tessa, Inge Moonens, Koen Van Praet, Emmy De Buck, and Philippe Vandekerckhove. “A Systematic Literature Search on Psychological First Aid: Lack of Evidence to Develop Guidelines.” PloS One 9, no. 12 (2014): e114714. doi:10.1371/journal.pone.0114714.
Everly, George S., Suzanne B. Phillips, Dianne Kane, and Daryl Feldman. “Introduction to and Overview of Group Psychological First Aid.” Brief Treatment and Crisis Intervention 6, no. 2 (2006): 130–36. doi:10.1093/brief-treatment/mhj009.
Fox, Jeffrey H., Frederick M. Jr Burkle, Judith Bass, Francesco A. Pia, Jonathan L. Epstein, and David Markenson. “The Effectiveness of Psychological First Aid as a Disaster Intervention Tool: Research Analysis of Peer-Reviewed Literature From 1990-2010.” Disaster Medicine and Public Health Preparedness 6, no. 3 (October 2012): 247–252. doi:10.1001/dmp.2012.39.
Shultz, James M., and David Forbes. “Psychological First Aid.” Disaster Health 2, no. 1 (January 1, 2014): 3–12. doi:10.4161/dish.26006.
Usher, Laura, Stefanie Friedhoff, Sam Victor Cochran, and Anand A. Pandya. Preparing for the Unimaginable: How Chiefs Can Safeguard Officer Mental Health before and after Mass Casualty Events. Washington, DC : Arlington, VA: Office of Community Oriented Policing Services, U.S. Department of Justice ; National Alliance on Mental Illness, 2016.
Zhang, Li, Jiangsong Zhou, and Lingjiang Li. “Crisis Intervention in the Acute Stage after Trauma.” International Journal of Emergency Mental Health and Human Resilience 2015 (January 1, 1970). doi:10.4172/1522-4821.1000299.
Copyright © 2016 Nick Arnett, Stress, Spirit, Science (http://nickarnett.net)
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