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Systematic Review of Psychological First Aid

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Systematic Review of Psychological First Aid

Systematic Review of
Psychological First Aid
Jonathan I Bisson
Reader in Psychiatry
Cardiff University
and
Catrin Lewis
PhD Student
Cardiff University
Commissioned by the World Health
Organisation
Systematic Review of Psychological First Aid – 31 July 2009
2
Psychological distress is common following extreme stressors (potentially
traumatic events), often short-lived but problematic in a significant minority.
More marked reactions include the development of psychiatric disorders such
as post-traumatic stress disorder (PTSD), depressive disorders, anxiety
disorders and substance use disorders. Attempts to develop early
interventions that can prevent the development of these disorders have
yielded disappointing results and there remains considerable debate
regarding how best to respond to the psychosocial needs of those affected by
traumatic events.
Systematic reviews have found no convincing evidence for the ability of any
psychosocial intervention directed at everyone involved shortly after a
traumatic event to reduce mental health symptoms
1
. This is true for single
session interventions such as individual psychological debriefing
2
and multiple
session interventions including those based on cognitive behavioural
therapy
3
. Thankfully, there is room to be more optimistic regarding the
efficacy of trauma focused cognitive behavioural therapy when delivered to
individuals who have developed either acute stress disorder or acute post-
traumatic stress disorder
4
. This has led to the recommendation that trauma
focused cognitive behavioural therapy is delivered to individuals who develop
these diagnoses
1
.
Given the evidence available at present, it can be argued that no formal
intervention should be delivered following traumatic events unless individuals
develop a diagnosable condition. The option of doing nothing, however, risks
promoting a sense of lack of social support in those affected which has been
associated with the development of PTSD following traumatic events
5,6
. Many
guidelines caution against doing nothing shortly after traumatic events,
arguing for the delivery of supportive, practical and pragmatic input in a
supportive and empathic manner but avoidance of formal clinical
interventions
1,7,8
. Such approaches do not resemble psychological
treatments, in contrast to most of the early interventions that have been
subjected to randomised controlled trials. They are psychosocial with key
social elements that address people’s basic needs, such as housing, finances
and nutrition.
Such approaches have been advocated as important for many years and the
term Psychological First Aid (PFA) is not a new one
9
. More recently and
driven by the work of the National Centre for Post-Traumatic Stress Disorder
(NC-PTSD) in the United States of America PFA has been developed into a
specific intervention
10
. PFA has become very popular and is increasingly
used and recommended. The cautions against the use of individual
psychological debriefing and the absence of an evidence based early
intervention to recommend
1
have fuelled the popularity of PFA. The term
PFA, however, like other terms such as counselling and debriefing, is often
used as a blanket term to describe a range of different approaches and would
benefit from more formal definition. NC-PTSD define PFA as:
Systematic Review of Psychological First Aid – 31 July 2009
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‘an evidence informed, modular approach for assisting people in the
immediate aftermath of disaster and terrorism to reduce initial distress and to
foster short and long-term adaptive functioning.’
The NATO guidelines on psychosocial care for people affected by disasters
and major incidents
8
usefully describe PFA as:
not a single intervention or treatment but an approach that is designed to
respond to people’s psychosocial needs after major incidents or disasters
which comprises of a number of elements”.
The Sphere Handbook describes PFA as:
" basic, non-intrusive pragmatic care with a focus on: listening but not forcing
talk; assessing needs and ensuring that basic needs are met; encouraging but
not forcing company from significant others; and protecting from further harm."
The Inter-Agency Standing Committee (IASC)
11
describe PFA as:
“…..is often mistakenly seen as a clinical or emergency psychiatric
intervention. Rather, it is a description of a humane, supportive response to a
fellow human being who is suffering and who may need support. PFA is very
different from psychological debriefing in that it does not necessarily involve a
discussion of the event that caused the distress.”
The key components of PFA described by NATO, IASC and a joint UK-USA
group of experts
12
are listed alongside each other in Table 1.
Table 1: Components of Psychological First Aid
UK-USA Group
12
NATO
8
IASC
11
Active listening Providing comfort and
consolation
Protecting from
further harm
Reassurance through
normalisation
Protecting people from
further threat and
distress
Providing the
opportunity for
survivors to talk
about the events,
but without
Pressure and
respecting the wish
not to talk
Provision of appropriate and
supportive advice and
information to include self
care and self monitoring
Providing immediate
physical care
Listening patiently
in an accepting
and non-
judgemental
manner
Helping people to identify
problems they cannot handle
Encouraging goal
orientated and
purposeful behaviour
Conveying genuine
compassion
Modelling helpful reactions to
traumatic stress
Helping people to
reunite with loved ones
Identifying basic
practical needs
Systematic Review of Psychological First Aid – 31 July 2009
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and ensuring that
these are met
Advice and guidance on
maintaining a lifestyle
favourable to mental health
and wellbeing
Enabling voluntary
sharing of experiences
Asking for people’s
concerns and
trying to address
these
Providing information on how
and when to refer themselves
Linking survivors with
sources of support
Discouraging
negative ways of
coping (specifically
through use of
substances
Specific attention to the
needs of children, young
people and other specific
groups
Facilitating a sense of
being in control
Encouraging
participation in
normal daily
routines (if
possible) and use
of positive means
of coping
Helping people understand
the needs and reactions of
others and how they can
support others
Identifying people who
need further help
(triage)
Encouraging, but
not forcing,
company from one
or more family
member or friends
Referral to other more
specialist or supportive
services where indicated
As appropriate,
offering the
possibility to return
for further support
Considering and addressing
ethical matters
As appropriate,
referring to locally
available support
mechanisms or to
trained clinicians
Evaluating risk (including
suicide risk)
PFA continues to be described as an evidence-informed approach but has not
yet been subjected to a formal systematic review of its effectiveness. In order
to address this, the World Health Organisation commissioned us to conduct a
systematic review to determine the current evidence base. As we were not
aware of any randomised controlled trials of PFA we decided to consider any
data containing study regarding its effectiveness. We also conducted a
systematic review of predictors of PTSD and depression to determine if there
were other sources of research that could inform its potential effectiveness.
Systematic Review of Psychological First Aid – 31 July 2009
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Methods and Results
Systematic review of Psychological First Aid (PFA)
Using the search terms ‘psychological first aid’ and ‘PFA’ the 16 widely used
online bibliographic databases listed in Table 2 were searched.
Table 2: Online bibliographic databases searched
AMED (Allied and Complementary Medicine)
ASSIA (Applied Social Sciences Index and Abstracts)
British Nursing Index and Archive
CINAHL (Cumulative Index to Nursing & Allied Health Literature)
Cochrane Central Register of Controlled Trials (CENTRAL)
Cochrane Database of Systematic Reviews (CDSR)
EMBASE (Excerpta Medica)
HMIC (Health Management Information Consortium)
ISI Science Citation Index
ISI Social Sciences Citation Index
International Bibliography of the Social Sciences (IBSS)
MEDLINE
MEDLINE In-Process & Other Non-Indexed Citations
PILOTS
PsychINFO
Sociological Abstracts
The search yielded 779 citations which were imported into EndNoteX1
reference management software. Removal of duplicates resulted in 516
abstracts for consideration. These were scrutinized one by one to ascertain
potential relevance. 298 were removed on the basis that they did not relate to
PFA or disaster response. This left 218 abstracts for more in depth
consideration. Of these only 74 were directly related to PFA and none
contained any data. These articles provided description, commentary, expert
opinion or discussion of PFA. This search revealed no RCTs, observational or
any other empirical study of PFA.
Systematic review of existing systematic reviews of
protective/risk factors for PTSD
The databases listed in Table 2 were searched using the terms ‘PTSD’, ‘Post
traumatic stress disorder’ and ‘traumatic stress’ combined with the terms
‘predictors’, ‘risk factors’, ‘resilience’ and ‘protective’ limited only to ‘reviews’.
The search revealed 901 citations. Removal of duplicates left 798. Reviewing
the abstracts revealed 70 reviews of the literature related to protective/risk
factors for PTSD. 15 were systematic reviews. The reference sections of
these papers were checked for additional systematic reviews, none were
found. Table 3 summarises the results of the systematic reviews identified.
Systematic Review of Psychological First Aid – 31 July 2009
6
The quality of the reviews included was variable and the reviews of Brewin et
al and Ozer et al remain the most comprehensive ones in the field. Only five
of the reviews included a meta-analysis, two of which only considered peri-
traumatic dissociation. In these five studies, the factors associated with the
presence of PTSD with an effect size over 0.2 were peri-traumatic
dissociation, lack of social support post trauma, trauma severity, life stress
post-trauma, perceived life-threat and peri-traumatic emotional response. In
children the associated factors were pre-trauma psychopathology, threat to
life and pre-trauma parental distress. All effect sizes were weighted average
correlations (Pearson’s r)
Systematic Review of Psychological First Aid – 31 July 2009
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Table 3: Systematic reviews of risk/ protective factors for PTSD
Author Year
Traumatising
event(s)
Age
Group
Risk / protective
factors examined
Number
of
studies
included
Average effect size (r)/
Conclusion
Breh et al
13
2007
Various
traumas
Adults Peri-traumatic
dissociation
35 Peri-traumatic dissociation = 0.36
Brewin et al
5
2000
Various
traumas
Adults Gender
Age
Socio-economic status
Education
Intelligence
Race
Pre-trauma
psychopathology
Childhood abuse
Prior trauma
Other adverse childhood
Family psychiatric
history
Trauma severity
Lack of social support
Life stress
77 Gender (female) = 0.13
Age (younger) = 0.06
Socio-economic status (lower) = 0.14
Education (lack of) = 0.10
Intelligence (lower) = 0.18
Race (minority status) = 0.05
Pre-trauma psychopathology = 0.11
Childhood abuse = 0.14
Prior trauma = 0.12
Other adverse childhood = 0.19
Family psychiatric history = 0.13
Trauma severity = 0.23
Lack of social support = 0.40
Life stress = 0.32
Bruce
14
2006
Childhood
cancer
survivors and
their parents
All ages Parent sex
Age of child
Socioeconomic status
Time off treatment
Prior stressful life events
24 Parent sex – “mothers of childhood cancer
survivors exhibited higher rates of cancer-
related PTSS than fathers”
Age of child – one study supported
Socioeconomic status – “some findings
Systematic Review of Psychological First Aid – 31 July 2009
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Family support
Social support
Coping style
support the relationship between lower
socioeconomic status and PTSS, others find
the opposite”
Time off treatment – “the vast majority of
studies of studies reported no correlation
between time off treatment and PTSS”
Prior stressful life events – “both quantity
and quality of prior stressful life events were
shown to be associated with increased rates
of developing cancer related PTSD”
Family support – “greater family support
was associated with fewer PTSS”
Cox et al
15
2008
Accidental
traumatic
injury
Children
and
adolescents
Gender
Age
Pre-trauma
psychopathology
Injury severity
Threat to life
Prior trauma
Involvement of
family/friends in trauma
Pre-trauma parental
distress
14 Gender (female) = 0.18
Age (younger) = -0.04
Pre-trauma psychopathology = 0.22
Injury severity = 0.09
Threat to life = 0.38
Prior trauma = 0.08
Involvement of family/friends in trauma =
0.09
Pre-trauma parental distress = 0.29
Davydow et
al
16
2008
Individuals
admitted to
ICU
All ages Gender (female)
Age (younger)
Agitation in ICU
Physical restraint
Medication
Post ICU memories
15 No meta analysis.
The following predictors were identified:
Gender (female) – significant in 2 of 7
studies
Age (younger) – significant in 4 of 8 studies
Agitation in ICU – significant in 1 of 1 study
Systematic Review of Psychological First Aid – 31 July 2009
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Anxiety or depression
post ICU
Physical restraint - significant in 1 of 1 study
Anxiety or depression post ICU – significant
in 1 of 2 studies
Various factors to do with medication were
found significant in 1 or more study
Various factors to do with post ICU
memories were found significant in 1 or
more study
Gidron et al
17
2002
Terrorist
attacks
All ages Injury severity
Fear
Feeling treatment was
helpful
Depression
Dissatisfaction with crisis
support
6 No meta analysis
Conclusion:
“the literature is inconsistent concerning the
role of injury severity as a predictor of
PTSD”
Other factors discussed only in relation to
individual studies.
Johnson et
al
18
2008
Civilian
survivors of
war trauma
and torture
Adults Dose
Gender
Age
Refugee variables
Unclear No meta analysis.
Conclusions were as follows:
Dose – “there appears to be consistent
evidence of a dose-effect relationship
between cumulative trauma and the
development and maintenance of PTSD”
Gender – “there is also some evidence that
females are at higher risk than males for
developing PTSD”
Age – “there is also some evidence that
those of older age are more at risk of
developing PTSD”
Systematic Review of Psychological First Aid – 31 July 2009
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Refugee variables – “although there is a
dearth of studies investigating the impact of
refugee variables on the development of
PTSD it is likely that variables such as
uncertain refugee status and obstacles to
employment and lack of social support
exacerbate symptoms and contribute to
their maintainance”
Lensvelt-
Mulders et al
19
2008
Various
traumas
All ages Peri-traumatic
dissociation
59 Peritraumatic dissociation = 0.401
Olofsson et al
20
2009
RTAs Children
and
adolescents
Perceived threat
Gender (female)
Anxiety and depression
symptoms
Increased parental
vigilance after RTA
(reported by child)
Involvement in car
accidents
Child and parent PTSS
symptoms at 4-6 weeks
12 No meta analysis:
The following were significant risk factors in
multiple studies:
Perceived threat
Gender (female)
Anxiety and depression symptoms
The remainder were predictive in single
studies:
Increased parental vigilance after RTA
(reported by child)
Involvement in car accidents
Child and parent PTSS symptoms at 4-6
weeks
Ozer et al
6
2003
Various
traumas
Adults Prior trauma
Prior psychological
adjustment
Family history of
psychopathology
68 Prior trauma – 0.17
Prior psychological adjustment – 0.17
Family history of psychopathology – 0.17
Perceived threat to life – 0.26
Social support post-trauma - -0.28
Systematic Review of Psychological First Aid – 31 July 2009
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Perceived threat to life
Social support post-
trauma
Peri-traumatic emotional
response
Peri-traumatic
dissociation
Peri-traumatic emotional response – 0.26
Peri-traumatic dissociation – 0.35
Tedstone et
al
21
2003
Medical
illness and
treatment
Adults Existing characteristics
(e.g. personality,
previous life adversity,
previous mental health
difficulties)
Age
Aspects of trauma itself
Medication
14 No meta analysis.
The following conclusions were drawn:
Existing characteristics (e.g. personality,
previous life adversity, previous mental
health difficulties) – “may dispose
individuals to the development of PTSD”
Age – “there is mixed evidence concerning
the impact of age on the development of
PTSD in the physical health literature”
Aspects of trauma itself – “may also
predispose individuals to the development
of PTSD”
Medication – “little is known about how
these drugs may impede or enhance trauma
processing”
Tolin et al
22
2006
Various
traumas
All ages Gender 290 “Meta analyses of studies yielding sex-
specific risk of potentially traumatic events
and PTSD indicated that female participants
indicated that female participants were more
likely than male participants to meet criteria
for PTSD(I couldn’t see an effect size)
Van der Hart 2008
Various All ages Peri-traumatic 53 No meta analysis
Systematic Review of Psychological First Aid – 31 July 2009
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et al
23
traumas (only one
study
pertained to
children)
dissociation Conclusion:
“the majority of the empirical studies
reviewed supported the notion that the
experience of dissociative symptoms during
a potentially traumatising event increases
the risk of developing PTS”
Van der
Velden
24
2008
Various
traumas
All ages Peri-traumatic
dissociation (PD)
17 No meta analysis.
Conclusion:
“this systematic review demonstrates that
the majority of prospective studies found no
indications that PD is an independent
predictor for PTSD symptomatology 3
months or later after type I traumatic events,
although several studies reported a
significant cross-sectional or bivariate
association between PD and PTSD
symptomatology”
Systematic Review of Psychological First Aid – 31 July 2009
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Systematic review of existing systematic reviews of
protective/risk factors for depression after disaster/ traumatic
events
Using the search terms ‘depression’ combined with the terms ‘predictors’, ‘risk
factors’, ‘resilience’ and ‘protective’ together with ‘trauma’, ‘traumatic’,
‘disaster’ limited only to ‘reviews’ the online databases shown in Table 1 were
searched. The search yielded 3473 citations which were imported into
EndNoteX1 reference management software. Removal of duplicates resulted
in 2598 for consideration. These were scrutinized one by one to ascertain
potential relevance. This search however revealed no systematic reviews of
risk factors for depression after traumatic events.
Discussion
The absence of quantitative data containing evidence to support PFA makes it
impossible to determine whether it is effective or not following traumatic
events. It is apparent, however, that certain factors, in particular peri-
traumatic dissociation and perceived poor social support, are associated with
raised rates of PTSD. This provides support for the argument that effective
interventions should address these two factors. A recent Delphi study of over
100 experts, performed to develop the European Network for Traumatic
Stress’s (TENTS) Guidelines on psychosocial care following disasters
7
, found
strong consensus that, despite the absence of direct evidence, social care
should be provided for those involved in disasters
25
. There was also strong
consensus that responses should promote a sense of safety, self and
community efficacy/empowerment, connectedness, calm and hope. This is in
keeping with and informed by the work of Hobfoll and colleagues who argued
that indirect evidence pointed to these factors as being guiding principles for
early to mid-level intervention following disaster and mass violence
26
. The
TENTS Delphi study also found strong consensus for the provision of general
support, access to social support, physical support and psychological support.
The TENTS guidelines - like the IASC Guidelines - recommend that the
interventions provided to individuals should only be done with full
consideration of individuals’ wider social environment, especially their families
and communities
7
. They advocate the provision of practical help and
pragmatic support in an empathic manner. These recommendations are
consistent with the principles of PFA and are supported by the findings of our
systematic review of systematic reviews of predictors. They are also
consistent with considerable anecdotal evidence that individuals fare badly if
they feel they are not supported, particularly by those they feel should be
supporting them, for example employers or people in positions of authority.
It is clear that the principles of PFA have much in common with the
approaches recommended in guidelines for psychosocial responses following
major traumatic events and are supported by evidence that lack of social
support is associated with poorer outcome. It therefore seems reasonable to
Systematic Review of Psychological First Aid – 31 July 2009
14
advocate the use of interventions based on the principles of PFA, as several
guidelines do
8,11,12,27
although most fall short of recommending PFA as a
manualised step-by-step intervention. We would also caution against this
given the absence of direct evidence for PFA or any other formal intervention
for everyone involved in a traumatic event. Hobfoll et al
26
argue that there
are many ways to operationalise the five principles they identified and the
need for careful design of interventions that are tested in pilot programs,
refined, retested, and further evaluated before being implemented. They also
caution against hopes that such interventions will be an ultimate panacea that
prevent long-term difficulties and emphasise the need to consider cultural
factors, a point that led the NC-PTSD to note a potential limitation of its PFA
guide as its specific development for use in Western settings.
IASC’s guidance recommends the provision of PFA by “a variety of
community workers” for people in “acute trauma-induced distress”
11
. This is
consistent with Sphere’s recommendation that PFA is available to acutely
distressed individuals after traumatic events. IASC argue that some forms of
psychological support (“very basic psychological first aid”) for people in acute
psychological distress do not require advanced knowledge and can easily be
taught to workers who have no previous training in mental health. It seems
important that the principles of PFA can be taught quickly to both volunteers
and professionals
27
and that PFA is not seen as, and does not become, a
formal clinical intervention.
The NATO Guidelines favour the principles of PFA as an appropriate basis for
psychosocial plans because:
“the abilities of people to accept and use social support and the availability of
it are two of the key features of resilience.”
In common with others,
1,28
the NATO guidelines advocate a stepped model of
care, in which the needs of people determine the level of support they receive.
PFA is a key component in this model as shown in Table 4.
Table 4: NATO Stepped Care Model - the six main components
Strategic planning - multi-agency to include preparation, training and
rehearsal
Prevention services - planned and delivered in advance to develop
communities’ psychosocial resilience
Basic humanitarian and welfare services available to everyone
Psychological first aid delivered by trained and supervised lay persons
Screening, assessment and intervention services for people with ongoing
distress
Access to primary and secondary mental healthcare services for people who
are assessed as requiring them.
In summary, there is an absence of direct evidence for the effectiveness of
PFA but indirect evidence supports the delivery of services based on the
principles of PFA in the first few weeks after a traumatic event. We agree that
when delivered PFA should be consistent with research evidence on risk and
Systematic Review of Psychological First Aid – 31 July 2009
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resilience following trauma; applicable and practical in field settings;
appropriate for developmental levels across the lifespan; and culturally
informed and delivered in a flexible manner
8
.
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... The PFA does not include discussions about the traumatic events, but focuses on providing practical care and support, by assessing the needs and concerns of those affected and by helping people connect to information, services and social supports [15][16][17]. The three main principles of PFA are to look (for safety or for who needs help) listen (to those that are in distress) and link (to further support). ...
... The three main principles of PFA are to look (for safety or for who needs help) listen (to those that are in distress) and link (to further support). Evidence exists to suggest that PFA is a useful intervention to reduce the initial effects of trauma [16], however findings are typically based on studies based in war or natural disasters such as earthquakes and floods [17,18]. Recent studies suggest that PFA might be useful for reducing the initial distress caused by traumatic events and fostering resilience in healthcare professionals [16,19]; however, systematic reviews [17,18] have suggested that further research is needed to strengthen recommendations for more widespread use of PFA to support people following crises. ...
... Evidence exists to suggest that PFA is a useful intervention to reduce the initial effects of trauma [16], however findings are typically based on studies based in war or natural disasters such as earthquakes and floods [17,18]. Recent studies suggest that PFA might be useful for reducing the initial distress caused by traumatic events and fostering resilience in healthcare professionals [16,19]; however, systematic reviews [17,18] have suggested that further research is needed to strengthen recommendations for more widespread use of PFA to support people following crises. ...
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Background The Covid-19 pandemic has produced unprecedented challenges across all aspects of health and social care sectors globally. Nurses and healthcare workers in care homes have been particularly impacted due to rapid and dramatic changes to their job roles, workloads, and working environments, and residents’ multimorbidity. Developed by the World Health Organisation, Psychological First Aid (PFA) is a brief training course delivering social, emotional, supportive, and pragmatic support that can reduce the initial distress after disaster and foster future adaptive functioning. Objectives This review aimed to synthesise findings from studies exploring the usefulness of PFA for the well-being of nursing and residential care home staff. Methods A systematic search was conducted across 15 databases (Social Care Online, Kings Fund Library, Prospero, Dynamed, BMJ Best Practice, SIGN, NICE, Ovid, Proquest, Campbell Library, Clinical Trials, Web of Knowledge, Scopus, Ebsco CINAHL, and Cochrane Library), identifying peer-reviewed articles published in English language from database inception to 20th June 2021. Results Of the 1,159 articles screened, 1,146 were excluded at title and abstract; the remaining 13 articles were screened at full text, all of which were then excluded. Conclusion This review highlights that empirical evidence of the impact of PFA on the well-being of nursing and residential care home staff is absent. PFA has likely been recommended to healthcare staff during the Covid-19 pandemic. The lack of evidence found here reinforces the urgent need to conduct studies which evaluates the outcomes of PFA particularly in the care home staff population.
... 13 In addition, people who suffer from PTSD are likely to need psychosocial care in parallel with specialist mental health treatments. The need for non-specialist psychosocial care that is informed by the principles of psychological first aid 14 in relation to disasters is now widely accepted, and is recognised in formal models such as the North Atlantic Treaty Organization's stepped model of care, 15 and the model advocated in 2021 by NHS England. 16 The nature and consequences of social support ...
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Background Much of the psychosocial care people receive after major inci- dents and disasters is informal and is provided by families, friends, peer groups and wider social networks. Terrorist attacks have increased in recent years. Therefore, there is a need to better understand and facilitate the informal social support given to survivors. Aims We addressed three questions. First, what is the nature of any informal support-seeking and provision for people who experi- enced the 2017 Manchester Arena terrorist attack? Second, who provided support, and what makes it helpful? Third, to what extent do support groups based on shared experience of the attack operate as springboards to recovery? Method Semi-structured interviews were carried out with a purposive sample of 18 physically non-injured survivors of the Manchester Arena bombing, registered at the NHS Manchester Resilience Hub. Interview transcripts were thematically analysed. Results Participants often felt constrained from sharing their feelings with friends and families, who were perceived as unable to understand their experiences. They described a variety of forms of helpful informal social support, including social validation, which was a feature of support provided by others based on shared experience. For many participants, accessing groups based on shared experience was an important factor in their coping and recovery, and was a springboard to personal growth. Conclusions We recommend that people who respond to survivors’ psycho- social and mental healthcare needs after emergencies and major incidents should facilitate interventions for survivors and their social networks that maximise the benefits of shared experience and social validation.
... Psychological first aid (PFA) is an evidence-informed approach to assist individuals in the aftermath of disasters (4). PFA is delivered by disaster response workers who provide early assistance, including mental health professionals, religious professionals, disaster volunteers, and qualified music practitioners (5). ...
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Strict precautions during the COVID-19 pandemic left patients isolated during already stressful hospital stays. Research indicates that listening to music recruits regions in the brain involved with social interaction and reduces feelings of loneliness. We formed a team of clinicians and clinical musicians to bring music to the bedside, as “psychological first aid.” Our goal was to reduce feelings of anxiety and isolation in patients admitted to the Northwestern Memorial Hospital's neurosciences unit. Participants were offered 30–40-min live music sessions over FaceTime by a violist in consultation with a music therapist and a certified music practitioner. Music used for the interventions was personalized. Participants were evaluated with the Music Assessment Tool where they indicated their musical preferences and music to which they objected. Following the intervention, participants answered a questionnaire assessing how music impacted their emotional state based on a 1–10 Likert scale. Scores were then averaged across all patients and were calculated as percentages. Eighty-seven sessions were completed during a 3-month period. Despite different degrees of disability, most patients engaged aesthetically with the music. The likelihood to recommend (LTR) for the program was 98%; participants tended to highly agree that the intervention improved their emotional state (92%); that it provided a pleasurable experience (92.4%); and that it reduced their stress and anxiety (89.5%). This pilot project showed that the telemusic intervention was feasible for our neurosciences patients during the COVID-19 pandemic. Our results are consistent with previous in-person hospital-based music interventions and highlight the importance of such programs when in-person interventions are not possible. This pilot project serves as a prelude to further investigate mechanisms by which music interventions can support admitted neurology patients.
... PFA can be provided by anyone who has received proper training and who can make referrals to mental health professionals when required [24]. Although systematic reviews report that there is no direct evidence of PFA effectiveness, indirect evidence supports its delivery in a variety of settings [25,26]. ...
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Background The COVID-19 pandemic has stricken mental health worldwide. Marginalized populations in low- and middle-income countries have been the most affected, as they were already experiencing barriers to accessing mental health care prior to the pandemic and are unequally exposed to the stressors associated with the health emergency, such as economic ravages or increased risk of complicated disease outcomes. Objective The aim of this paper is to describe a comprehensive initiative resulting from a public-civil partnership to address the increased burden of mental health illness associated with the COVID-19 pandemic in rural Chiapas, Mexico. Methods To address the emerging health needs of the general population and health professionals resulting from the pandemic, Compañeros En Salud (CES), a non-profit civil society organization based in Chiapas, implemented a comprehensive strategy to compensate for the shortage of mental health services in the region in collaboration with the Chiapas Ministry of Health. The strategy included three components: capacity building in mental health care delivery, psychosocial support to the general population, and provision of mental health care to CES collaborating staff. In this capacity building article, implementers from CES and the government share descriptive information on the specific interventions carried out and their beneficiaries, as well as a critical discussion of the strategy followed. Results Through this strategy, we have been successful in filling the gaps in the public health system to ensure that CES-served populations and CES-collaborating health professionals have access to mental health care. However, further studies to quantify the impact of this intervention in alleviating the burden of mental health illnesses associated with the pandemic are needed. Conclusions The current situation represents an opportunity to reimagine global mental health. Only through the promotion of community-based initiatives and the development of integrated approaches will we ensure the well-being of marginalized populations.
... As a consequence of vague descriptions of PFA training content and delivery, it further highlights the difficulties of evaluating fidelity to the original PFA model. Thus, better reporting of PFA training interventions is essential to enable replication, implementation and also facilitate understanding the effectiveness, as there is still a lack of evidence on the use of PFA as a therapeutic intervention [66]. ...
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Worldwide commitment to disseminate Psychological First Aid (PFA) training to enable frontline workers to support distressed individuals and/or manage their own self-care is increasing, but the evidence base of PFA training is uncertain. Method: a scoping review was undertaken by searching seven databases and hand-searching grey literature to maximise coverage of potential studies. Results: Twenty-three studies met the inclusion criteria. Three PFA training models were commonly used in research studies. A broad selection of PFA training outcomes were observed including learning, behavior, satisfaction and practice in crisis mental and behavior health preparedness. Conclusions: Research evidence of reasonable quality demonstrates that PFA training significantly improves knowledge of appropriate psychosocial response and PFA skills in supporting people in acute distress, thereby enhancing self-efficacy and promoting resilience. However, this review highlights inadequate guidance on how PFA training should be applied and adapted, significant shortcomings of reporting PFA training delivery, limited training evaluation and unclear training outcomes. Whilst behavioral, knowledge and system impact of the PFA training are promising, methodologically stronger evaluations which include systematic training adaptation and selection of sensitive outcome measures is needed to strengthen future implementation of PFA training and thereby enhance population preparedness for future emergencies.
... Debriefing and CISD encourage verbalization immediately following a trauma and is an approach criticized for causing additional psychological harm (Carlier et al., 2000;van Emmerick et al., 2002;Rose et al., 2003). The same concern was not found with PFA (Bisson & Lewis, 2009;Dieltjens et al., 2014;Fox et al., 2012) indicating why this has become the global post-disaster support strategy (WHO, 2011). ...
Article
Psychological first aid is a form of support designed to lessen disaster‐related distress. In a pandemic, providers may need such support but with the high risk of exposure, such a program is offered only virtually. The research is scant for traditional post‐disaster support and non‐existent for virtual; therefore, by using related research this discussion considers the likelihood of providers accessing and benefiting from this program. The virtual platform is heralded as the responsible way to provide support in a pandemic but this standard may be ineffective and is inherently inequitable. As a global event, pandemics require containment strategies applicable on an international level; therefore, psychosocial support should also be developed with an international audience in mind. Online psychosocial support falls short of being such a strategy as it incorrectly assumes global internet access. Many low‐income areas such as Sub‐Saharan Africa will need support strategies which compliment local frontline staff and fit with community‐driven initiatives, whereas wealthier countries may use a combination of onsite and online support. Provider psychosocial support needs in a pandemic, if articulated, are globally similar but how this support is offered requires contextually sensitive considerations not yet found in the literature.
Chapter
Human beings are social animals, and social psychiatry is a key discipline within psychiatry around the world. The impact of social factors on the genesis and perpetuation of mental illnesses and maintenance of well-being of individuals and families is well recognized. Exploring social factors is the key to understanding aetiology and developing therapeutic interventions. Social psychiatry has led to deinstitutionalization and the setting up of community mental health teams. This has further helped develop home treatments, early interventions, crisis interventions, and so on. In addition to social interventions at individual, family, and community levels, social psychiatry has led the way in delivering recovery and improved social functioning. Furthermore, there is increasingly impressive evidence that social determinants and social factors affect the biology of human beings and biology, in turn, influences the social functioning of individuals. Inevitably, social psychiatry encompasses the whole age span. From adverse childhood experiences to connected life in older age groups, social factors play a significant role in the functioning of individuals. This book provides an overview of the history and development of social psychiatry, the social world, social determinants, clinical conditions, and the impact on special vulnerable groups, which is followed by a description of social interventions—old and new—and a critical overview of global mental health and the challenges in different parts of the world, emphasizing that one size does not fit all. The final chapter looks to the future of social psychiatry. This textbook brings together a number of giants of social psychiatry and younger, rising stars.
Article
A significant lack of evidence regarding the effectiveness of psychological first aid (PFA) training of first responders to emergency settings has been reported. The aim of the present study was to assess the effectiveness of a PFA training program on the feeling of confidence on providing help in crisis, knowledge, attitudes, and skills of police officers. Fifty police officers were trained in PFA, using an adapted version of the World Health Organization’s program, and they were compared to a control group of 53 police officers. A PFA questionnaire was used to compare the two groups, before and after the implementation of the PFA training. Results revealed significant improvementson confidence, knowledge, attitudes, and skills of trained police officers, in comparison to controls. Thus, the present results suggest that PFA training programs are effective and should be offered to police officers in order to enhance their capacity to provide PFA in emergency settings.
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The aims of this paper was to review a theoretical model useful for developing nursing knowledge in relation to nurse-patient interactions, Nurses are favorably viewed by the society, most often as virtuous, benevolent, angelic and admirable. Nurses have been stereotyped positively as 'ministering angels'. This positive view of the profession is frequently experienced first-hand in the clinical practice. The interaction between a nurse and the patient is in about four phases as defined by Peplau this includes-Orientation, Identification, Exploitation and Resolution, although these phases are defined separately, there is a considerable level of overlap between them. Issues such as power, the socio-cultural context, and interpersonal competence are shown to be important in the quality of nurse-patient interactions and nurses need to take cognizance of these factors in their interactions with patients. Method: A review of the literature on nurse-patient interaction was carried out to and areas for further studies identified. The literature was reviewed from the following perspectives, (1) nurse communication within the nurse-patient interaction, (2) nurse-patient interaction, (3) patient perception of the nurse-patient interaction, and (4) patient care-seeking communication. Theoretical model: Peplau's theory of Psychodynamic nursing. Results: Nurse-patient interaction is a central element of clinical nursing practice. This paper shows how Peplau's model can be used as a theoretical framework for understanding nurse-patient communication. Relevance to clinical practice: Issues such as power, the socio-cultural context, and interpersonal competence are important in the quality of nurse-patient interactions and nurses need to take cognizance of these factors in their interactions with patients.
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The aim of this present article is to discuss the Psychological First Aid (PFA) model designed for Ukrainian military personnel suffering from combat stress reactions (CSRs) in the War in Donbas. The PFA model and algorithm for casualties with signs of CSRs provide for simple measures aimed at ensuring the personal safety of the casualty, satisfying basic physiological needs, and stopping the action of combat stressors. The 3-level PFA model provides for the gradual transfer of the casualty to higher-level providers, as needed, where at the first level is his colleague (“peer-to-peer”), at the second, is his commander, at the third is a psychologist. The main activities carried out at all levels of PFA in the event of the occurrence of CSRs are disclosed. For their effective relief, an algorithm was developed that provides a clear relationship between the levels of PFA. Criteria for assessing PFA based on the results of the restoration of impaired mental functions of the casualty are proposed. The PFA model for military personnel suffering from combat stress was tested in practice (2016–2019) in combat operations with illegal armed groups in the East of Ukraine.
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A review of 2,647 studies of posttraumatic stress disorder (PTSD) yielded 476 potential candidates for a meta-analysis of predictors of PTSD or of its symptoms. From these, 68 studies met criteria for inclusion in a meta-analysis of 7 predictors: (a) prior trauma, (b) prior psychological adjustment, (c) family history of psychopathology, (d) perceived life threat during the trauma, (e) posttrauma social support, (f) peritraumatic emotional responses, and (g) peritraumatic dissociation. All yielded significant effect sizes, with family history, prior trauma, and prior adjustment the smallest (weighted r = .17) and peritraumatic dissociation the largest (weighted r = .35). The results suggest that peritraumatic psychological processes, not prior characteristics, are the strongest predictors of PTSD.
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This paper critically reviews the empirical literature addressing the relationship of peritraumatic dissociation to posttraumatic stress. PSYCHLIT and MEDLINE literature searches were conducted to identify relevant studies. The list of articles generated was supplemented by a review of their bibliographies, which resulted in a total of 53 empirical studies. These studies were classified according to the type of potentially traumatizing event investigated and discussed. In the majority of studies, evidence was found for a positive association between peritraumatic dissociation and posttraumatic stress. However, research in this area is limited by several methodological differences and shortcomings with respect to study design, sample characteristics, measurement instruments, and control for moderating or mediating variables. In addition, research is also limited by conceptual problems and the lack of specific time parameters for the occurrence of peritraumatic dissociation. The literature is evaluated according to these methodological differences or shortcomings, and directions for future research are provided.
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How best to plan and provide psychosocial care following disasters remains keenly debated. To develop evidence-informed post-disaster psychosocial management guidelines. A three-round web-based Delphi process was conducted. One hundred and six experts rated the importance of statements generated from existing evidence using a one to nine scale. Participants reassessed their original scores in the light of others' responses in the subsequent rounds. A total of 80 (72%) of 111 statements achieved consensus for inclusion. The statement 'all responses should provide access to pharmacological assessment and management' did not achieve consensus. The final guidelines recommend that every area has a multi-agency psychosocial care planning group, that responses provide general support, access to social, physical and psychological support and that specific mental health interventions are only provided if indicated by a comprehensive assessment. Trauma-focused cognitive-behavioural therapy (CBT) is recommended for acute stress disorder or acute post-traumatic stress disorder, with other treatments with an evidence base for chronic post-traumatic stress disorder being made available if trauma-focused CBT is not tolerated. The Delphi process allowed a consensus to be achieved in an area where there are limitations to the current evidence.
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Psychological debriefing for preventing post traumatic stress disorder (PTSD) This review concerns the efficacy of single session psychological "debriefing" in reducing psychological distress and preventing the development of post traumatic stress disorder (PTSD) after traumatic events. Psychological debriefing is either equivalent to, or worse than, control or educational interventions in preventing or reducing the severity of PTSD, depression, anxiety and general psychological morbidity. There is some suggestion that it may increase the risk of PTSD and depression. The routine use of single session debriefing given to non selected trauma victims is not supported. No evidence has been found that this procedure is effective.
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Traumatic events can have a significant impact on individuals', families' and communities' abilities to cope. In the past, single session interventions such as psychological debriefing were widely used with the aim of preventing continuing psychological difficulties. However, previous reviews have found that single session individual interventions have not been effective at preventing post -traumatic stress disorder (PTSD). A range of other forms of intervention have been developed to try to prevent individuals exposed to trauma developing PTSD. This review evaluated the results of 11 studies that tested a diverse range of psychological interventions aimed at preventing PTSD. The results did not find any evidence to support the use of an intervention offered to everyone. There was some evidence that multiple session interventions may result in worse outcome than no intervention for some individuals. Further research is required to evaluate the most effective ways of providing psychological help in the early stages after a traumatic event.
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The authors sought to determine the efficacy of multiple-session psychological interventions to prevent and treat traumatic stress symptoms beginning within 3 months of a traumatic event. Nine computerized databases were searched, and manual searches were conducted of reference lists of selected articles as well as two journals. In addition, key researchers in the field were contacted to determine whether they were aware of other relevant studies. The reviewers identified randomized controlled trials of multiple-session psychological treatments aimed at preventing or reducing traumatic stress symptoms in individuals within 3 months of exposure to a traumatic event. Details of the studies were independently extracted by two reviewers, and outcome data were entered into the Review Manager software package. Quality assessment was also conducted by two researchers independently. Twenty-five studies examining a range of interventions were identified. For treatment of individuals exposed to a trauma irrespective of their symptoms, there was no significant difference between any intervention and usual care. For treatment of traumatic stress symptoms irrespective of diagnosis, trauma-focused cognitive-behavioral therapy (CBT) was more effective than waiting list or supportive counseling conditions. The difference was greatest for treatment of acute stress disorder and acute posttraumatic stress disorder. Trauma-focused CBT within 3 months of a traumatic event appears to be effective for individuals with traumatic stress symptoms, especially those who meet the threshold for a clinical diagnosis.
Article
There remains uncertainty on how best to respond to the psychological needs of individuals following traumatic events. Various approaches have been tried, but there is now a growing body of research in this area that allows us to plan appropriate responses in an evidence-based and coordinated manner. This paper describes the development of a local initiative through a partnership between the local traumatic stress service and the emergency planning department.
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To identify the prevalence of post-traumatic stress disorder (PTSD) and PTSD symptoms (PTSS) among children and adolescents injured in traffic, and to assess predictors of such post-traumatic stress. Studies identified from electronic databases were reviewed. Based on a review of 12 studies, fulfilling specified criteria, the prevalence of PTSS was estimated at 30% within 1 month and 13% at 3-6 months. The prevalence of PTSD was almost 30% at 1-2 months and decreased to the same level as PTSS at 3-6 months. Perceived threat and high levels of distress, anxiety symptoms and being female were significantly associated with PTSD and PTSS. Injury severity was positively related to the number of PTSD symptoms in one of eight studies. Types of accident, age and socioeconomic status were not related to the development of PTSD/PTSS. Any child will be at risk of PTSD/PTSS, not just those with severe injuries. Trauma care should include procedures that could identify and prevent stress reactions in order to minimize the risk of associated psychological consequences.
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Our objective was to summarize and critically review data on the prevalence of posttraumatic stress disorder (PTSD) in general intensive care unit (ICU) survivors, risk factors for post-ICU PTSD and the impact of post-ICU PTSD on health-related quality of life (HRQOL). We conducted a systematic literature review using Medline, EMBASE, Cochrane Library, CINAHL, PsycINFO and a hand-search of 13 journals. Fifteen studies were eligible. The median point prevalence of questionnaire-ascertained "clinically significant" PTSD symptoms was 22% (n=1,104), and the median point prevalence of clinician-diagnosed PTSD was 19% (n=93). Consistent predictors of post-ICU PTSD included prior psychopathology, greater ICU benzodiazepine administration and post-ICU memories of in-ICU frightening and/or psychotic experiences. Female sex and younger age were less consistent predictors, and severity of critical illness was consistently not a predictor. Post-ICU PTSD was associated with substantially lower HRQOL. The prevalence of PTSD in ICU survivors is high and negatively impacts survivors' HRQOL. Future studies should comprehensively address how patient-specific factors (e.g., pre-ICU psychopathology), ICU management factors (e.g., administration of sedatives) and ICU clinical factors (e.g., in-ICU delirium) relate to one another and to post-ICU PTSD. Clinicians caring for the growing population of ICU survivors should be aware of PTSD risk factors and monitor patients' needs for early intervention.