IJEMHHR • VOL. 20, No. 2 • 2018 1
Correspondence regarding this article should be directed to:
International Journal of Emergency Mental Health and Human Resilience,Vol.20, No. 2, pp 1-12 © 2018 OMICS International ISSN 1522-4821
The SIX Cs model for Immediate Cognitive Psychological First
Aid: From Helplessness to Active Efcient Coping
ABSTRACT: Acute stress reactions immediately after exposure to trauma or crisis have received growing
attention in recent years and are gaining momentum in light of recent mass traumatic events worldwide
including conicts, terrorist attacks and natural disasters. Unlike routine life, traumatic or emergency situations
are unexpected and unstructured events. Early helping responses in these situations is of utmost importance:
immediate, focused and efcient interventions are benecial for the reduction of acute stress reactions and a
return to normal functioning as well as decreasing the risk for future onset of post-traumatic stress disorder
symptoms. However, many early efforts were either found to be ineffective or are based on narrative expression
and empathy alone. The aim of this paper is to present the SIX Cs model - a new psychological rst aid approach
- immediate cognitive-functional psychological rst aid - for the global nonprofessional community as well as for
rst responders. The model addresses the need to standardize interventions during an Acute Stress Reaction and
intends to help shift the person from helplessness & passiveness into active effective functioning, within minutes,
in the immediate aftermath of a perceived traumatic event. The model is based on four theoretical and empirically
tested concepts: (1) Hardiness, (2) Sense of Coherence, (3) Self-Efcacy, and (4) on the Neuro-psychology of the
stress response, focusing on shifting people from a limbic system hyperactivity to a prefrontal cortex activation
during stressful events. Preliminary results on the effectiveness of the SIX Cs model in terms of increasing
resiliency, reducing anxiety and improving perceived self-efcacy are presented. To date, this approach has been
recognized by the Israeli Ministry of Health as the Israeli national model for psychological rst aid.
KEYWORDS: Traumatic stress, Psychological rst aid, Self-efcacy, Resilience, Cognitive-functional rst aid
Ph.D., M.P.H., Stress, Trauma & Resilience Studies,
Department of Social Work, Tel-Hai Academic College,
Kiryat Shmona, Israel
Tal Bergman Levy
M.D., Head of Mental Health Division, Ministry of Health,
Bella Ben Gershon
MSW., National ofcer for emotional trauma, Ministry of
Miriam Ben Hirsch-Gornemann
M.D., Ph.D., M.P.H. Tel Hai Academic College, Kiryat
M.SW, Faculty of Social Welfare and Health Sciences,
School of Social Work, University of Haifa, Haifa, Israel
Ph.D., Department of Psychooncology, Scalab, Lille 3
University, Lille, France
Acute Stress reactions immediately after exposure to trauma or
crisis have received growing attention in recent years (Rowlands,
2013) and are gaining momentum in light of recent mass traumatic
events worldwide including conicts, terrorist attacks and natural
Perception of an event as a potentially traumatic event (e.g.,
trafc accident, injury, terror attacks, and natural disasters) is rooted
in the individual’s feelings of fear, sense of threat and subsequent
sense of helplessness (ICD-10) (World Health Organization, 2015).
Furthermore, the event may be perceived as traumatic depending
on the cognitive appraisals and fear responses people experience
during or soon after exposure to such events. The pioneering study
of Speisman et al. (Speisman, Lazarus, Mordkoff, & Davison,
1964) demonstrated the causal role cognitive appraisals have in
determining the stress response. More recent studies have shown
the role of appraisal using other methods and participants including
affecting distress and emotion-modulating brain regions (Buhle
et al., 2014; Gidron & Nyklicek, 2009; Goldin, McRae, Ramel, &
Gross, 2008; Lazarus & Folkman, 1984; Walker, Smith, Garber, &
The natural course of post-traumatic responses following
the Acute Stress Reaction (ASR, up to 48 hours after the event)
could include spontaneous remission, development of Acute
Stress Disorder (ASD) up to one month later, and the subsequent
development of Post-Traumatic Stress Disorder (PTSD) more than
a month after the event. The ASR, ASD and PTSD include the
symptom clusters of intrusions, avoidance and arousal according to
the ICD-10 (World Health Organization, 2015), and differ only in
the timeframe ascribed to the symptoms to separate the diagnostic
The incidence of ASD after a traumatic event ranges from
14% among victims of motor vehicle accidents (Harvey & Bryant,
2000) to 33% among survivors of mass shootings (Classen,
Koopman, Hales, & Spiegel, 1998). However, there is a dearth of
information on the incidence of the ASR, mostly due to the fact that
this response needs to be assessed during the early hours or days
after the event. Soldatos et al. (2006), in a study among earthquake
victims, found that 85.3% of subjects fullled the criteria for ASR
according to ICD-10 criteria (World Health Organization, 2015).
In that study, 97.1% of those diagnosed with ASR went on to
develop the most protracted form of the stress related disorders,
PTSD, nding a signicant associations between the occurrence of
ASR and the development of PTSD (Soldatos et al., 2006).
It has been estimated by the Israel Home Front Command
(Colonel A. Bar, personal communication, January 4, 2010) that on
the micro and macro levels, the ratio between casualties suffering
from physical injuries and mental health injuries is 1:4-1:8. In other
words, for every individual incurring in a physical injury, four to
eight others will suffer from acute anxiety and may develop an
ASR, which could potentially become an ASD. Unlike routine life,
traumatic or emergency situations are unexpected and unstructured
events – An individual does not know where or when they will
occur or who will be in need of help. Such a situation demands,
among other things, instant mental health interventions and
adaptation of these interventions to the particular characteristics
of the event (Schreiber et al., 2004). Some authors have studied
the challenges involved in early and long-term interventions to
reduce distress and prevent chronic mental health problems after
disasters. They concluded that evidence based mental health
interventions should be in place in the immediate aftermath of a
traumatic event (Dyregrov, 2008; Yule, 2006). Early response in
these situations is of utmost importance. Immediate, focused and
efcient interventions are benecial for the reduction of acute
stress reactions and a return to normal functioning, as well as for
decreasing the risk of future onset of post-traumatic symptoms
(Shapiro, 2012; Zohar, Sonnino, Juven-Wetzler, & Cohen, 2009).
Furthermore, studies in both animal (Cohen, Matar, Buskila,
Kaplan, & Zohar, 2008) and human (Zohar, Yahalom, et al., 2011)
models have suggested that there is a window of opportunity in the
immediate hours of a perceived traumatic event, to reduce anxiety
and confusion, restore stability and effective coping, and that this
“window of opportunity” is not wider than six hours (Cohen et al.,
2008; Zohar, Yahalom, et al., 2011).
Up to this day, the only generalized approach to early
intervention in the immediate aftermath of a traumatic event is
Psychological First Aid (PFA). PFA is an approach built on the
concept of resilience and designed to help people in the immediate
aftermath of any emergency situation (Brymer et al., 2006). It
was originally developed to be used by mental health and other
disaster responders in emergency situations and is currently
recommended by the World Health Organization (WHO) as an
alternative to debrieng (World Health Organization, War Trauma
Foundation, World Vision International, & 2011), the latter found
in several reviews to be ineffective in preventing PTSD or even
harmful (Bastos, Furuta, Small, McKenzie-McHarg, & Bick, 2015;
Forneris et al., 2013). PFA is based on an understanding that people
affected by traumatic events will experience early stress reactions
which may cause sufcient distress to impede adaptive coping and
recovery (Brymer et al., 2006; Ruzek et al., 2007). Therefore, PFA
is intended to reduce the initial ASR caused by events which are
perceived as traumatic and to foster short- and long-term adaptive
functioning and coping.
Hobfoll (2007) recommended ve core principles that
should be used to guide intervention efforts in communities
following exposure to crises and emergencies: (1) to foster a
sense of safety, (2) to provide calmness, (3) to induce a sense of
self- and community efcacy, (4) connectedness, and (5) hope.
Following these principles and since the rst approach to PFA was
established, several guidelines have been developed worldwide
such as the guidelines developed by the National Child Traumatic
Stress Network and National Center for PTSD in the US (NCTSN-
NCPTSD (Brymer et al., 2006), the European Network for
Traumatic Stress (Bisson & Tavakoly, 2008), the WHO (World
Health Organization et al., 2011) and the Australian Red Cross
(Burke, Richardson, & Whitton, 2013). All these guidelines share
similar approaches, all based on Hobfoll’s principles, although
tailored to the particular needs of the countries and frameworks
in which they are to be applied. For example, the comprehensive
manual developed by the WHO is stated to be applicable only for
low and middle income countries.
However useful and providing a framework to intervene
during the immediate hours or days after a Perceived Traumatic
Event (PTE), current PFA guidelines suffer from two crucial
limitations. First, as reported in a critical review, PFA guidelines
lack empirical scientic evidence for their effectiveness (Dieltjens
et al., 2014). This situation risks repeating the same errors done
with other untested methods which were and are still provided to
people soon after perceived traumatic events. Second, they were
originally intended for professional teams and focus on “what to
do” and “what not to do” but fall short to explain exactly “how to
do it”. In the absence of a formal protocol management system,
individuals (i.e., volunteers, rst responders) carry out rst
response interventions using only their personal judgment, which
Farchi M, Hirsch-Gornemann MB, Whiteson A, Gidron Y • The SIX Cs model for Immediate Cognitive Psychological First Aid: From Help-
lessness to Active Efcient Coping
IJEMHHR • VOL. 20, No. 2 • 2018 3
may sometimes cause additional chaos beyond the event itself in
the affected community (Dyregrov, 2008; Fernandez, Barbera, &
Van Dorp, 2006; Hantman & Farchi, 2015). Additionally, and most
importantly, to the best of our knowledge, the current guidelines
for PFA are basically designed to provide supportive help, care
and calmness, all of which lead to increased sense of helplessness
which is one of the major triggers for PTE (ICD-10, World
Health Organization, 2015). Moreover, the current protocols are
provided for emergency response systems that are in place, that
is, to operate only within the framework of an authorized disaster
response system. In other words, they are not specically designed
to be use in the immediate minutes following an emergency event,
but hours or even days after the event has occurred and once a
disaster response system is in place. Such responses may be too
late to reduce the ASR that follows a PTE and eventually prevent
PTSD. Furthermore, PFA guidelines are not specic enough for
rst responders (people who attend to victims before or at the
same time security or medical teams arrive at the scene), as well
as any other non-professionals who are involved in the event. Such
specic instructions are needed to feel competent to provide the
necessary immediate emotional rst aid intervention to reduce
ASR symptoms and to return the person to a more functional
state. In addition, as mentioned before, some of these guidelines,
following Hobfoll’s and other PFA principles, put the emphasis
on providing comfort, calmness and sense of safety to the victim
of a PTE. These compassionate efforts may eventually increase
passiveness and enhance the sense of helplessness, which is one
of the main triggers for perceiving an event as traumatic (ICD-
10, World Health Organization, 2015) and predict PTSD later
(Simeon, Greenberg, Nelson, Schmeidler, & Hollander, 2005).
Previous attempts at treating ASR and preventing PTSD
have included psychological debrieng and treatment with
benzodiazepines which have been showed to be either ineffective
or even harmful (Bastos et al., 2015; Forneris et al., 2013;
Zohar, Juven-Wetzler, et al., 2011). Furthermore, reviews of the
effectiveness of early interventions in preventing PTSD have
concluded that only Trauma Focused Cognitive-Behavioral
Therapy (TF-CBT), Cognitive Behavioral Therapy (CBT) and
modied prolonged exposure may help prevent PTSD (Howlett &
Stein, 2016; Qi, Gevonden, & Shalev, 2016; Roberts, Kitchiner,
Kenardy, & Bisson, 2010). However, their effectiveness may
depend upon type of traumatic event (Rothbaum et al., 2012), and
may not be helpful in all cases (Shalev et al., 2012). Yet, all the
above treatments may be administered only by professional mental
health workers and are not intended for immediate administration.
The main aim of the above treatments is the reduction of risk
for PTSD symptoms. In our perspective, the main objective of
immediate interventions should be increasing one’s functional
ability, and as a result, decreasing the sense of helplessness and
confusion that follows the immediate minutes and hours after a
PTE; subsequently, these may reduce PTSD risk in the long run.
The focus on rst responders is as a consequence of their higher
risk of developing negative mental health outcomes including
ASD and PTSD themselves, compared to the general population,
rst due to their higher exposure to either natural or manmade
disasters (Benedek, Fullerton, & Ursano, 2007; Sakuma et al.,
2015) and second, due to their continuous exposure to traumatized
populations rendering them at risk for secondary traumatic stress
(STS) (Bride, 2007; Cieslak et al., 2013; Sifaki-Pistolla, Chatzea,
Vlachaki, Melidoniotis, & Pistolla, 2017). However, this risk has
been shown to be mediated by previous low resilience status and
preparedness (Lee, Ahn, Jeong, Chae, & Choi, 2014; Sakuma et
al., 2015), emphasizing the importance of developing a working
model by which rst responders are provided with the right and
empowering tools to confront emergency situations as early as
possible (Cacciatore, Carlson, Michaelis, Klimek, & Steffan,
From our point of view, ideally, just as every lay person should
know how to provide basic physical emergency rst aid in order
to help those who are physically injured and prevent further harm
before emergency teams arrive to the scene, the same should exist
for PFA. There should be a common knowledge base throughout
all community levels concerning brief interventions that can reduce
distress sufciently, so that each person who perceives any event as
traumatic can be helped to return to normal effective functioning.
The SIX Cs model was created to ll this gap and to provide a
simple user-friendly working model for professionals, non-
professionals, rst responders and the general population, based
on the neuropsychological and psychological correlates of stress.
The aim of this paper is to present the SIX Cs model - a new
PFA approach-immediate cognitive-functional psychological rst
aid (ICF-PFA) designed to provide the global nonprofessional
community as well as professionals and rst responders, with
practical tools that equip them with the necessary knowledge
base and intervention skills to assist others who are currently
perceiving an event as traumatic and developing ASR symptoms.
The justication for the model leans on two assumptions. The
rst assumption, supported by recent studies, is that intervening
during the rst minutes/hours following the PTE provides the
best “window of opportunity” for reducing an ASR and helps the
person return to normal functioning (Bremner, 2006; Hantman &
Farchi, 2015; Hobfoll, 2007; Schulenberg, 2016; Zohar, Juven-
Wetzler, et al., 2011). The second assumption, as noted before,
is that the skills needed to provide basic immediate cognitive-
functional psychological rst aid (ICF-PFA) interventions should
be accessible to the global nonprofessional community, as well as
to professional rst responders, just as basic medical rst aid skills
are accessible. Furthermore, teaching ICF-PFA skills to the general
nonprofessional community will decrease their dependency
on professional mental health personnel while increasing the
independence of nonprofessionals in managing stressful events,
and improving their resilience, self-efcacy and sense of trust – all
leading to increased sense of safety.
THE SIX Cs MODEL
The SIX Cs model addresses the need to standardize PFA
interventions during an Acute Stress Reaction (ASR) and intends
to help shift the person from a helpless, passive and functional
incompetent state to active effective coping, within minutes, in
the immediate aftermath of a PTE. The model is based on four
theoretical and empirically tested concepts: 1) Hardiness (Kobasa,
the condence in one’s ability to inuence events that affect one’s
life. People with high self-efcacy - that is, those who believe they
can achieve things based on their own abilities - and are more likely
to think that difculties are challenges to overcome instead of being
avoided. During stressful situations, people commonly exhibit
signs of distress. People with high self-efcacy tend to interpret
this ”distress” as normal and unrelated to their ability to control the
situation, therefore responding better and more “in control” when
confronted with stressful situations. Indeed, self-efcacy predicts
long-term recovery after assaults (Nygaard, Johansen, Siqveland,
Hussain, & Heir, 2017).
The Neuropsychology of the Stress Response
The focus is on the brain circuits responsible for the stress
response and the interaction between the limbic system and
the Prefrontal Cortex (PFC) during stressful events (Arnsten et
al., 2012; Arnsten, 2009; Arnsten et al., 2015; Bremner, 2006;
Hendler et al., 2001; Shin et al., 2004; Taylor et al., 2008). The
PFC has extensive connections that accentuate or inhibit actions
in other brain regions, including inhibiting the fear responses of
the amygdala, providing top-down regulation of behavior, thought
and emotion related to the stress response (Arnsten et al., 2015).
It has been shown that the PFC is very sensitive to the damaging
effects of stress and that even mild acute unmanageable stress can
cause a rapid failure of prefrontal cognitive function (Arnsten et
al., 2012; Arnsten, 2009). Studies have underlined the negative
correlation between amygdala hyperactivity and the prefrontal
cortex activity (Arnsten, 2009; Banks, Eddy, Angstadt, Nathan,
& Phan, 2007; Motzkin, Philippi, Wolf, Baskaya, & Koenigs,
2015). During stressful events, hyperactivity of the amygdala tends
to “shut down” the PFC, thus reducing its cognitive capacities
and its ability to down regulate and control the amygdala’s fear
response. This creates a vicious circle in which primitive circuits
of the brain control behavior (Arnsten et al., 2015). Activation of
the PFC, through cognitive focused interventions or appraisals,
helps reduce the stress response and down regulate the amygdala
(Goldin et al., 2008). These provide the best environment for a
calmer, more rational and exible response after trauma exposure.
In contrast, lack of PFC activity that maintains dominance of the
limbic system, increasing the sense of helplessness, which is one of
the major triggers for perceived trauma (Hantman & Farchi, 2015).
Interestingly, activating the ventromedial prefrontal cortex can
prevent the adverse effects of uncontrollable stress (Amat, Paul,
Watkins, & Maier, 2008).
Studies have revealed that memories of events perceived as
traumatic, are processed in more fragmented and automatic ways
(Foa, Feske, Murdock, Kozak, & McCarthy, 1991; Liberzon et al.,
1999; van der Kolk & Fisler, 1995). Furthermore, post-traumatic
pathological conditions are associated with trauma processing with
reduced prefrontal activity, which deals with cognitive processing,
and enhanced limbic (amygdala) activation, responsible for negative
emotional processing (Bremner, 2006; Hendler et al., 2001; Shin
et al., 2004). In contrast, sense of mastery (akin to self-efcacy)
and future orientation, among other psychosocial resources, are
positively related to frontal activation and inversely related to
amygdala activity (Taylor et al., 2008). These ndings form the
base to attempt to shift the processing of traumatic memories from
1979; Maddi, 2006); 2) Sense of Coherence (Antonovsky, 1979);
3) Self-Efcacy (Bandura, Ciof, Taylor, & Brouillard, 1988) and;
4) on the Neuro-psychology of the stress response, specically the
interaction between the limbic system and the prefrontal cortex
during stressful events (Arnsten, Mazure, & Sinha, 2012; Arnsten,
2009; Arnsten, Raskind, Taylor, & Connor, 2015; Bremner, 2006;
Hendler, Rotshtein, & Hadar, 2001; Shin et al., 2004; Taylor et al.,
The Concept of Hardiness
Originally introduced by Suzanne C. Kobasa in 1979 (Kobasa,
1979) and later developed by Maddi, Kobasa and colleagues
(Khoshaba & Maddi, 1999; Maddi, 2006; Maddi, Khoshaba, &
Pammenter, 1999), the concept of hardiness refers to a personality
construct which combines three attitudes that provide resistance to
stressful events: commitment, control and challenge. Commitment
is the willingness to be involved with people, things and situations
rather than to be disconnected, isolated or alienated. Control
involves struggling to be in charge of the events taking place in our
lives through our own ability to make choices between available
options, instead of sinking into passivity and helplessness.
Challenge implies being willing to learn constantly from one’s
experience instead of avoiding uncertainties and potential threats
(Maddi, 2002). According to the authors, these three factors are
needed for people to nd the necessary stimulus and courage to turn
potentially threatening stressful circumstances into opportunities
for personal growth. Indeed, hardiness is inversely related to long-
term PTSD (Zerach & Elklit, 2017).
Sense of Coherence (SOC)
Developed by Aaron Antonovsky (1979), describes the
resources (i.e., psychological, social, and cultural) that people
successfully use to defy illness. According to Antonovsky, the
sense of coherence has three components:
A) Comprehensibility: A conviction that things happen in
an ordered and expected way and a feeling that one can
understand and predict events in life;
B) Manageability: A belief that one has the necessary skills
and the resources to take care of what happens in life, that
events are controllable and can be managed and;
C) Meaningfulness: A sense that what happens in life is
appealing and a source of satisfaction, that things in life
are worthwhile one’s efforts, that the world in some way
According to the author, SOC is a major factor in managing
stress in a healthy way. In addition, SOC has been found to
increase quality of life (Eriksson & Lindström, 2007) and to be
strongly related to perceived mental health (Eriksson & Lindström,
2006). Importantly, in people with high SOC, stressful events have
less impact on biological outcomes than people with low SOC
(Lutgendorf, Vitaliano, Tripp-Reimer, Harvey, & Lubaroff, 1999).
The concept of self-efcacy (Bandura et al., 1988) represents
Farchi M, Hirsch-Gornemann MB, Whiteson A, Gidron Y • The SIX Cs model for Immediate Cognitive Psychological First Aid: From Help-
lessness to Active Efcient Coping
IJEMHHR • VOL. 20, No. 2 • 2018 5
a fragmented and limbic dominance mode to a more organized and
prefrontal processing; a shift from narrative-based and emotion-
focused interventions into cognitive focused interventions.
The SIX Cs Model: Its Basic Elements
The SIX Cs model integrates these concepts and neurobiological
underpinnings of stress and resilience into six main intervention
elements, each one addressing different symptoms of the acute
stress reaction or reecting resilience factors as shown in Figures
1 and 2.
Amygdala hyper activity => Cognitive verbal communication:
As previously mentioned, right after a PTE, hyperactivity of the
amygdala tends to “shut down” the PFC creating a vicious circle
in which primitive circuits of the brain control behavior, therefore
calling for the need to have the PFC down regulate and control
the amygdala’s response. This is accomplished by asking short
cognitive questions that are related to the event. The questions
focus on three main dimensions: Time e.g., “how long have you
been here?” Quantity: e.g., “how many people are injured?” And
choosing from simple options: e.g., “Do you want to talk rst
to your parents or your teacher?” The intention is to stimulate
cognitive verbal communication to reduce the hyperactivity of
the amygdala while increasing activation of the prefrontal cortex.
The main objective is to “snap” the person out of the emotionally
loaded reactions and induce the person to think more clearly, set
priorities and make effective decisions.
Helplessness => Challenge: One of the most frustrating
outcomes resulting from experiencing an acute stress reaction is
the sense of inability and failure, which can increase helplessness
and passiveness (Hantman & Farchi 2016). In order to reduce
the sense of failure, we need to provide the person with a sense
of success (Antonovsky, 1979) and self-efcacy (Bandura et al.,
1988). This can be achieved by challenging the person to succeed
in small simple cognitive based behavioral tasks related to the
event (we will NOT try to distract the person’s mind from the
event), e.g., “Please collect all your things into your bag and make
sure that nothing is missing”. In this way, we challenge the person
for effective activity related to the event as well as providing
cognitive challenges, all decreasing one’s sense of helplessness
and restoring a sense of self-efcacy and mastery. These may then
increase activity of the ventromedial prefrontal activity and reduce
amygdala activity (Amat et al., 2008; Taylor et al., 2008).
Helplessness => Control: According to ICD-10, helplessness
is one of the factors that dene the event as traumatic; therefore
it is important to reduce this sensation immediately in order to
shift the person to a more functional state without trying to distract
the person from the event. This is accomplished by providing the
person with several simple options to choose from, (e.g., “We need
to count all the people, do you want to start counting or help with
the registration of everybody?”; “In which area do you prefer the
blood perfusion?”). This activity reinforces the cognitive activation
of the PFC, improving the individual’s sense of control as opposed
to the sense of helplessness and incompetence, and again, may
modulate an over-active amygdala (Amat et al., 2008; Taylor
et al., 2008).
Loneliness => Commitment: Loneliness is one of the frequent
symptoms present after a PTE leading to difculties to return
to normal functioning; therefore it is important to reverse this
symptom as soon as possible. This is accomplished by providing
the person with a verbal commitment to his/her safety and support,
assuring the person the helper will stay until the stressful event
is over; e.g., “We are here with you, we are not going anywhere
until you are safe again”. This alleviates the feeling of loneliness
and fear and therefore increases the ability to collaborate with the
Confusion => Continuity: Confusion is the inability to create a
synchronized narrative of the event. The confusion in the aftermath
of a PTE results from the hyper arousal of the sympathetic nervous
system (Hantman & Farchi, 2016). In addition, when the narrative
is not synchronized, the person also fails to determine the accurate
ending point of the event –which may contribute to the intrusive
thoughts because, from the perspective of the person suffering from
the ASR, the event has not ended and is still happening. Studies in
both animal and human models have suggested that the window
of opportunity to intervene and resolve this confusion state is no
longer than six hours (Cohen et al., 2008; Zohar, Yahalom, et al.,
Figure 1: Summary of the SIX Cs major principles.
Figure 2: Processes of the SIX Cs model.
2011). This underlines the need to help the person to reconstruct
the event in an orderly and continuous manner as soon as possible
in the immediate aftermath of the PTE. Providing “Continuity”
entails explaining the person the basic chronological elements of
the event and emphasizing the ending point, e.g., “Three minutes
ago, you where involved in a car accident. Right now, the medics
are here and are starting to treat the people who are injured. In the
next 2-3 minutes, we will walk to the ambulance and you will be
taken to the hospital for further checkups. The accident has ended!”
Traumatized women, who were able to chronologically organize
their recollection of the event, had reduced symptomatology (Foa,
Riggs, Massie, & Yarczower, 1995).
To date, this approach has been recognized by the Israeli
Ministry of Health as the Israeli national PFA model. The model
has already been implemented and adopted as the main model
for immediate assistance in stressful and emergency situation
by several ministries and institutions such as the Ministries of
Education, Health, and Internal Security; Israel trafc police;
and by the Israel Defense Forces (IDF); under the assumption
that, while interventions in emergencies are brief, at times lasting
only seconds or minutes, their subsequent consequences may
reverberate for many years after the event (Herman, 1992). Up
until now, the model’s operational viability has been proven in
extreme emergency conditions (Operation Pillar of Defense,
Operation Protective Edge, earthquakes, etc.) as well as in many
local events like rescues and accidents. We now demonstrate some
standard empirical evidence for the method’s effectiveness.
THE SIX Cs MODEL: PRELIMINARY EMPIRICAL
EVIDENCE FOR ITS EFFICACY
For obvious ethical and logistical reasons, it is extremely
difcult to conduct randomized controlled trials during very urgent
events or during war time, to test this model. Nevertheless, in
order to empirically evaluate this intervention, several studies were
conducted and two are briey reported here. Study one tested the
actual efcacy of the model in reducing anxiety symptoms in the
aftermath of the event as well as PTSD symptoms two and four
months following the event. Study two tested the effectiveness
of the model in improving general self-efcacy, professional
self-efcacy and resiliency, and in reducing perceived stress in
high school students who received training in the SIX Cs model,
compared to controls who did not receive the training.
Study One: A Six C’s Intervention during War-Time
in the Community of Ofakim
Ofakim is a small town in the south of Israel, which was
targeted by Hamas rockets during Operation “Protective Edge” in
2014. Over a period of 51 days, 280 individuals were treated for
various stress reactions. Interventions were based on the SIX Cs
protocols which included a 24/7 hotline, face-to-face interventions
and community outreach. The hotline was available to individuals
who were too frightened to leave their bomb shelters and reach
the Center For Traumatized Persons (CTP). Most calls were from
parents asking for advice regarding their children’s anxiety and
stress, caused by the massive rocket and missile attacks. The face-
to-face intervention included individual or small group treatment
for those who came to the center. Community outreach included
day and night patrols throughout the various neighborhoods
and shelters carried out by trained students. People identied as
suffering from ASR received the intervention on the spot. We
sought to measure the effects of the intervention in reducing anxiety
levels immediately after the event, as well as PTSD symptoms at
four months follow-up after the event.
Materials and Methods
Participants and Procedures
Data was collected from 211 individuals 18 years and older who
received a face-to-face intervention at the center for traumatized
persons (CTP). Of the 211, 81.7% were women and 18.3% were
men, 77.9% where urban dwellers (vs. 22.1% rural), 87% where
Jewish and 13% were Bedouin Arabs.
Anxiety measures were taken upon arrival at the center before
the intervention and right after the intervention, which lasted no
longer than 45 minutes. Every person who entered the CTP and
asked for assistance received the intervention. Baseline levels of
General Self-Efcacy (GSE) and Post Traumatic Stress Disorder
(PTSD) symptoms were collected two months after the event and
follow up measures of GSE and PTSD symptoms were collected
four months later, using phone-calls. The data collection was
mandated by the Ministry of health as part of clinical Routine
Outcome Monitoring (ROM) to evaluate clinical status as well as
the effect of the intervention right after the event, and at the two
month and four month follow up. Therefore, the need for obtaining
informed consent was waived. Participants were asked for their
permission to be contacted by telephone to ascertain their clinical
status at follow up. Aggregated and anonymous data was used for
the research purposes of this study.
Measurements and Statistical Analysis
Anxiety scores were collected as an integral part of the
intervention using the one item question: Please rate your current
anxiety from 1 (very low) to 10 (very high). This question reected
the person’s current anxiety state, and was validated by Davey et
al. (2007) showing good correlations with the State Trait Anxiety
Inventory (STAI). At the two and four month clinical routine
evaluation follow ups, General self-efcacy (GSE) scores were
collected using the GSE 20 items questionnaire (Schwarzer &
Jerusalem, 1995) and PTSD symptoms were collected using Foa’s
17-item PTSD questionnaire (Foa, Riggs, Dancu, & Rothbaum,
1993). Means and standard deviations (SD) where calculated and
paired sample t-tests of change over time were performed using
SPSS© statistical package version 23.
Summary of Results
Mean anxiety level at baseline was 7.34 (SD±2.55). Mean
anxiety level post-intervention dropped to 3.47 (SD±2.31),
(t=16.28; p<0.000). There was a signicant 52% reduction in the
mean anxiety level as measured with the one-item anxiety scale.
Clinical follow up measures of PTSD symptoms and GSE are
depicted in Table 1. PTSD symptoms dropped signicantly and
Farchi M, Hirsch-Gornemann MB, Whiteson A, Gidron Y • The SIX Cs model for Immediate Cognitive Psychological First Aid: From Help-
lessness to Active Efcient Coping
IJEMHHR • VOL. 20, No. 2 • 2018 7
were below the clinical threshold (score lower than 15) while GSE
increased only slightly but signicantly at follow up.
The data presented here are unique since they were collected
during real emergency events, during missile threat. The use of
the SIX C’s model as IC-PFA during the very early minutes after
arriving to the CTP was found to be successful in terms of reducing
anxiety levels immediately after the intervention and PTSD
symptoms below clinical threshold levels at the four month follow-
up, while GSE scores increased less, but signicantly as well. The
main limitation of this preliminary study was the lack of a control
group and the non-random nature of the study. However, due to
ethical and logistic reasons of conducting a randomized controlled
trial under an ongoing war and since the results are part of good
clinical practice of monitoring patients’ outcomes, these were not
possible. However, statistical data published by the Ministry of
Health showed that the percentage of people who had to be referred
to hospitals from other CTPs not using the SIX Cs intervention
was approximately 25%, while only 0.5% of those in the CTP
that provided the SIX Cs intervention had to be hospitalized (one
person out of 250 who entered the CTP). Again, though not based
on a randomized controlled trial, these gures provide additional
preliminary evidence that the results obtained may be ascribed to
the SIX Cs intervention.
Study Two: Effectiveness of a Six Cs Training
Program for Adolescents
From October 2015 to September 2016, a longitudinal
controlled study on the effects of training in the SIX Cs method on
various outcomes was conducted among high school students. The
study evaluated students’ general self-efcacy (GSE), Professional
Self-Efcacy (PSE), resilience and perceived stress, before the
intervention and at two weeks and three months follow-up.
Materials and Methods
Participants and Procedures
A total of 232 high school students between grades nine
to eleven participated in the study. Of those, 108 students
(42.59% males; mean age 15.84±0.48) went through two days of
training, for three hours each day, of the SIX Cs model, and 124
controls (44.35% males; mean age 16.64±0.44) completed the
questionnaires, but did not receive the SIX Cs training. The trainers
were third year students in the stress, trauma & resilience program
of Tel-Hai College, who completed an eight-hour training on the
SIX Cs model in order to train others. Data on GSE, PSE, resilience
and perceived stress were collected before the SIX Cs training
(baseline, time 1), at two weeks follow-up after the training (time
2) and at three months follow-up after the training (time 3). Ethical
approval was granted by the Ministry of Education’s review board
prior to the study and informed consent was obtained from all
Measurements and Statistical Analysis
The General Self-Efcacy scale (GSE) (Schwarzer & Jerusalem,
1995), was used to assess general self-efcacy. Cronbach’s alpha
in this study was adequate: 0.84. Professional Self-efcacy (PSE)
was assessed by a modied scale (Farchi, Cohen, & Mosek, 2014)
based on an adaptation of the measure for specic self-efcacy
developed by Boehm (Boehm, 2006). The measure consists of
seven statements that refer to the respondent’s perception of self-
efcacy concerning the capacity to act successfully in the eld
of stress and trauma; ability to inuence people or organizations;
knowledge of useful informants and contacts; prociency in
negotiation skills; expertise in using stress and trauma techniques;
ability to form an appropriate support network; and mastery of
required skills. The students were asked to indicate the degree of
their agreement with each statement. The internal reliability of the
original scale was α=0.85, and the scale’s Cronbach’s alpha for the
present study was adequate, α=0.86.
The Connor-Davidson Resilience scale (CD-RISC) (K. M.
Connor & J. R. T. Davidson, 2003); was used as a measure of the
ability to cope with stress. This is a ve-factor scale that includes
25 items, each rated on a 5-point scale (0-4). Factor 1 reects the
notion of personal competence, high standards, and tenacity. Factor
2 corresponds to trust in one’s instincts, tolerance of negative
affect, and the strengthening effects of stress. Factor 3 relates to the
positive acceptance of change and of secure relationships. Factor
4 is related to control and Factor 5 to spiritual inuences. The CD-
RISC has been tested in the general population as well as in clinical
samples and demonstrates good psychometric properties, with
sound internal consistency (Cronbach’s alpha=0.89), test–retest
reliability, and good distinction between those with greater and
lesser resilience (K. Connor & J. Davidson, 2003). The Cronbach’s
alpha of this scale in the present study was adequate, α=0.80.
Perceived stress was assessed by the Perceived Stress Scale
(PSS) (Cohen, Kamarck, & Mermelstein, 1983). This scale has
been widely used to assess perception of stress in daily life and has
proven to have good psychometric properties in several studies.
The scale includes 14 items regarding feelings and thoughts in
the past month and provides responses on the frequency of these
thoughts and feelings during the last month according to a Likert-
scale ranging from 0=never to 4=very frequently. The scale reects
perceptions of stress and the ability to cope with it. A total score
was calculated for each participant. Reliability of the PSS in the
present study was adequate as well: α=0.81.
Variables Two-month post intervention (baseline) Four-month post intervention t-value
M SD M SD t
PTSD symptoms 21.75 12.33 12.99 10.52 7.335***
GSE 29.77 6.33 30.83 6.05 1.76*
*** p<0.001; *p<0.05
Baseline and follow up PTSD symptoms and general self efcacy scores
Means and standard deviations (SD) were calculated for GSE,
PSE, perceived stress and resiliency scores. A repeated measures
ANOVA was conducted to explore the impact of change from
baseline to time 2 and 3 and effects of intervention on students’
scores on GSE, PES, resilience and perceived stress, using the
SPSS© statistical package version 23. In all analyses, we focused
on the Time x Group interaction in relation to all outcomes.
Summary of Results
After excluding participants from the analyses due to missing
information at follow up, the nal sample was n=69 (63.8% of the
initial sample) for the intervention group and n=86 (69.3% of the
initial sample) for the control group, in relation to the outcomes
of GSE, PSE and resilience. For perceived stress, 23 cases in the
intervention group (21.29%) and 13 cases in the control group
(10.48%) had to be excluded from the analysis due to missing
data. Changes in GSE, PSE, Resiliency and Perceived stress scores
among intervention and control groups are shown in Table 2.
At baseline, groups were signicantly different on GSE, PSE,
perceived stress and resilience. Controls scored signicantly higher
on GSE (t(234)=1.78, p<0.005), PSE (t(233)=3.49, p=0.001),
resilience (t(234)=2.15, p<0.05) and perceived stress (t(232)=1.98,
p<0.05). Therefore, and due to signicant group differences at
baseline, we statistically adjusted for all baseline measures in
the following Analyses of Covariance (ANCOVA), except when
analyzing each outcome variable, whose levels were considered in
a within-subjects analysis, while the remaining baseline variables
were entered as covariates.
The ANCOVA for GSE revealed a signicant Time x Group
interaction (F(2,256)=64,66), p<0.001). Simple effects analyses
revealed that Time signicantly affected GSE scores only in
the SIX Cs group (F(2,128)=4.10, p<0.05) but not in controls
(F(2,122)=0.76, p>0.05). We nevertheless examined certain mean
differences within each condition separately, over time. Baseline
GSE scores increased signicantly at T2 for both the SIX Cs
group (F(1,74)=4.49, p<0.05) and in controls (F(1,70)=5.47,
p<0.05), independent of covariates. Additionally, GSE scores
tended to decrease signicantly in controls from baseline to T3
(F(1,82)=3.74, p<0.06) and increased signicantly in the SIX Cs
group (F(1,83)=10.64, p<0.005). At T3, the SIX Cs group scored
signicantly higher on GSE than controls, independent of baseline
covariates (F(1,164)=74.51, p<0.001).
The ANCOVA for PSE revealed a signicant Time x Group
interaction (F(2,262)=44,60), p<0.001). Simple effects analyses
revealed that time signicantly affected PSE scores only in
the SIX Cs group (F(2,126)=4.38, p<0.05) but not in controls
((F(2,130)=1.78, p>0.05). However, subsequent analyses found
that PSE scores increased signicantly in the SIX Cs group
(F(1,73)=6.60, p<0.05) and in controls (F(1,70=4.04, p<0.05),
independent of covariates. Furthermore, PSE levels were still
signicantly higher at T3 in the SIX Cs group compared to baseline
(F(1,83)=5.60, p<0.05) but decreased, though not signicantly
in the controls (F(1,87)=0.64, p>0.05). At T3, the SIX Cs group
scored signicantly higher on PSE than controls, independent of
baseline covariates (F(1,169)=90.04, p<0.001).
The ANCOVA for perceived stress revealed a signicant
Time x Group interaction (F(2,260)=24,00), p<0.001). Simple
effects analyses revealed that time tended to signicantly affected
perceived stress scores only in the SIX Cs group (F(2,126)=2.75,
p<0.07) but not in controls ((F(2,128)=0.99, p>0.05). Nevertheless,
subsequent analyses found that perceived stress scores were
reduced signicantly in the SIX Cs group from baseline to T3
(F(1,83)=4.52, p<0.05) but increased though not signicantly
in the control group (F(1,86)=1.22, p>0.05). At T3, the SIX Cs
group scored signicantly lower on perceived stress than controls,
independent of baseline covariates (F(1,168)=62.46 p<0.001).
Finally, the ANCOVA for resilience revealed a signicant
Time x Group interaction (F(2,262 )=51.26, p<0.001). Following
this interaction, Time had a signicant effect only in the SIX Cs
condition (F(2,126)=4.26, p<0.05) while in controls time had not
Variables Intervention (n=69) Control (n=86)
M SD M SD
Baseline 32.38 2.98 32.87 3.29
Time 2 32.00 5.08 32.59 4.75
Time-3 33.42 3.94 20.78 9.25
Baseline 29.39 7.04 33.40 9.01
Time-2 38.23 6.99 34.77 8.21
Time-3 34.59 8.68 25.59 5.86
Baseline 26.77 6.38 28.76 6.70
Time-2 28.30 6.29 29.71 6.29
Time-3 29.16 6.25 19.98 8.75
Baseline 25.74 5.97 23.44 6.36
Time-2 23.62 5.57 22.51 7.35
Time-3 22.48 6.33 30.09 7.57
Group differences at baseline and follow up: GSE, PSE, Resiliency, Perceived Stress
lessness to Active Efcient Coping
IJEMHHR • VOL. 20, No. 2 • 2018 9
effect (F(2,130)=1.22, p>0.05). Indeed, from T1 to T2, resilience
scores signicantly increased in both the SIX Cs (F(1,74)=6.37,
p<0.05) and controls (F(1,70)=4.34, p<0.05), independent of
covariates. Furthermore, levels of resilience signicantly increased
from T1 to T3 in the SIX Cs group (F(1,82)=4.14, p<0.05) and
tended to decrease in controls (F(1,87)=2.76, p=0.10). At T3, the
SIX Cs group scored signicantly higher on resilience than controls,
independent of baseline covariates (F(1,168)=69.50, p<0.001).
These results were mediated by a tragic event that happened
between time 2 and 3, an unfortunate car accident occurred and
one of the participants in the control group, well known by both
groups, died as a consequence of the accident. This event had an
important impact on the study results. Following the car accident,
the intervention group maintained a better score at 3 months follow-
up compared to baseline while controls did not in all measures.
Furthermore, at T3 the SIX Cs group scored signicantly better
on all outcomes compared to controls independent of covariates.
Thus, this event could have partly affected the observed results.
This study was originally aimed to test the effects of the SIX Cs
model ICF-PFA training on GSE and PSE as well as resilience and
perceived stress, among high school students. As a result of a trafc
accident, in which a very popular girl who belonged to the control
group, but well known to both groups, control and intervention,
died, the study was able to actually test the immediate effectiveness
of the training in the aftermath of a perceived traumatic event.
Scores for all variables measured were better at T3 (after the
accident) for the intervention group compared to the control group.
These results support the effectiveness of the SIX Cs interventions
in providing and maintaining improved GSE, PSE and resilience
and reduced levels of perceived stress in the long term. In addition,
these results show improvement in actual resilience, (i.e., the
ability to bounce back after a disaster), and reduced perception of
stress for the intervention group in the face of a PTE
This article presents a new PFA approach - Immediate
Cognitive-Functional Psychological First Aid (ICF-PFA) designed
to provide the global nonprofessional community, professionals,
and rst responders, with practical tools that equip them with the
necessary knowledge base and intervention skills to manage and
assist others who perceive an event as traumatic and are at risk
of developing ASR symptoms. The model emphasizes the need to
shift a person who experienced a perceived traumatic event, from
being in a helpless and passive state to an active and effective
functioning person. This approach is based on the ICD-10 criteria
for perceived trauma and on studies concerning the negative
relationship between the activation of the amygdala and cognitive
processing. Based on these two understandings, the SIX Cs model
tries to directly target common ASR symptoms such as confusion,
loneliness and emotional overow. It aims to enable a person who
experienced a PTE to return to previous effective functioning
levels shortly (usually in less than two minutes) after receiving the
intervention. Preliminary results point at the effectiveness of the
SIX Cs model in terms of increasing resiliency and improving self-
efcacy in non-professionals trained to respond to traumatic events.
In addition, preliminary results observed during war-time suggest
that this method may reduce anxiety and symptoms associated with
PTSD in victims of a PTE. To the best of our knowledge, the SIX
Cs model is the rst PFA method designed to be implemented in all
community levels, including rst responder and both professionals
and non-professionals. From this perspective, just like emergency
medical rst aid, each person, regardless of his or her profession,
should have the basic knowledge, skills and ability to provide basic
PFA to any other person in need. The SIX Cs approach is only
meant as initial immediate cognitive-functional psychological
rst aid (ICF-PFA) to be used on the site of the event, on people
showing signs of an ASR and as long as the person has not returned
to his previous state of normal functioning.
RECOMMENDATION FOR FURTHER STUDIES
The SIX Cs model has already been recognized by the Israeli
Ministry of Health as the Israeli National PFA model, and has been
adopted by most of the Israeli governmental ofces, the Ministry
of Education, Israel’s Internal Security Agency, Israel’s trafc
police, and Israel Defense Forces (IDF) and it also has now several
sub-protocols for emergency responders, educational system staff
and high school children in place. Yet, there is a need for further
evaluation of its effectiveness in the eld, with greater samples and
stronger methodological designs. Given the particular environment
in which this model is implemented (i.e., terrorist attacks, war
operations, earthquakes, etc.), it is a serious challenge, both
ethically and methodologically, to test the model. These issues
need to be tackled and resolved. The SIX Cs is a PFA model but
also can be considered as a philosophic approach to handling crises
and emergencies. In that sense, we hope and expect that the wide
use of the model will contribute to increased personal, community
and national resiliency and wellbeing. Currently, the model is
being evaluated by the Israeli Defense Forces among soldiers that
are being trained to provide psychological rst aid in combat and
in other situations, and among victims of trauma in the emergency
room at several hospitals in Israel.
The authors have no conict of interest to report.
We would like to acknowledge the Ministry of health’s
Mental Health Branch, for their support and professional help
in developing and promoting the model. We would also like to
acknowledge the Israeli ministry of education in particular Dr.
Yochi Siman Tov, Head of the stress intervention unit for their
support and willingness to host the study in the Israeli education
system. Last but not least, we would like to thanks the students
from the Stress, Trauma & Resilience studies program Tel-Hai
College who were instrumental in collecting the data on Study One
during the attack escalation in the town of Ofakim.
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