Psychological First Aid

Psychological First Aid can help support family and friends through a crisis.

George S. Everly, Jr. Ph.D., ABPP

The Greek philosopher Heraclitus of Ephesus noted that the only constant is change. We currently live in an era of unprecedented personal, social, economic, and political change.

While change can often be uplifting, it can also be distressing. Due to current events, or perhaps life in general, most of us have directly observed another person in psychological distress, such as a friend, family member, coworker, or even a complete stranger. Similarly, those of us who have observed someone in distress have often been motivated to offer some form of support in an attempt to ease the suffering we witnessed. Sometimes our efforts were effective, and sometimes they were not. At other times, despite our best efforts, our actions actually appeared to make matters worse, intensifying the acute distress.

During such times, we may have lamented the absence of a psychological magic bullet, a verbal Hail Mary that would immediately end the suffering and lead to the realization of the promise we’d made that “everything will be ok.” Consistent with our intuitions, a recommendation in the American Journal of Psychiatry stated that shortly after a stressful event, it is important that those affected be provided empathic, practical psychological support beginning with a compassionate and supportive presence (Bisson, Brayne, Ochberg, & Everly, 2007, p. 1017). Over the past 100 years, there has evolved a simple yet effective helping process we now refer to as psychological first aid (PFA). The American Red Cross, the American Psychological Association, and even the United Nations have recognized the importance of PFA. In its guidelines for mental health response, the Inter-Agency Standing Committee (IASC) of the United Nations wrote that most people experiencing acute psychological distress following exposure to stressful events are “best supported without medication” and that “all aid workers, and especially health workers, should be able to provide very basic psychological first aid” (2007, pp. 118-119).

Defining Psychological First Aid

Perhaps the best way to conceptualize PFA is as the psychological health analogue to physical first aid. It’s applying a psychological bandage.

PFA may simply be defined as a supportive and compassionate presence designed to do three things: 1) stabilize (prevent the stress from worsening) 2) mitigate (de-escalate and dampen) acute distress 3) facilitate access to continued supportive care, if necessary. PFA does not entail diagnosis or treatment. Nevertheless, like physical first aid, it requires basic training to be effective and reduce the risk of inadvertently making things worse (Everly & Lating, 2017).

According to one of the early writers in the field of psychological crisis intervention, “A little help, rationally directed and purposely focused at a strategic time, is more effective than extensive help given at a period of less emotional accessibility” (Rapoport 1965, p. 30). That help can be effectively provided by a friend, teacher, coach, supervisor, or family member, especially a parent, if certain simple “first aid” guidelines are followed.

Over the last decade, the Johns Hopkins Center for Public Health Preparedness has worked to develop a simple, yet evidence-based, model of psychological first aid referred to as RAPID PFA (Everly & Lating, 2017).

As an example of how PFA might look, I have distilled some of its key steps and listed them below. I provide them here, not as guidelines, but to familiarize you with the PFA process. Although seemingly simple, as with physical first aid, some formalized training in PFA is still necessary.

Generally speaking, there are three ways that PFA might begin:

1. Sometimes a person may approach you and ask for assistance. For example, your best friend calls you and says, “Hey, I’m feeling pretty stressed out, do you have some time to talk?” In that situation, a simple response like, “Sure, what’s going on?” In many instances, the person simply wants to vent. They don’t have any expectation that you will resolve the issue at hand. They simply want to be heard. In these situations, it’s important to listen. Do not rush to diminish or solve the problem, unless that is the expectation. Once you’ve heard what they have to say, you can simply reply something like, “I’m sorry you are going through that, how can I help?” This then becomes a good time to help the person make a plan to address the problem, if possible, or to develop a plan to help them better cope with a problem that might persist. If the person declines your assistance then you might just say, “Well let me know if it turns out there is something I can do, even if it’s just listening.” Follow up with that person in a day or two to see how they are doing.
2. A second way PFA might begin is when someone approaches you on someone else’s behalf. They will suggest that you speak with the third party because something seems wrong. Be sure to ascertain from that person specifically what makes them believe something is wrong with the third party. For example, your son’s teacher may contact you and say your son seems to be having a hard time at school. Your response might be, “What specifically is concerning you?” It might be grades, conflict with other students, or just a significant change in his behavior. With that information, at the right time, you could say to your son, “Your teacher spoke with me yesterday. He said you seem to be distressed. He says you don’t seem to be your usual self lately. What’s going on?” After listening to what your son has to say, it might be useful to say something like in the previous example, “I’m sorry you are going through that, how can I help?” If there is really nothing you can do to assist directly at that point, then just say, “Well let me know if it turns out there is something I can do, even if it’s just listening.” Again, periodic follow up is important.
3. An especially challenging way PFA might begin is when you see someone who looks or sounds distressed. Based upon your concern for that person’s well-being, you approach them, but what do you say? How about, “I couldn’t help but notice you don’t seem yourself today.” Or, “I couldn’t help but notice you seem distressed.” If they respond, ask, “How can I help?” Then help them develop a plan to address the problem, or help them develop a plan for coping, or both. If they do not respond, or say there is nothing you can do, simply say “I’m a good listener.” Again, if possible, follow up with that person at an appropriate time to see how the person is doing.

   The three scenarios above are merely examples of how PFA might begin.  While they are not comprehensive in their structure or analysis, they will give you an idea of what PFA might sound like in the beginning. To further assist, listed below are 15 general Dos and Don’ts for consideration.

   15 Dos and Don’ts

   1. Do remain calm when speaking to a person in distress. Show concern but be a confident reassuring presence. The other person will gain confidence from your confidence.
   2. Don’t get caught up in the situation. Remember the antidote for stress is calm and confidence.
   3. Do listen. Encourage the person to talk about what happened and their reactions to those events. If the person does not want to speak at that time, ask if you can check back with them later.
   4. Don’t interrupt, unless the disclosure seems to be escalating the distress.
   5. Do try to identify “the worst part” of the situation, if possible. Do this carefully, and it can help you identify the core issues at hand if they are not otherwise obvious.
   6. Don’t rush. If the person is medically stable and safe, the passage of time alone begins to de-escalate situations.
   7. Don’t be dismissive. Don’t minimize their concerns or say, “Well at least…” as an attempt to distract, or help the person feel better.
   8. Don’t act on some preconceived notion of what you think the person needs. Ask what they need (Everly, Brelesky & Everly, 2018). Perspective taking such as this will foster trust.
   9. Don’t hesitate to ask specific questions about the person’s ability to competently attend to others (significant relationships, childcare, eldercare) or perform the duties of their job.
   10. Don’t hesitate to ask about intention to harm themselves or others. Seldom will this be an issue, but sometimes you may sense feelings of profound hopelessness, depression, anger, or vindictiveness. In such cases, it’s important to inquire and follow up. In the most rare and extreme cases, you may have to help the person get immediate professional care.
   11. Don’t make promises you can’t keep.
   12. Do determine what else if anything is needed after your initial conversation. Don’t hesitate to ask for guidance or assistance from a healthcare professional if you are worried about the person’s well-being.
   13. Do serve as a liaison to connect the person with continued assistance, if necessary.
   14. Do advocate for this person in seeking further assistance, if necessary.
   15. Do follow up a day or so later to see how the person is doing.

   In sum, PFA is no panacea, nor is it a substitute for mental healthcare, but years of research and experience has shown it can be a useful tool to assist people in acute distress when applied by those with proper training in PFA.

   References:

   Bisson, J. I., Brayne, M., Ochberg, F., & Everly, G. S., Jr. (2007). Early psychological intervention following traumatic events. American Journal of Psychiatry, 164, 1016-1019. http://dx.doi.org/10.1176/ajp.2007.164.7.1016.

   Everly, G.S., Jr., Brelesky, G., & Everly, A.N. (2018).  Rodney the Rabbit makes a friend. RSI.

   Everly, G.S., Jr., & Lating, J.M. (2017).  Johns Hopkins guide to psychological first aid. Baltimore: Johns Hopkins Press.