What is Psychological First Aid?
For those that remember World Mental Health Day in 2016, the theme was psychological first aid (PFA). The WHO produced a document ‘Psychological First Aid’, identifying a role for PFA in crisis events (on their site) and outlined the history and application. In this document, the WHO described PFA as
‘First-line psychosocial support after a crisis event’.
They identify PFA as being delivered not just by professionals but also by lay people and detail a number of principles of PFA.
Turning to another source, a simple definition of crisis is ‘a time of great disagreement, confusion or suffering’. There are other variations on this definition but the essence is the same and it is not too difficult to argue that the Covid-19 pandemic fits with this definition. The pandemic differs perhaps from many other crises in the extended nature in comparison for instance with natural disasters such as earthquakes.
(Dieltejns et al, 2014) outline a definition of psychological first aid (PFA) in their paper:-
“PFA is defined by the World Health Organization (WHO) as “a humane, supportive response to a fellow human being who is suffering and who may need support” . It includes interventions such as listening, comforting, helping people to connect with others and providing information and practical support to address basic needs , . These interventions are consistent with the guidelines of Hobfoll et al.  and center on five key principles: safety, connectedness, self and collective efficacy, calm and hope, that together in essence ease the transition to normality . This implies that the practice of PFA is not restricted to mental health professionals but could also be delivered by lay people“.
A More Detailed Look at PFA
Turning again to the WHO document, PFA is described as
‘Non-intrusive, practical care and support‘
‘Assessing needs and concerns‘
‘Helping people to address basic needs‘
‘Listening but not pressuring people to talk‘
‘Comforting people and helping them to feel calm‘
‘Helping people connect to information, services and social supports‘
‘Protecting people from further harm‘
The document also describes what it is NOT a few examples of which I have given below
‘NOT something only professionals can do‘
‘NOT professional counselling‘
‘NOT a clinical or psychiatric intervention‘
Also PFA can be provided
‘When encountering a person in distress, usually immediately following a crisis event‘
‘Anywhere that is safe for the helper and affected person, ideally with some privacy as appropriate to the situation‘.
There are some important ethical guidelines that are outlines in the document.
The PFA principles are described as
‘Look, listen, link‘.
- Look (‘Observe for safety, observe for people with obvious urgent basic needs, observe for people with serious distress reactions’)
- Listen (‘Make contact with people who may need support, ask about people’s needs and concerns, listen to people and help them feel calm’)
- Link (‘Help people address basic needs and access services, help people cope with problems, give information, connect people with loved ones and social support’).
The document also gives examples of things to say and do a few examples of which are given below
‘Be patient and calm’
‘Provide factual information if you have it’
‘Acknowledge how they are feeling and any losses or important events they share with you’
‘Give information in a way the person can understand – keep it simple’
A Brief Review of the Literature on PFA
I undertook a brief review of the literature using a medline search using ‘Psychological First Aid’ as a search term and identifying relevant papers. Broadly speaking there is the very early literature dating back to the 1960’s. In the early 2010’s there are papers looking for supporting evidence. More recently there are a number of randomised clinical trials showing evidence of efficacy (depending on the outcome).
The recognition of the significance of PFA can be seen in this early paper (Gillespie, 1963). In a relatively early paper (Dieltejns et al, 2014) reviewed the literature on psychological first aid in disaster and trauma victims but didn’t find evidence of effectiveness at that time. They identified 11237 references with 102 being selected for further analysis. They acknowledged that important articles could have been missed whilst at the same time commenting that ‘high-quality experimental and observational studies’ on the effectiveness of PFA were needed.
A competence-based model was developed by the CDC and described in this paper by (McCabe et al, 2014). The authors describe three learning domains: Cognitive skills, physical skills and attitudes which are then applied across the 6 competency domains. They describe how this framework is used to train lay volunteers that can be activated in public health emergencies.
Later studies have provided evidence. For instance this group based PFA intervention was found to have benefit in comparison with a conversational model in reducing anxiety and negative effect (Despaux et al, 2019). Another RCT demonstrated benefits at six-months in terms of response to case scenarios (Sijbrandij et al, 2020).
The Covid-19 Pandemic and PFA
From the above search I identified a number of papers that were specific to the Covid-19 pandemic. Broadly speaking, the majority of papers were either delivered to or by healthcare professionals through a range of mechanisms including online and telephone services. Many of the papers looked at PFA as being a healthcare professional delivered service in contrast with the principle for instance of first aid.
(Talevi et al, 2020) describe the many challenges of the pandemic for the mental health of a population. (Shah et al, 2020) similarly describe these many challenges. (Shah et al, 2020) in another paper look at lessons from previous outbreaks and how these could be applied in the Covid-19 pandemic as well as emphasising the important role of PFA.
(Minihan et al, 2020) argue for a role for PFA in the pandemic. (Asaoka et al, 2021) found evidence of increasing psychological distress among physicians in the early part of the pandemic and also that this was reduced in those with PFA training. (Malik et al, 2021) also describe the benefits of a PFA program for frontline staff. The Malaysian experience in the remote delivery of PFA training for frontline staff was described by (Francis et al, 2020). (Kantaris et al, 2020) describe the experience of healthcare assistant delivery of PFA in inpatient settings. (Landa-Ramirez et al, 2020) describe a protocol for healthcare staff delivering bad news in the context of the Covid-19 pandemic.
(Barbarin et al, 2021) describe a broader organisational approach to PFA programmes including working with NGO’s. (Lovera et al, 2021) describe a PFA program delivered in the Dominican Republic and outline the model. (Ravindran et al, 2020) describe the experience of delivering PFA through a helpline in India. (Arenliu et al, 2020) describe the Kosovan experience of delivering PFA using online chat, video resources, as well as PFA delivered by telephone.
Adapting PFA For Social Media
There are a number of questions that follow on from the review above when we consider PFA in a social media context in the Covid-19 pandemic.
- Who is PFA for? The answer from the WHO document is clear. PFA is for everyone and that makes sense when we compare it with first aid. The literature review in comparison is weighted towards delivery by healthcare professionals although instances of population training are given. In a social media context, that means that PFA is intended for social media users whether they are healthcare professionals or otherwise.
- Is PFA appropriate for social media? It would make sense for this to be appropriate for social media but there are lots of complexities. For instance, there is a reference to privacy/confidentiality. There are various social media settings which support this – for instance DM’s on Twitter and so on. However there is a more subtle aspect of PFA which is the communication of the principles of PFA and here social media is highly relevant. This is a medium which supports creative endeavours in the area of communications. Thus social media offers a potentially highly effective platform for disseminating the principles of PFA.
- Could PFA be tailored to social media? There is a case for tailoring PFA to social media. As well as delivering PFA to individuals there is a case for delivering messaging to a larger audience increasing the accessibility of the message. Thus the PFA principles can be packaged into simple messages that can be promoted on social media. Collaborations between domain experts and non-professional could be valuable in amplifying the message. Take for instance the following remarkable creation by people from around the world which would have been unimaginable just five years ago. If the same creative talents could be applied to the communication of PFA principles, this would be invaluable in promoting and instilling valuable knowledge to improve the resilience of the population [https://youtu.be/Oszl95YWfbs]. On the medium of Twitter for instance there is an opportunity for health experts to collaborate with the population to raise the profile of PFA and aspects of PFA using hashtags for instance – if there is sufficient support then the hashtags will trend.
- Dual Messaging. In the pandemic, there are serious health messages which are communicated to the population. There is an opportunity for dual messaging in the sense that selected principles of PFA could be identified to accompany those messages to optimise the ability of the population to process those messages and support could be developed within the population.
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