Psychological First Aid

Definition: PFA may be simply defined as a supportive and compassionate presence

designed to stabilise and mitigate acute distress, as well as facilitate access to continued
care.

John Hopkins PFA RAPID Model

The goals of this model of PFA are:

1. to meet basic needs;

2. to stabilize acute psychological and/or behavioral reactions;
3. to mitigate acute distress, impairment, or dysfunction to assist in the
recovery of some degree of adaptive functionality (resilience);
4. to foster natural coping and resilience mechanisms; and
5. to facilitate access to continued support or higher-level care, if indicated.

R: Rapport and Reflective Listening

Build a connection with the person in distress. Listen attentively and respond
empathetically to create a safe and supportive environment.

A: Assessment

Determine if immediate help is needed and assess the severity of the situation. Focus on
understanding the person's experience, including the stressful event and their reactions.

P: Prioritization

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Decide how urgent the need for intervention is. Use psychological triage to prioritize
cases based on the level of risk.

I: Intervention

Provide immediate support to stabilize the person and mitigate adverse reactions. Learn
various practical crisis intervention techniques to use effectively.

D: Disposition

Determine the next steps. Consider whether the person can recover independently or if
referral to additional resources is necessary. Develop guidelines for both recovery and
referral.

The Johns Hopkins RAPID PFA model is unique in that it is theory driven, evidence
informed, and empirically validated.

The Development of PFA (Psychological First Aid)

PFA (Psychological First Aid) is a mix of two main ideas: psychological crisis
intervention and physical first aid. One of the early thinkers in this field said, “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). Later,
Swanson and Carbon (1989) added, “Crisis intervention is a proven approach to helping
in the pain of an emotional crisis.”

Psychological crisis intervention got its start during World War I when soldiers were
experiencing what we now call PTSD, but back then was known as shell shock. Standard
therapies weren’t working, so Dr. T. S. Salmon suggested moving psychiatric care closer

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to the battlefield. This change showed great results and led to what’s now known as the
P-I-E principles: proximity, immediacy, and expectancy.

What’s P-I-E?

1. Proximity – In military terms, this means having psychiatric services near the
battlefield. For civilians, it means providing help in community settings like
shelters or walk-in clinics.
2. Immediacy – This is all about offering help as soon as someone shows signs of a
psychological crisis. The key here isn’t just rushing after a traumatic event, but
helping once symptoms appear.
3. Expectancy – This principle focuses on seeing emotional reactions as temporary,
not a permanent problem. The idea is that with the right support, people can
bounce back.

These P-I-E principles have been shown to work well on the battlefield, and they’re
different from traditional therapy in that they aim to provide immediate help rather than
long-term cures.

The Cocoanut Grove Nightclub Fire

A major contribution to PFA happened during World War II, but it didn’t take place on a
battlefield. Instead, it came after a tragedy at the Cocoanut Grove nightclub in Boston on
November 28, 1942. A fire broke out, killing 492 people and injuring 166. The disaster
traumatized not just the victims but the entire community. Eric Lindemann’s study on the
aftermath of this event introduced the idea of “grief work” — the active process of
working through grief to recover. While not fully backed by later research, his work
helped lay the foundation for what we now call disaster mental health.

Community Mental Health Movement

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In the 1960s and 1970s, there was a big push for community-based mental health care.
Large psychiatric hospitals were replaced with local community centers offering walk-in
crisis clinics and hotlines. Many of these services were run by trained volunteers and
paraprofessionals, and research showed they were effective in reducing the number of
psychiatric hospitalizations. This helped make psychological crisis intervention a key part
of mental health services.

Dr. Bertram Brown, assistant surgeon general of the U.S., championed this approach,
proving that community-based interventions could reduce the strain on hospitals and
improve long-term mental health care.

PFA in Action: Israeli Soldiers

Israeli psychologist Zahava Solomon took the P-I-E principles into the field during the
Lebanon War in 1982. She found that these principles, especially expectancy, were
highly effective in reducing psychological distress. A 20-year study showed that soldiers
who received frontline crisis intervention had better long-term outcomes compared to
those who didn’t get the same support. This long-term research proved that PFA has
lasting positive effects.

Physical First Aid’s History

The concept of physical first aid goes back even further than psychological crisis
intervention. The Order of St. John, founded in 1048, aimed to train people in medical
first aid for travelers and battlefield victims. During the Crusades, they helped spread this
knowledge.

Later, in 1859, Henry Dunant, a Swiss businessman, witnessed the horrors of war at the
Battle of Solferino in Italy. He rallied local villagers to provide first aid, which eventually
led to the founding of the International Red Cross. Ambulance services, like the iconic St.
John Ambulance in Britain, grew during the Industrial Revolution, extending first aid to
workers like miners and police officers.

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So, when you think about PFA, remember that it’s the result of centuries of development,
combining both psychological and physical first aid to offer help when it’s needed most.

The Evolution of Psychological First Aid (PFA)

Early Origins of PFA

Psychological First Aid (PFA) emerged during World War II as a means to address the
psychological distress experienced by sailors. A curriculum was developed in 1944 and
presented at the American Psychiatric Association meeting, emphasizing the importance
of preventative measures to prevent maladjustments and neurotic symptoms.

Key Topics in the Early PFA Curriculum

● 1. What are war nerves?

● 2. Symptoms: diagnosis, cause, treatment, and prognosis.
● 3. Understanding physical reactions.
● 4. Understanding emotional reactions.
● 5. Personal hygiene.
● 6. Managing one’s own adverse reactions (stress management, self-help).
● 7. Managing adverse reactions in others.

Expansion of the PFA Concept

Over time, the concept of PFA expanded beyond its initial focus on wartime stress.
Thorne, in 1952, highlighted its role in quickly recognizing and managing acute
psychological distress. The American Psychiatric Association officially defined PFA in
1954 in the context of community disasters, stressing the importance of equipping
disaster workers with PFA skills.

Reintroduction of PFA and Disaster Response

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Beverley Raphael’s 1986 text When Disaster Strikes reintroduced PFA, noting its
importance in the immediate aftermath of disasters. The American Red Cross introduced
a comprehensive mental health initiative to provide PFA to disaster survivors. However,
the methods used, such as Critical Incident Stress Management (CISM) and Critical
Incident Stress Debriefing (CISD), sparked debates and received mixed reviews in
research studies.

Controversies Surrounding CISD

CISD, while widely popular, faced scrutiny for being applied outside its original scope
and for methodological flaws in early studies. Despite this, later research showed that
CISM and CISD could be beneficial when applied correctly, especially for emergency
workers.

Ongoing Debate and Research

The discussion around PFA and CISD continues, with experts highlighting the
importance of proper methods and training for effective application. More recent studies
have shown positive outcomes for those who receive CISM after traumatic events,
especially in the context of group crisis intervention.

Conclusion

While PFA and CISD have evolved over time, understanding how to apply them
effectively remains crucial in supporting individuals during times of crisis.

Core Competencies of Psychological First Aid (PFA)

So, what exactly are the core competencies of Psychological First Aid (PFA)? Over time,
there's been a growing consensus about what PFA entails. It’s important to note that PFA
isn’t the same as medicine, clinical psychology, or social work. It doesn’t involve
diagnosis or treatment. Instead, it’s a form of psychological crisis intervention. This

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means that anyone who might normally be taught physical first aid can also be taught
PFA. So, non-mental health professionals like public health workers, clergy, teachers,
police, firefighters, and military personnel are among the key groups trained in PFA.

PFA serves as a starting point for psychological crisis intervention. It’s considered the
first step on the psychological care continuum. According to the Institute of Medicine
(2003), PFA is designed to help limit distress and reduce negative health behaviors. It
involves teaching active listening skills, educating people about normal psychological
reactions to stress and trauma, and promoting physical well-being, including sleep,
nutrition, and rest. Knowing when to refer someone to professional caregivers is also key
(IOM, 2003, p.7).

In her influential 1986 work, Raphael suggested the following key elements of PFA:

1. Comfort and support

2. Physical protection
3. Providing necessities like food or shelter
4. Helping direct energy into positive activities
5. Reuniting people with loved ones
6. Offering emotional support during tough tasks
7. Allowing emotional expression
8. Restoring a sense of security
9. Using social and community networks for support
10. Triaging those who need urgent care
11. Referring people to longer-term support systems

Everly and Flynn (2006) expanded on this by adding some core behavioral elements:

1. Assessment: Checking the person’s psychological and behavioral state.

2. Stabilization: Preventing things from getting worse psychologically.
3. Triage: Assessing functionality and determining the need for further care.

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 4. Communication: Offering reassurance and stress management advice.
5. Connection: Helping the individual access informal or formal support systems.

The National Institute of Mental Health (2002) also outlined PFA’s primary goals:

● Protecting survivors from further harm

● Reducing stress and anxiety
● Mobilizing support for those most distressed
● Keeping families together and encouraging reunions
● Providing clear information and education

The Inter-Agency Standing Committee (IASC) guidelines for mental health responses
emphasize that most people don’t need medication in the immediate aftermath of trauma.
Aid workers, including health professionals, should know basic PFA. The guidelines
clarify that PFA isn’t a clinical or psychiatric intervention. Rather, it’s a compassionate,
supportive response to someone who’s suffering. Some key elements of PFA according
to the IASC include:

1. Protecting individuals from further harm

2. Offering the chance to talk about their experiences without pressure
3. Listening in a non-judgmental way
4. Showing genuine compassion
5. Addressing basic practical needs
6. Discouraging harmful coping methods (e.g., alcohol or drugs)
7. Encouraging positive coping strategies and participation in daily routines
8. Offering continued support or referral as needed

Hobfoll et al. (2007) boiled down PFA into five key principles: ensuring safety,
promoting calm, helping people solve problems, fostering social support, and instilling
hope.

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Everly et al. (2008) built on this further with recommendations from the Centers for
Disease Control and Prevention (CDC) and the Association of Schools of Public Health.
They emphasized that disaster response workers should be able to assess needs, develop
action plans, and care for themselves and their peers during disaster situations.

McCabe et al. (2013) took things a step further by creating a competency-based training
model for PFA. This model includes knowledge, skills, and attitudes (KSA) to help
responders in disaster situations. It covers six domains: initial contact, brief assessment,
intervention, triage, referral, and self-care.

In essence, the core components of PFA involve:

1. Stabilization: Helping people feel calm and avoid impulsive actions.

2. Assessment: Checking on someone’s psychological state and their ability to
function.
3. Triage: Prioritizing who needs help the most urgently.
4. Supportive communication: Communicating with empathy and respect.
5. Intervention: Offering immediate support, such as stress management.
6. Referral: Connecting individuals to further care, if needed.
7. Self-care: Ensuring responders practice good self-care while helping others.

And there you have it! Psychological First Aid is all about providing basic,
compassionate support in times of crisis, ensuring people feel safe, calm, and connected,
and knowing when to refer them for further help.

The Johns Hopkins RAPID PFA Model: A Comprehensive

Approach to Psychological First Aid

A Foundation Built on History, Theory, and Evidence

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The Johns Hopkins RAPID PFA model is a unique approach to psychological first aid
that is grounded in a strong foundation of history, theory, and empirical evidence. This
approach is aligned with the principles outlined by renowned Harvard psychiatrist
Theodore Millon, who emphasized the importance of these three pillars for effective
clinical science.

Historical Roots

● Deep Dive into Stress Research: Our model is deeply rooted in the rich history of
stress research. We have drawn inspiration from the pioneering works of
renowned scholars like Selye, Beck, Lazarus, Folkman, and Everly. Their
groundbreaking research on stress and stress management has served as the
cornerstone of our theoretical framework.

A Robust Theoretical Framework

● Integrating Key Concepts: The RAPID PFA model incorporates key concepts
from stress and stress management research, providing a comprehensive
understanding of the psychological aspects of crisis response.
● A Holistic Approach: By integrating these theoretical frameworks, we have
developed a holistic approach that addresses the multifaceted nature of
psychological distress.

Empirical Validation: Rigorous Testing and Refinement

To ensure the effectiveness and reliability of our model, we have conducted rigorous
empirical research over the course of two decades.

Structural Equation Modeling

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 ● Model Refinement: We have employed structural equation modeling to refine the
structure of the RAPID PFA model, ensuring its optimal organization and
coherence.

Content Validation Studies

● Extensive Participant Involvement: We have conducted content validation

studies with over 1,500 participants, gathering valuable insights into the model's
effectiveness and relevance.
● Positive Outcomes: These studies have demonstrated that training in the RAPID
PFA model leads to significant improvements in participants' knowledge,
confidence, and readiness to apply PFA.

Promoting Resilience and Preparedness

● Personal Resilience: Our research has shown that the RAPID PFA model
enhances personal resilience, empowering individuals to cope effectively with
challenging situations.
● Community Resilience: By incorporating components related to preparedness,
our model also promotes community resilience, fostering a sense of collective
readiness to face crises.

A Proven Approach to Reducing Acute Distress

Randomized Clinical Trial

● Comparative Analysis: In a smaller randomized clinical trial, we compared the

RAPID PFA model to a purely cathartic (venting) approach.
● Superior Outcomes: The results consistently demonstrated that the RAPID PFA
model is more effective in reducing acute distress, providing individuals with a
more effective and sustainable approach to coping with crises.

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Conclusion

The Johns Hopkins RAPID PFA model is a well-established and evidence-based

approach to psychological first aid. By combining a strong historical foundation, a robust
theoretical framework, and rigorous empirical validation, we have developed a
comprehensive model that empowers individuals and communities to build resilience and
navigate challenging times effectively.

KEY POINT SUMMARY

1. Psychological first aid may be defined as a supportive and compassionate

presence designed to first stabilize, then mitigate acute distress, and finally

facilitate access to continued care, if indicated.

2. PFA is first aid; it does not entail diagnosis, nor does it entail treatment.

3. The goals of the current model of PFA, which will be discussed in this

book, are:

a. To meet basic needs

b. To stabilize acute psychological and/or behavioral reactions

c. To mitigate acute distress, impairment, or dysfunction to assist in recovering

some degree of adaptive functionality

d. To foster natural coping mechanisms

e. To facilitate access to continued support, or higher-level care, if indicated

4. PFA may be thought of as a variation of the 100-year-old field of psychological crisis

intervention.

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5. PFA can be traced back to World War I.

6. PFA enjoys almost universal endorsement by national and international agencies;

however, the recommendations are based on expert opinion and evidence-informed
research.

7. There seems to be a constellation of core active ingredients within PFA,

consisting of stabilization, assessment, triage, acute intervention for mitigation of

distress, and liaison/advocacy.

8. The Johns Hopkins RAPID PFA model is unique because it is theory driven, evidence
informed, and empirically validated.

9. Self-care and buddy care should be considered essential elements of PFA.

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