Introduction to Psychological First Aid (PFA) ADDC Practitioner Interest Forum Sept. 2013 Note this will be an introduction to the basic concepts of PFA It will NOT be a skills based training on PFA – which usually requires a full day training that comprises of many role plays and simulations The PFA guide can be downloaded for free from the WHO website, in English and a range of other languages, including, French, Spanish, Arabic, Chinese, Urdu, Romanian, Sinhala, Tamil, Russian and others. Hard copies of the guide can also be purchased online for about $6 USD from the WHO bookshop – though it is usually cheaper to purchase multiple copies to save on packaging and delivery overheads.

The Psychological First Aid Field Guide Acknowledgements  Writing and Editorial Team - Leslie Snider (War Trauma Foundation, WTF), Mark van Ommeren (World Health Organization, WHO) and Alison Schafer (World Vision International, WVI).  Steering Group (alphabetical) - Stefan Germann (WVI), Erin Jones (WVI), Marieke Schouten (WTF), Shekhar Saxena (WHO), Alison Schafer (WVI), Leslie Snider (WTF), Mark van Ommeren (WHO). Funding - World Vision International Illustrator – Julie Smith, PD Consulting  In addition, we acknowledge the 27 anonymous respondents who participated in a pre-consultation survey on the need to develop this document. Plus the many individuals and agencies who contributed to the peer review process. This guide will be formally endorsed by many member organisations of the IASC Mental Health and Psychosocial Support Reference Group, including ….. Showing a hard copy of the PFA Guide, introduce this as the tool WV has endorsed for use and training in PFA; noting that WV contributed to its content and production, in partnership with World Health Organization and War Trauma Foundation. You can point out also that the guide underwent significant peer review (twice in fact) and in-field testing.

The Psychological First Aid Field Guide - Endorsements This guide is one of the most inter-agency endorsed tools, second only to the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007)

Group Discussion What comes to mind when you think about “First Aid”? What comes to mind when you think about “Psychological First Aid”? Broad Group Discussion Key message here is that PFA is similar to physical first aid. It is a first line and immediate intervention for distress. Much like you would apply pressure and a bandage to a person who was bleeding. If the bleeding was so bad, you may need to take that person to hospital. But if it is a mild cut and bleeding can be eased, this may be all that they require in the immediate term. So too with PFA. Some people may require immediate assistance and support to access more specialised care (be that for practical assistance (e.g., food, water, shelter, medicine); while others may just require someone to listen to them, help them prioritise their needs and feel comforted. PFA is not a long term intervention.

PFA is not.... It is NOT something only professionals can do It is NOT professional counseling It is NOT a clinical or psychiatric intervention (although it can be part of good clinical care) It is NOT psychological debriefing It is NOT asking someone to analyze what happened to them or to put time and events in order It is NOT pressing people to tell you their story It is NOT asking people details about how they feel or what happened One of the reasons lay people can build up their skills in PFA and provide it to others is because PFA is NOT professional counselling – or any of the other things noted in this slide. Remember, PFA is a humane, supportive response to a fellow human being who is suffering and who may need support. PFA really just tries to tap into the natural human instinct of us all to assist others – in a way that does not intrude, cause further harm or claim to be a clinical or psychiatric intervention.

Psychological First Aid (PFA) is: A description of a humane, supportive response to a fellow human being who is suffering and who may need support. PFA involves the following themes: Providing practical care and support that does not intrude Assessing needs and concerns Helping people to access basic needs (e.g. food and water, information) Comforting people and helping them to feel calm Helping people connect to information, services and social supports Protecting people from further harm Based on Sphere (2011) & IASC MHPSS Guidelines (2007) PFA is a recommended first line intervention for people who have recently experienced a distressing event – this recommendation is found in both the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings, the Sphere Guidelines, and many other guidelines, such as the WHO mental health gap program, and SGBV guidelines.

Basic services and security The place of PFA in overall mental health and psychosocial response Examples: Mental health care by mental health specialists (psychiatric nurse, psychologist, psychiatrist etc) Specialised services Basic mental health care by PHC doctors Basic emotional and practical support by community workers (Psychological First Aid) Focused (person-to-person) non-specialised supports Activating social networks Communal traditional supports Supportive child-friendly spaces Community and family supports Strengthening community and family supports PFA, according to this intervention pyramid of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings is classified as a Focused (meaning person-to-person) intervention, but a non-specialised type of support. Therefore, non-professional people can be trained in PFA – as either a disaster preparedness activity or in readiness for deployment to a crisis. PFA can also be provided as a matter of course for any event that may require you to respond to people in distress. For example, people who have just been in a car accident, are significantly bereaved, or are experiencing any form of significant distress. Advocacy for basic services that are safe, socially appropriate and protect dignity Basic services and security Social considerations in basic services and security

Why PFA? Following crises, people do better over the long-term if they… Feel safe, connected to others, calm and hopeful Have access to social, physical and emotional support Feeling able to help themselves, as individuals and communities Many years ago, a standard first line intervention was psychological debriefing (which is a systematic approach for promoting people to ‘ventilate’ their experience and feelings by asking them to recount their perceptions, thoughts and emotional reactions during a recent stressful event. WHO (2010) and Sphere (2011), also the IASC MHPSS Guidelines do not recommend this approach because literature has found that at best, psychological debriefing is ineffective, and at worse, can cause further harm. PFA came about as an evidence-informed approach by a number of international experts, who all agreed that simple, humane engagement and support to people in distress is the minimum do no harm approach, with the highest likelihood for long-term recovery. It is important to note here that currently, PFA is evidence-informed not evidence-based. This means that experts have developed a PFA approach as a combination of factors that are based on existing evidence – e.g., social support reduces mental illness, hopefulness assists recovery after crises, people cope better when they are connected socially to others and feel a sense of belonging to a group, family or community. PFA is also based on basic human rights principles, such as the right to life and dignity. PFA on it’s own is yet to be fully researched and “proven” as being effective in reducing long term mental health consequences of crises. But in the absence of other approaches, this evidence-informed approach is currently the best the humanitarian community has to offer. World Vision Indonesia is currently applying, in partnership with John Hopkins University and WV Australia, to begin researching PFA. Articles for the recommendation of PFA (including it’s need to replace psychological debriefing) and the need for evidence-base can be provided on request.

Who is PFA for? PFA is for very distressed people who have been recently exposed to an extremely distressing event. It can be provided to children and adults Not everyone who experiences a crisis event will need or want PFA. Do not force help on people who do not want it PFA is not necessarily for everybody Again, similar to physical first aid, some individuals may feel completely capable (or might personally prefer) to care for their own needs. Same with PFA – not everyone will require it or want it, and that is OK too. Note that the principles for PFA for children and adults is exactly the same, however you may need to adjust your language or body language to provide PFA to younger children. Of course, PFA should also be adapted to culture and context – refer to next slide.

Adapting to culture (& context) What might be necessary to consider to adapt to culture? What might be necessary to consider to adapt to context? Depending on how the group is going with concentration, you could either discuss this as a large group, get small groups to discuss together and quickly report back to plenum.

What is covered in PFA Skills Training? Careful analysis of culture and context Ethical principles of PFA, including a number of do’s and don’ts Practicing of good and effective communication Preparing yourselves to provide PFA – practically and emotionally (e.g., self-care) A detailed overview of the Action Principles of PFA Consideration of people who may likely need more specialised care, such as vulnerable groups, children and adolescents, etc. How to provide PFA for children Lots and lots of role plays, simulations and communication exercises to develop SKILLS in PFA As already identified, this is a basic introduction to PFA – it’s not a training on developing the SKILLS to provide PFA. Additional to what I’m covering today, a full PFA skills training would cover these aspects of PFA skills as well. It is important to note that PFA is not something extra that is done in an emergency response. Rather, it is a skill-set or competency for those likely to be working with individuals experiencing distress. PFA is used as part of their normal work. For example, you can integrate the provision of PFA as you speak to individuals when they are receiving food aid, or NFI distributions. You can integrate PFA for health staff as they treat physical ailments. You can integrate PFA into a Child Friendly Space so the facilitators can calm and support children and their parents. It’s something done as you work with and alongside affected people. So today, I will introduce the basic action principles of PFA, but keep in mind this is not training specifically on the skills for PFA.

The Action Principles of PFA Actions LOOK . Check for safety. Check for people with obvious urgent basic needs. Check for people with serious distress reactions. LISTEN Approach people who may need support. Ask about people’s needs and concerns. Listen to people, and help them to 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 Action Principles of PFA are: Look, Listen and Link. Once done a few times over, they can sit again and you can review the components of each action principle. Look: Note that safety is always first – safety of self, and others. Then you begin looking for individuals who may need support. Listen: Approaching people needing support would include introducing yourself, asking people if they’d like some assistance (remember PFA should never be forced on a person) and listen to them and their needs. In the training, good listening is practiced with good communication skills and people are shown some practical ways we can help others feel calm. Link: Linking is about helping people address their own concerns and helping them to find ways of coping with their problem. It may involve providing people with information and linking them back to their loved ones, family, community or other social supports. The following slides provide just one example of what is covered in PFA skills training for each of the Look, Listen, Link action principles

Examples of distress responses Physical symptoms (e.g. Shaking, headaches, fatigue, loss of appetite, aches & pains) Crying, sadness, depressed mood, grief Anxiety, fear Being “on guard” or “jumpy” Being afraid that something really bad is going to happen Insomnia, nightmares Irritability, anger Guilt, shame Confused, emotionally numb, or feeling unreal or in a daze Being immobile or withdrawn Not responding to others, not speaking at all Disorientation (not knowing one’s name, where they are from or what is happening) Not being able to care for oneself or one’s children When looking, people need to be aware of what are common distress responses to crisis event. Distress comes in many shapes and forms, as outlined in this slide.

Helping people feel calm Brief breathing exercise Brief “tapping” exercise Brief mindfulness exercise using items in the room When listening to peoples’ needs, it is sometimes necessary or helpful to assist a person to feel calm. The skills training uses simple breathing, tapping and mindfulness exercises that PFA providers can use to achieve this.

Positive Coping Strategies Getting rest Easting as regularly as possible Drinking plenty of water Spending time with family & friends Discuss problems with someone you trust Do activities that help you relax – e.g. Walking, singing, praying, playing with children) Engage in physical exercise Find safe ways to help others When Linking, one of the ways people are encouraged to support others in coping is to promote positive coping strategies and help people to avoid negative coping strategies. Review the positive and negative coping strategies as per this slide and the next one.

Negative Coping Strategies Taking drugs, smoking or drinking alcohol Sleeping all day Working all the time without any R&R Isolating yourself from friends and loved ones Neglecting basic personal hygiene Violence

Questions? Principle Actions LOOK . Check for safety. Check for people with obvious urgent basic needs. Check for people with serious distress reactions. LISTEN Approach people who may need support. Ask about people’s needs and concerns. Listen to people, and help them to 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 Questions?