Sustainability of Psychological First Aid Training for the Disaster Response Workforce

Psychological first aid (PFA) is a set of tools designed to help responders address stress-related reactions among survivors immediately after a disaster or traumatic event. Helping survivors feel safe, reducing stress-related symptoms, and fostering positive coping strategies enable responders to better meet survivors’ basic needs and ensure their linkage to critical resources and social support. These are important steps in initiating the recovery process. Addressing survivors’ immediate needs is also important because prolonged stress in the aftermath of a disaster or traumatic event may lead to longer-term mental health problems such as posttraumatic stress disorder, depression, and substance use. Early intervention after a disaster may be important to prevent these long-term sequelae.

Psychological first aid is evidence informed but not evidence based because of the difficulty of studying it under controlled conditions and because the elements employed may vary depending on the needs of the individuals being assisted. Rather, the concepts of PFA have been derived from an initial set of “empirically supported intervention principles”—promoting a sense of safety and calming along with a sense of self-efficacy, community efficacy, connectedness, and hope—developed by an expert panel in 2007.¹ Although different PFA models have been developed over time, all share these core principles, which are encompassed in the eight PFA core actions described in the National Child Traumatic Stress Network’s PFA field operations guide² and outlined in Table 1.

TABLE 1—

Psychological First Aid Core Actions

Action	Goal
Contact and engagement	Responding to contacts initiated by survivors or initiating contacts in a nonintrusive, compassionate, and helpful manner
Provision of safety and comfort	Enhancing immediate and ongoing safety and providing physical and emotional comfort
Stabilization (if needed)	Calming and orienting emotionally overwhelmed or disoriented survivors
Information gathering: current needs and concerns	Identifying immediate needs and concerns, gathering additional information, and tailoring psychological first aid interventions
Practical assistance	Offering practical help to survivors in addressing immediate needs and concerns
Connections with social support networks	Helping establish brief or ongoing contact with sources of primary support and other sources of support, including family members, friends, and community helping resources
Provision of information on coping	Providing information about stress reactions and coping to reduce distress and promote adaptive functioning
Linkage with collaborative services	Linking survivors with available services needed at the time or in the future

Note. Information was derived from the National Child Traumatic Stress Network.²

Psychological first aid relates to mental health care as “first aid” relates to medical care. All responders, particularly those who will be interacting with survivors, should be aware of the principles of PFA. In addition, PFA may be of benefit to the responders themselves to help them understand and cope with their own stress reactions and those of their colleagues. In this way, PFA is important in creating not only resilient communities but a resilient response workforce. Also, PFA is not an intervention that must be delivered by mental health professionals, the supply of whom would probably not be sufficient to meet the needs of all survivors in a large-scale disaster. For these reasons, PFA training should be accessible to workers in a wide range of response agencies.

PSYCHOLOGICAL FIRST AID TRAINING

The Centers for Disease Control and Prevention (CDC) has recognized the need for a wide range of public health emergency response training opportunities and in the past provided funding to support Preparedness and Emergency Response Learning Centers (PERLCs) at schools of public health in developing such training.³ In 2013, a group of PERLCs developed a competency-based training model for PFA consisting of six competency domains: initial contact, rapport building, and stabilization; brief assessment and triage; intervention; triage; referral, liaison, and advocacy; and self-awareness and self-care.⁴ A number of online training courses on the background and core principles of PFA exist, some of which were developed by PERLCs with CDC funding.

Despite these efforts and initial rounds of training in many states, PFA training may not have been sustained everywhere to an optimal degree, at least to judge, for example, from surveys of local health departments at which a lack of staff trained in disaster mental health and PFA was perceived to be a barrier to their ability to respond to emergencies.⁵

When the CDC announced its final funding opportunity for PERLCs in 2015 through the Association of Schools and Programs of Public Health (the results of which are reported in this issue of AJPH), the Center for Public Health Preparedness (CPHP), the PERLC at the University at Albany, met with the four regional health emergency preparedness coalitions funded by the New York State Department of Health, which represented more than 125 hospitals, 57 county health departments, and other community response agencies. These organizations identified the need for technical assistance with PFA training and the lack of PFA training policies as the top priorities for CPHP’s funding application. The CPHP proposal addressed the need for a more standardized and systematic approach to ensure the effective and sustained delivery of PFA training across response agencies.

SUSTAINABLE TRAINING APPROACHES

According to Hambrick and colleagues, training approaches that are flexible, modular, and multifaceted and can be adapted to site-specific needs are more likely to be sustainable.⁶ With CDC funding, CPHP developed a PFA training guide including a catalog of available online courses and other PFA training materials, a set of 10 disaster response scenarios for face-to-face PFA role-play practice, and three videos modeling the role-play training (these materials are available at https://www.albany.edu/sph/cphp.php). This allows a flexible approach to designing training rather than a one-size-fits-all approach. CPHP trained educational coordinators at the regional health emergency preparedness coalitions in the use of these materials and recruited mental health professionals to provide technical assistance to hospitals, county health departments, and other response agencies to assist with PFA staff training.

Finally, CPHP reached out to hospital and county health department leadership to encourage the adoption of formal PFA training policies, which did not exist in most agencies. A follow-up survey conducted approximately six months after the training showed that agencies that participated in the training were more likely to be planning staff-wide PFA training and developing PFA training policies than those that did not.

Although the long-term sustainability of the CPHP training guide approach is not known, we believe that engagement of health-related response agencies through health emergency preparedness coalitions is important to the success of this approach. These coalitions are required, in accordance with the CDC preparedness funding awarded to state health departments, to engage local health care and public health agencies in ongoing assessments, drills, and training activities. The sustainability of PFA training has likely been strengthened by its specific inclusion in the 2017–2022 Health Care Preparedness and Response Capabilities⁷ as well as the current Public Health Emergency Preparedness and Hospital Preparedness Program funding to state health departments.

Although funding for the CPHP psychological first aid training project has ended, the New York State Department of Health is now funding additional train-the-trainer activities using some of the tools developed under this grant and is requiring hospital and county health department subgrantees to participate in them. Because the PERLC funding for schools of public health has been discontinued, it is more important than ever that federal preparedness funding to state health departments include specific requirements for training of local health department, hospital, and other response staffs in a range of topics, including PFA. Ideally, this funding would enable and encourage evaluation of training methods via a competency-based approach to ensure that training is effective and continues to improve. Such evaluation could then lead to development of fully evidence-based PFA training practices. The ability of our communities to be resilient and effectively respond to disasters in the future depends on it.