Ebola survivor Abdul Rahman Sanu counsels a patient at a health centre in Sierra Leone. Ebola survivor Abdul Rahman Sanu counsels a patient at a health centre in Sierra Leone. Photo credit: © Idriss Kpange
Applications of Psychological First Aid around the world: summary of a five-year retrospective
by Leslie Snider, Alison Schafer and Carina Hjelmstam Winberg July 2018

When terrible things happen, we want to reach out a helping hand to those who have been affected. Psychological First Aid is … an approach to help people recover by responding to their basic needs and showing them concern and care, in a way that respects their wishes, culture, dignity and capabilities. – Psychological First Aid Brief, WHO for World Mental Health Day, 2016

In 2011, on World Humanitarian Day, the World Health Organisation (WHO) and partners launched guidance in Psychological First Aid (PFA) in a simply worded format designed for professionals and non-professionals alike.+World Health Organisation, War Trauma Foundation and World Vision International, Psychological First Aid: Guide for Field Workers (Geneva: WHO, 2011). To be as accessible as possible, the guidance was made freely available online, with content that was easy to translate and adapt for different languages and cultures. Sixty international peer reviewers from various countries, cultures and crisis contexts provided input into the guidance over the two-year period of its development, and 24 UN and NGO agencies endorsed the final product. A facilitation manual followed in 2013, and in 2014 revisions to both documents were developed to meet the particular needs of field staff working in the Ebola virus disease outbreak in West Africa.

PFA is not new: the concept and term were coined in the 1940s as a way to help Merchant Marines suffering from ‘war stress’. Today, several formulations of PFA exist, but the WHO guide appeared to fill an unmet need for practical guidance in non-technical language for people meeting or working with individuals in distress. This includes, but is not limited to, people affected by humanitarian emergencies, or in lower-resource settings. PFA has become a widely used, frontline approach to mental health and psychosocial support (MHPSS) for people affected by crisis events large and small. As part of humanitarian emergency preparedness and response, large-scale national and regional PFA capacity-building efforts have been undertaken by various entities, including the Japanese government, the Pan American Health Organization (PAHO) and NGO consortia in Asia, the Middle East and Africa. Many aid organisations orient staff and volunteers as standard practice in humanitarian emergencies, including the Nepal earthquake and the European refugee influx.

The guidance quickly became the second-highest selling publication in the WHO bookstore, and there are now over 20 language translations around the world. That the guidance was so rapidly taken up is likely due to its simplicity. Illustrated with engaging cartoons depicting different cultural contexts, it promotes concrete skills that anyone can learn in order to assist in practical, humane ways. Helpers – from firefighters, police and community volunteers to health and mental health staff – could grasp the guidance and apply it to their particular roles in helping distressed people, and often to their daily lives. It appeared to make abstract concepts, such as psychosocial support, more practical, defined and understandable for nonmental health humanitarian responders.

As the MHPSS field evolved, with a growing evidence base and a variety of innovative intervention strategies undergoing field testing, the time was right to critically reflect on PFA and its place within the spectrum of MHPSS approaches. The Church of Sweden, with advisory support from World Vision International (both Reference Group members), commissioned a five-year retrospective (2011–16) to understand how the WHO PFA guidance has been perceived and applied since its launch.+Church of Sweden, Peace in Practice and World Vision International, Psychological First Aid: Five Year Retrospective (2011–2016), Church of Sweden, 2018 (https://www.svenskakyrkan.se/internationelltarbete/reports-policydocuments–and-positions-on-church-of-swedens-international-work) Utilising a desk review, online survey, case studies and interviews, the retrospective looked at:

  • translation and adaptation processes;
  • applications (and misapplications) in different crisis contexts;
  • use by different types of helpers, from lay people to professionals;
  • the place of PFA in the larger field of MHPSS in emergency response; and
  • recommendations for the future.

The retrospective provides a rich overview of respondents’ experiences with the materials (including adaptation and translation), with PFA orientation and training-of-trainers, and their perceptions of PFA, including the name itself, how it is understood and its key strengths and risks. The case studies provide further analysis on how PFA has been applied, from large capacity-building efforts to applications in particular settings such as the Ebola crisis, in staff and team care and in emergency response coordination and advocacy for MHPSS in general.

Five key recommendations summarise the priorities that emerged from these varied perspectives, and provide a roadmap for next steps for practitioners, the authors of the guide and stakeholders in the global MHPSS community:

1. Provide an updated overview of the MHPSS field that clarifies the place of PFA within the broader spectrum of support

According to respondents, the simplicity and accessibility of PFA was both its greatest strength and its greatest potential danger. In the experience of some practitioners and donors, ‘PFA’ became synonymous with ‘MHPSS’, and so the full range of multi-layered, integrated MHPSS support and interventions in emergencies tended to be overlooked (and sometimes underfunded) in favour of this one, useful yet insufficient approach. Asking respondents to locate PFA on the Inter-Agency Standing Committee (IASC)’s MHPSS intervention pyramid also highlighted the lack of clarity and consensus about where PFA fits on the spectrum of MHPSS actions and interventions.

The MHPSS field is evolving rapidly as new, accessible resources are developed and tested and the evidence base expands. It would be timely to update the MHPSS field with an overview of the range of resources in the repertoire of MHPSS practitioners, when and how they should be used, and how they complement each other in a coordinated system of support. PFA can then be situated more appropriately within the larger sphere of psychosocial approaches and mental health interventions.

2. Keep attention to PFA as a foundational component of MHPSS approaches and tend to its applications in practice

Respondents recognised the value of ensuring that PFA guidance is widely accessible and freely available, and recommended promoting it further within disaster preparedness initiatives. Many noted that PFA helped to raise the profile of MHPSS in emergencies, reached across cultures and contexts through the translations and opened the door to mainstreaming MHPSS within other sectors. However, despite guidance on facilitating orientations little is known about how PFA has actually been applied or orientations have been conducted, and the ethical principles of safety, dignity and rights that underpin PFA sometimes got lost. One concrete recommendation was to acknowledge that PFA provides core guidance on basic psychosocial support skills, and to focus attention on how it is incorporated within ongoing and new initiatives – including as an integral component of new scalable mental health care interventions.

3. Continue to develop innovative PFA resources and technologies

Few respondents in the survey were aware that an e-learning course for PFA exists on the website of one international NGO, Plan International,+See Plan International Plan Academy website: http://www.plan-academy.org/enrol/index.php?id=31. or that there is an online forum linking practitioners on MHPSS.net.+See the PFA Adaptation and Training Group on MHPSS.net. Respondents were very interested in these types of resources and technologies, as a complement to face-to-face orientations, to broaden the reach of PFA in lower-resource settings and to help clarify its use. Apps, online forums and e-learning utilising video clips and simulation demonstrations would be highly valued and would help in future applications of PFA.

4. Promote fidelity to the model with support to capacity-building initiatives and dialogue among communities of practice

Respondents generally felt the content of the PFA guidance had held up over time, and asked that the original guidance be kept intact. What they felt would be helpful at this stage is more information on how best to adapt and apply PFA in different contexts, including a compilation of case scenarios and orientation approaches from crisis situations. There are successful examples of national and regional capacity-building efforts that have led to the formation of communities of practice offering peer support for the application of PFA, improved attention to the care of staff and other helpers in crisis response, more coordinated advocacy for MHPSS in general and improved preparedness. A reinvigoration of existing online forums (e.g. the MHPSS.net PFA group) could be a good place to start, along with innovative technologies that could further develop communities of practice.

5. Develop common approaches and tools for monitoring and evaluation of and research on PFA

One question that has come increasingly to the fore as PFA has gained popularity is: what is the evidence that it works? PFA as articulated in the WHO guide is purportedly ‘evidenceinformed’ and ‘consensus-based’. The evidence informing PFA comes from disaster research focused on risk and the resilience of individuals and communities and, in particular, findings around the importance of social support in recovery from crisis events. Through the Look, Listen, Link actions of PFA, it is designed to improve the ability of responders to appropriately make contact with survivors, listen supportively and help affected people connect with services and their natural sources of support. PFA is also consistent with the literature promoting the factors known to support individuals in their recovery from crisis events, namely hope, safety, calming, self and community efficacy and (again) social support.

However, ‘evidence-informed’ is not ‘evidence-based’, and calls to evaluate the efficacy of PFA have increasingly revealed challenges and diverging points of view. PFA is not a discrete ‘intervention’ with one, agreed definition, and it is used flexibly according to the needs of affected people and the skills and roles of different helpers. Some liken PFA to a set of good communication and helping skills or a good bedside manner, and do not see it as an intervention at all. Indeed, as PFA has been increasingly utilised by helpers outside of the MHPSS field, it more clearly emerges as guidance for any helper to communicate better, be aware of safety considerations and other support and services, and minimise further harm to a survivor by poorly chosen words or actions. Furthermore, the WHO PFA guidance explicitly distances itself from the notion that offering PFA as a brief, supportive approach can prevent later mental disorder or distress, or that it can be used to reliably identify people at risk of developing longer-term mental health problems. Thus, clinical evaluation methods and outcomes defined by mental health symptoms would not be appropriate for evaluating the efficacy of PFA.

Opinions on the importance of establishing an evidence base for PFA varied widely among respondents in the retrospective study. Some emphasised that it was critical to evaluate PFA, while others believed an evidence base for common-sense, basic helping skills is unnecessary. However, respondents generally agreed on the need to develop a common, practical approach to monitoring and evaluating PFA – including developing relevant indicators and simple tools that could be used to collect data on its application during crisis response. Focus areas recommended for evaluation and research included fidelity to the model described in the guidance and the impact of orientation on helpers themselves. In addition, based on the influence of PFA in general MHPSS approaches, a systems-level perspective for evaluation and research may be warranted.

In conclusion, the PFA retrospective study allowed us the chance to Look at the progression of the WHO PFA guidance, Listen carefully to people’s experiences and perceptions and hopefully now Link PFA within holistic, comprehensive MHPSS responses in emergencies. Just as medical first aid does not constitute a comprehensive health response, so PFA is not a panacea for all the mental health needs of people affected by crisis events – it must be integrated as a component of wider MHPSS frameworks and services to most effectively ‘reach out a helping hand’. It is the hope of the authors of the retrospective study that these findings can help to guide future applications of this widely used resource in ways that will benefit the larger MHPSS field, and to provide a clear picture of the wealth of MHPSS resources and knowledge now available to field practitioners.

Leslie Snider is an independent consultant and the founder of Peace in Practice. Alison Schafer is MHPSS Technical Advisor at World Vision International. They were involved in the development of the original PFA guide in 2011. Carina Hjelmstam Winberg is with the humanitarian team of Church of Sweden, which commissioned the PFA retrospective.