Psychological First Aid:Supporting Friends and Family through

the Stress of Critical Incidents

Dr. Naomi Paget, BCC, BCCCFellow, American Academy of Experts in Traumatic Stress

Fellow, National Center for Crisis ManagementCalifornia SBC Disaster Relief Chaplain Director

Course Purpose

…To enable you to provide compassionate care, comfort, and support to people who are experiencing crisis-related stress…

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Seminar Objectives

• Notice the signs of stress in family and friends -and yourself

• Give immediate support to people who may be experiencing stress by implementing PFA principles

• Know when to obtain additional mental health support for yourself, co-workers, and clients

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After completing this seminar, you will be able to:

What is Psychological First Aid?

The practice of recognizing and responding to people who need help because they are feeling stress, resulting from the crisis situations within which they find themselves.

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Why is PFA Important?

• Knowing how to provide Psychological First Aid can help you to:– Create a compassionate environment for

those impacted by crisis– Assess what might be helpful for a person at a

particular time– Provide immediate support to those in stressful

situations– Help others cope in the face of stressful events

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At the end of our lives, we will not be judged by how many diplomas we have received, how much money we have made, or how many great things we have done. We will be judged by “I was hungry and you gave me food to eat. I was naked and you clothed me. I was homeless and

you took me in.”

Mother Teresa (1910-1997)

What Constitutes A Traumatic Community Crisis?

• Affects several people or entire communities

• Is unexpected or sudden• Has an element of danger• Causes significant chaos and confusion• Causes injury or loss of human life• Causes property damage or loss• Generates significant media coverage

Classifications of Those who are Impacted

• Directly impacted

• Indirectly impacted

• Impacted but “hidden”

A response to a stimulus characterized by increased physical and psychological

AROUSAL

(Everly, 1999)

Three Faces of Stress

• Stress is essential for:– Strength and toughness– Growth and development– Acquire new skills– Meeting challenges– Performing difficult missions

• Stress can lead to:– Persistent internal distress– Functional impairment– Misconduct– Substance abuse– Mental disorders

STRESS REACTION CATEGORIES

• FIGHT

• FLIGHT

• FREEZE

• FLOW

Stress Reactions of Adults

• Stress reactions vary from person to person and:– Can disappear– Remain the same– Get somewhat better– Grow considerably worse

• The severity and duration of stress depends on how well people manage and cope with their situations

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Stress Reactions In Adults: Feelings

• Rage, anger, irritability• Resentment• Anxiety, fear• Despair, hopelessness• Numb• Terrified

• Guilty, ashamed• Sad• Helpless, loss of control• Uninterested• Overwhelmed

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Stress Reactions In Adults: Thoughts

• Difficulty concentrating and thinking

• Difficulty making decisions

• Forgetful• Confused• Distortion of sense of

time• Illogical, irrational

• Self-blame• Intrusive thoughts,

memories, flashbacks• Worry• A sense of being cut off

from reality• Self-harm • Lowered self-esteem

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Stress Reactions In Adults: Physical Effects

• Fatigue, difficulty sleeping• Agitation• Physical complaints (e.g.,

stomach and gastro problems)

• Decreased or increased appetite

• Decreased or increased sex drive

• Easily startled• Increased cravings for

and use of caffeine, nicotine, sweets, alcohol, illicit substances

• Lightheaded• Weak• Headaches, muscle pain• Nervous tics, spasms

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Stress Reactions In Adults: Behaviors

• Crying spells• Angry outbursts• Avoiding people, places,

and situations• Argumentative• Isolation, withdrawal• Abuse of substances

• School and work problems

• Risky behaviors (driving erratically, multiple sexual partners, unsafe sex)

• Inattention to appearance, personal hygiene, self-care

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Stress Reactions In Adults: Spiritual

• Change in relationship with or belief about God/Higher Power

• Abandonment of prayer, ritual, scripture, devotions, sacraments

• Questioning the beliefs of one’s faith

• Rejection of spiritual care providers

• Struggle with questions about the meaning of life, justice, fairness, afterlife

• Loss of familiar spiritual supports

• Loss of faith • Doubt, unforgiveness,

lack of gratitude

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Peritraumatic Behavior Checklist of Traumatic Stress Behaviors

1. Not acting like their normal self2. Acting fearless and invulnerable, as if nothing could harm them3. Not caring about their own or others’ welfare or safety4. Feeling no remorse for doing things that would have bothered them before5. Acting determined to get revenge6. Being unable to stop laughing, crying, or screaming7. Seeming helpless and unable to look out for their own welfare8. Acting confused, having difficulty making sense of what was happening9. Disoriented, and uncertain about what day or time it is10. Unable to move parts of their body11. Freezing, moving very slowly, and unable to do all that they intended12. Speech changed (stuttering, repeating words, or shaky or squeaky voice)13. Not able to fully carry out duties (during or immediately after an event)14. Seemed to believe they were going to die15. Had an intense physical reaction: sweating, shaking, or heart pounding

Stress Reactions of Children

• Stress reactions in children can vary by child and age

• Children are particularly sensitive to:– Separation from familiar

surroundings, people, and possessions

– Disruption of routines

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Stress Reactions In Children: Feelings

• Fear, terrified• Anxious• Sad• Guilty • Rage, anger,

irritability helpless• Loss of interest• Changing mood

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Stress Reactions In Children: Thinking

• Difficulty concentrating and thinking

• Difficulty making decisions

• Forgetful• Confused

• Self-blame• Intrusive thoughts,

memories, flashbacks• Worry• A sense of being cut

off from reality• Self-harm • Distortion of sense of

time• Lowered self-esteem

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Stress Reactions In Children: Physical

• Fatigue, difficulty sleeping• Agitation• Increased activity

level/hyperactive• Physical complaints

(e.g., headaches, stomach aches)

• Decreased or increased appetite

• Easily startled• Bed wetting

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Stress Reactions In Children: Behaviors

• Crying, whining, screaming• Trembling• Clinging • Aggressive or disruptive

behavior, temper tantrums• Withdrawn• Avoiding people, places,

situations• Regressive behaviors

(thumb sucking, bedwetting, not wanting to sleep alone)

• Refusal to attend school or day care

• Difficulty getting along with siblings and parents

• Using drugs and alcohol• Re-living events through

play (young children)• Asking a lot of questions or

telling stories related to event

• Argumentative, defiant23

Contributing Factors to the Stress Response

• Crisis characteristics• Crisis response characteristics• Individual characteristics• Factors that affect you as a crisis responder

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Crisis Characteristics• Type of critical event• When it occurs• Who is affected• What is affected• Where it happens

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Crisis Response Characteristics

• Level of preparedness• Post-crisis living situation (e.g., Individuals may

need to wait in hospitals, evacuate their homes and stay in shelters, with friends or family, or in a hotel.)

• Limited availability of food and water• Delays in receiving relief services or medical care• Delays in receiving accurate information• Isolation or separation from loved ones• Excessive media coverage or contact

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Individual Characteristics• Age, gender• Family composition• Cultural, ethnic, racial

background• Level of exposure to the

disaster• Loss of or injury to family

member, other loved ones, pets

• Loss of possessions• Pre-crisis stress • Connectedness with others

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Factors that Affect You as a Friend or Family Member During Crisis Events

• Leaving family members and loved ones behind

• Listening to survivors’ stories

• Seeing disturbing sights• Inability to “do” something• Repeated media coverage• Returning home

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Psychological First Aid Actions

• Making a connection• Helping people be safe• Being kind, calm, and

compassionate• Meeting people’s basic

needs• Listening• Giving realistic

assurance

• Encouraging good coping

• Helping people connect

• Giving accurate and timely information

• Linking to collaborative services

• Ending the conversation

• Taking care of yourself

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Make a Connection with the Impacted Person

• Introduce your self if you are unknown to the person

• Greet the person warmly and offer condolences if this is the first time to make the connection

• Be fully present – physically, emotionally, spiritually

• Be aware of cultural implications and act accordingly

• Build trust and rapport“People will not remember all you say, but they will remember how they felt when they were with you.”

Help People be Safe

• Help people be safe:• Be aware of your surroundings• Enter a scene only when you are sure it is safe• Help people to reach a safe place• Call for medical assistance, if needed (Call 9-1-1)• Help people to follow emergency instructions• Introduce yourself and if appropriate, explain why are are

connecting with the person

Be Kind, Calm, and Compassionate

• Express patience and compassion, even if people are being difficult

• Speak in a calm voice• Remain courteous and respectful of people• Pay attention to cultural appropriateness of

physical proximity, eye contact, and gestures

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Maslow’s Hierarchy Is Still True forCrisis and Trauma

SelfActualization

Needs

Esteem Needs

Belonging Needs

Safety Needs

Physiological Needs

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Maslow’s Hierarchy of Needs– Assess the victim’s immediate need

• What’s the victim’s perceived need?• What’s the caregiver’s assessment?

– Physical survival is first– Victims need to perceive they are safe– Victims need to feel connected, not isolated

Luke 10ff – Parable of the Good Samaritan

Understanding the age-specific human response to crisis – Erik Erikson

– Trust vs. Mistrust - 2 yrs– Autonomy vs. Doubt – 2-3 yrs– Initiative vs. Guilt – 3-6 yrs– Industry vs. Inferiority – 6-12 yrs– Identity vs. Identity Confusion – 12-18 yrs– Intimacy vs. Isolation – 19-35 yrs– Generativity vs. Stagnation - 35-65 yrs– Integrity vs. Despair – after 65 yrs

Meet People’s Basic Needs• Offer or direct them to food and water• Provide or direct them to a safe place or shelter• Check to see if they are with family or friends• Encourage them to sleep and get rest.

(e.g., “Take a break, take a walk.”)• If necessary, direct them to a professional

helper– Medical provider– Mental health worker – Others

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Listen• Be attentive, focus• Be honest, truthful• Be respectful, polite• Clarify to understand• Use a calm voice• Build rapport• Validate• Convey interest

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Ethics of Listening

• Know the difference between privilege, privacy, and confidentiality

• Provide a sense of privacy• Confidentiality is essential• Ask questions on a “need to know” basis• Know the policies and statutes that govern your

confidentiality

Ministry of Presence

Presence is grace, availability, physical, emotional, and spiritual presence, awareness, openness,

and acceptance

“…In Your presence is fullness of joy…”Psalm 16:11

Ministry of Silence

• Sometimes, silence is “golden”

• If in doubt, don’t say it• Is it the truth?• Does it mitigate distress?• Will it be perceived as helpful?• Will it be a step toward healing?

Improving Listening Skills

• Clarify

• Paraphrase

• Summarize

• Echo

• Reflect

• Paraphrase or Summary with Extrapolation

People may misinterpret what you say

Listen, clarify, paraphrase, summarize, reflect, and listen some more . . .

The Art of Story-Listening

• Listen – assimilate and integrate to make meaning of words

• Provide a sense of privacy• Maintain confidentiality• Be present in body and spirit• Be silent sometimes• Use reflective empathetic listening

Give Realistic Reassurance

Help people to feel less anxious or worried by letting them know that what they are feeling or thinking is understandable

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Encourage Good Coping

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• Realistic perspectives• Eliminate stressors• Changing emotional

reactions• Acquire skills

Realistic perspectives

• Modify thinking– Denial– Distancing– Alter goals– Change values– Multiply options

• Positive reappraisal• Negative reappraisal• Mindfulness (peaceful abiding)

Eliminate stressors• Environmental

– Smells– Sounds, noise, silence– Light– Temperature– Sights

• Problems– Gain control– Get information– Evaluate pro and cons

Changing emotional reactions

• Catharsis– Release pent-up emotions– Process what happened (verbal, writing, art,

etc.)• Relaxation

– Meditation– Diaphragmatic breathing– Systematic muscle relaxation

• Boundaries– Rejecting blame or responsibility– Exercising self-control

Acquire skills

• Awareness– Stress– Critical events– Resources

• Problem solving• Conflict management• Coping mechanisms• Adaptive functioning

Help People Connect• Get them access to a phone so they can

contact their loved ones• Suggest other methods of communication

such as e-mail• Facilitate access to the Safe and Well

website so they can reconnect with their loved ones (www.redcross.org/safeandwell)

• Initiate the connection from time to time• Clarify options for social connections

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Give Accurate and Timely Information

• Guide people to the appropriate sources or resources for information in your setting

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Take Care of Yourself

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You can’t give people what you

don’t have!

Self care includes intentional rest and restoration

• Give yourself permission to rest and get plenty of sleep• Talk to someone you trust – someone who cares about you• Get some exercise or take a walk• Take a break from time to time• Eat healthier during this time• Stay hydrated• Ask for help

Self care includes maintaining a healthy perspective

• You can’t “fix” everything – you can’t “fix” somethings, either • There are no good answers to some very difficult questions• Some people take longer to accept “strangers”• You may feel distressed about things, too• It’s okay to have your own boundaries• Not everyone wants or needs your help• You may need some help, too

Make Appropriate Referrals:Link people to collaborative servicesIMMEDIATE

• Danger to self– Thinking of hurting or

killing oneself• Danger to others

– Abusing or neglecting a child, an elderly person, or anyone who is vulnerable

• Medical injury or illness

VERY SOON• Felt/expressed extreme panic• Significant legal or financial

issues• Missing family member• You are uncertain about the

situation

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End the Conversation

• Provide helpful resources• Provide contact number(s) for additional assistance• Ask:

– Is there anything else that would be helpful for you?– Is there anyone else that could be a good supporter

and encourager to you?• Say “thank you” Ex. “Thank you for talking with me and

letting me share this difficult time with you.”

Dos and Don’tsDo Do Not

Behavior

(your actions and body language)

Sit at an angel facing or beside the person

Make eye contact as appropriate, depending upon cultural expectations

Speak slowly and calmly Use shorter sentences

Sit back with your arms folded in front of you Look around the room or appear distracted

while the person is talking to you Look at your watch or cell phone while in the

conversation Walk away from the person while he or she is

talking to you. Frown, raise your eyebrows, or sigh while

listeningExpression

(what you say and how you say it)

“It sounds like that may have been a very difficult (frustrating/frightening/stressful) situation?”

“Is there anything that would be helpful for you right now?”

“You should be thankful that you and your family got out alive.”

“That doesn’t sound so bad…you should hear what this other guy went through.”

“It must have been God’s will.” “You really shouldn’t feel that way.” “Don’t feel (guilty, bad, nervous, etc.).” “At least you made it out alive.” “He/she’s in a better place.”

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Active ComfortingINVOLVES:

• Presence = showing up to listen & watchValidating the experience & highlighting divine perspective

• Companioning = walking along side through the valley(s)Assuring them that they are not alone & reminding them

• Supporting = encourage, refresh & render aide as requiredSharing & spreading the weight of the burden

• Protecting = shielding & leading in a safe directionStepping in to prevent further harm

• Resourcing = providing connections to the community & to the faith family (grace gifts of the Spirit); informing and guiding to additional help

Thank you for attending today’s seminar

October 27, 2017Henderson, NV

Psychological First Aid:Supporting Friends and Family through the Stress of

Critical Incidents

Dr. Naomi Paget, BCC, BCCC, FAAETS, FNCCMnpaget@earthlink.net

www.crisisplumbline.com www.crisisresponse.org/train/