Overview of Psychological First Aid and

Field Interventions

Elissa Epel, PhD

University of California, San Francisco

Department of Psychiatry and Behavioral Sciences

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Elissa E

Vibrant Emotional Health Disaster Services

January 23, 2025

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Meet Your Trainers

April Naturale, PhD, is Vice President, Disaster Services, Vibrant Emotional Health; She has a long history in health/mental health administration and since leading the 9/11 mental health response for NY, has worked as a Traumatic Stress Specialist focused on response to disasters and mass violence in the US and Europe.

Dr. Sander Koyfman is a Psychiatrist with dual Board Certification in General Adult Psychiatry and Addiction Medicine. He is the Chief Medical Officer at Languages of Care - a disaster mental health non-profit focused on language equity and a psychiatrist at Athena Psych and RiverSpring Health. He completed his medical degree at the State University of New York Downstate Medical Center College of Medicine. He is a graduate of Mount Sinai Hospital Adult Psychiatry Program in New York City.

Dr. Grant Brenner, Assistant Clinical Professor, Mount Sinai Beth Israel Department of Psychiatry and Behavioral Health

• Co-Chair, Committee on Disasters, Trauma and Global Health, Group for the Advancement of Psychiatry
• Psychiatrist, Private Practice, NYC

Psychological First Aid (PFA)

PFA is an evidence informed model to address victims, families and community members impacted by a natural or human caused disaster or emergency. The focus is on providing a supportive and compassionate presence designed to do three things:

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• De-escalate acute distress responses to mitigate worsening
• Provide psychoeducational information on common responses, effective coping and connection to resources
• Facilitate access to continued emotional and mental health care as needed*

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Requirements for PFA Providers

Ability to:

• Work in chaotic and unpredictable environments
• Conduct rapid assessment
• Provide services tailored to timing of intervention,

context, and culture

• Tolerate intense distress and reactions
• Accept tasks that are not initially viewed as mental

health activities; outside your normal role

• Work with diverse cultures, ethnic groups, developmental levels, and faith backgrounds
• Have the capacity for self-care

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PFA Basic Assumptions

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• Anyone can learn PFA and engage with victims and family members
• Apply culturally applicable language, signs of respect, understanding of health and mental health as well as mental illness, community rituals
• Emotional distress is not mental illness
• Normalize common reactions to trauma
• Access natural and social coping and recovery tools

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PFA Basic Assumptions

Distress reactions are:

• Common
• Expected

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While utilizing these techniques:

• Don’t expect immediate improvement
• Focus on stopping the “flood”

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Without good coping, risk increases

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Expected Distress Reactions

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• Sleep problems
• Sadness, fatigue, depressive-like symptoms
• Anger, irritation
• Difficulty focusing/listening/concentrating
• Difficulty or inability to complete tasks
• Getting more emotional than usual for that person

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• Intrusive images
• Hyper-vigilance
• Avoidance
• Emotional numbness
• Problems functioning at work or school

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Strength Based Reactions

People can also respond positively to distress and can become involved in the helping process…

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• Find meaning in their work or in the recovery efforts
• Develop appreciation and gratitude for what they do have, their relationships and work helping opportunities

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Psychological First Aid �Core Action

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Contact and Engagement

Psychological First Aid Core Actions

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Contact and Engagement

Goal: Initiate contact and respond in a compassionate and helpful manner

• Monitoring and surveillance: be on the lookout for those at risk - (over emotional, isolated, children)
• Start with those that reach out to you
• Be a compassionate presence: give your full attention
• Introduce yourself (name/brief description of your role)
• Check on immediate needs

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Contact and Engagement

• Find reasons to connect – (water bottle, handouts

etc.)

• Ask for permission to talk and respect person/culture - think about touch, personal space, eye contact
• Respect the decision not to talk
• Provide information on when they could speak with

someone later on

• Listen for more severe or prolonged reactions

Goal: Initiate contact and respond in a compassionate and helpful manner

“Rules” of Engagement

• Focus on hearing what someone is saying and how they say it
• Pay attention to what is not being said (body language, details that may be left out)
• Watch how someone behaves/copes
• Listen to and prioritize concerns with those affected

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Tip:

• Work with groups of survivors with same exposure together
• Identify a ‘buddy’

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Safety and Comfort

Goal: enhance safety and provide physical and emotional comfort

• Ensure the physical environment is safe and comfortable as possible

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• Offer first aid and medical assistance as needed
• Food, water, shelter, adequate clothing
• Connect with needed medications and assistive devices (i.e. wheelchair or walker)

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• Avoid triggering sights, smells, news, and social media by giving specific advice (“no more than 10 minutes of social media at a time no more than twice a day”)

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• Stay out of ‘hot zone’ area of disaster that may not be stable or safe yet

Safety and Comfort

Ask about pre-existing conditions

The stigma of mental health may prevent survivors from asking and we may wrongly assume access to care is not disrupted. Providers need to focus on usual care including:

• Injectable antipsychotics
• Opioid use disorder
• Medication Assisted Treatments

Safety and Comfort

Goal: enhance safety and provide physical and emotional comfort

• Obtain and provide only up to date information
• Avoid sharing incomplete or upsetting information
• Avoid giving false hope

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Consider and practice statements such as:

• “I don’t have that answer, but I will work to find out.”
• “There are many qualified professionals working to help - let me help connect you to the right person/agency”

Stabilization

Goal: Calm and orient emotionally overwhelmed survivors

• Strong emotions should be expected in a disaster
• Most individuals can calm themselves with instruction

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• Watch for those that are disoriented, numb, confused, panicked, hysterical, frantic, or frozen
• Focus on level of function and assist as needed;
• Present a calm presence-model helpful behavior

Stabilization

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• Give some time before engagement
• Remain calm, quiet, and present to give help when needed
• Give information about the person and his/her surroundings to orient him/her
• Clarify misinformation
• Explain that intense emotions can be expected and may occur in waves

Goal: Calm and orient emotionally overwhelmed survivors

Information Gathering

Goal: Gather more information, identify immediate needs, and provide targeted support

• Begins immediately after initial contact and continues

through the entire process

• Ask questions informally as you are providing education or

assistance

• Follow the survivor’s lead about traumatic events
• Avoid asking for in-depth descriptions that may traumatize

further

Information Gathering

Goal: Gather more information, identify immediate needs, and provide more personalized interventions

Ask only enough questions to determine if the survivor need more support or referral

• Examples:
• Separation from loved ones and/or death of loved ones
• Physical and/or mental illness
• Substance use
• Need for medications
• Thoughts about harming self or others

Information Gathering

• Listen for extreme feelings of guilt or shame
• Determine availability – or lack – of social supports

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• Specific concerns about developmental impact and protection of:
• Children/youth
• Older Adults
• Family
• Be alert for specifically vulnerable members of the community (LGBTQ+, Domestic Violence, Trafficking)

Goal: Gather more information, identify immediate needs, and provide more personalized interventions

Psychological First Aid Core Actions

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Practical Assistance

Goal: Offer practical help to address immediate needs

• Stress can affect ability to think and plan
• Ways to assist:
• Identify immediate concerns
• Clarify the need - “What I am understanding would be helpful for you is…”
• Make an action plan with simple, clear steps. Verify understanding
• Determine when to operationalize action plan

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Connect with Social Supports

Goal: establish connection with primary supports and community resources

• Assist with access to family, friends, loved ones
• Encourage supportive social and group interactions in the immediate environment
• Provide information about community resources such as social services, mental health resources, medical resources, addiction services, child care, religious support

Information on Coping

Goal: Provide information about stress reactions, reduce distress, and promote adaptive functioning.

• Provide basic information about stress reactions and explain that they are expected/understandable
• Identify coping strategies that have worked in the past
• Provide additional coping strategies:

Focus on the CORE 4

• Relaxation techniques
• Sleep hygiene tools and advice
• Ways to manage negative emotions
• How to seek out further support

Psychoeducation and Information on Coping

• Provide basic information about coping
• Provide techniques for anger management
• Address highly negative emotions (basic CBT)
• Address alcohol and substance use: Determine if usage is more or more impactful than before event
• Connect to peer and clinical supports as needed

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De-escalation and grounding

Box Breathing

Take a deep breath in to the count of 4�Then hold it for 4 seconds�Then release it to the count of 4�Then hold for 4 seconds before you take the next breath in

4x 4x 4x 4

You may also want to think about what you want to put in the box and put away for today; or to help compartmentalize everything you are thinking about

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De-escalation and Grounding

Mobilizers

Make circles with your hips, if you are seated, move your rib cage. Remember to breathe deeply, move slowly and pay attention to your body. Do 3 circles in one direction, then do circles in the opposite direction 

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For the next movement, make an arch with your whole body slowly. As you arch back inhale. Then slowly crouch forward and exhale as you crouch. 

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Inhale slowly, bring your chin-up, push your chest out, arms reach back with your thumbs up and stick your butt out to make an arch.

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Then exhale, bring your chin down, chest in, arms come across in front and butt in to curl your body. 

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Do 5 repetitions. Everyone, move at your own pace. Inhale and exhale as slowly as possible.

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About

Sleep

https://mobile.va.gov/app/cbt-i-coach

https://www.cstsonline.org/assets/media/documents

https://www.cstsonline.org/assets/media/documents/CSTS_Infographic_MakeSleepAPriority.pdf

https://www.physiciansupportline.com/

Linkage with Collaborative Services�

• Provide information on local, state and federal (FEMA)

resources (e.g. social services, mental health, medical,

addiction services, child care & religious support

• Know services that are available and how to connect

survivors with them

• Collaborate w/survivors to choose services they need
• When leaving a response site, let the survivors know

and provide a hand-off to the next provider whenever

possible

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Goal is to promote continuity in helping relationships for long-term recovery

In the Field

• Continuously build awareness of culture (a.k.a.

cultural humility)

• Recognize diversity
• Learn community history especially experiences

with government; understanding of health, mental

health and mental illness

• Respect traditions and rituals
• Don’t assume any perspectives
• Recognize importance of community resources

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Important Topics

• Reactions will vary across disaster and levels of trauma exposure
• Domestic Violence doesn’t disappear
• Monitor for Child Care and Child Abuse issues; Interface with community resources
• Ask about prior mental illnesses and suicide thoughts or attempts
• Ask about prescribed and other medication and substance use/misuse

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Alcohol and Substance Use / Misuse Concerns

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Red Flags

• Continued nightmares and flashbacks
• Hypervigilance
• Extreme avoidance of thinking or talking about the event
• Continued numbness/dissociation
• “Workaholism”
• Social isolation or withdrawal
• Anger or violence
• Frequent use of alcohol or drugs

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Risk Factors

• Death of a family member or friend
• Seeing serious injury or the death of another person
• Feeling extreme panic, fearing for one’s life or that of loved ones was in danger
• Being unable to evacuate quickly or becoming trapped
• Missing family members
• Getting hurt or becoming sick due to the disaster
• Worrying about becoming sick
• Losing one’s home, job and/or belongings
• Having to relocate and change neighborhoods, schools, etc.
• Dealing with financial burdens
• Having past traumatic experiences
• Losing a pet

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Self Care for Responders

Common attitudinal obstacles to self-care:

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“It would be selfish to take time to rest.”

“Others are working around the clock, so should I.”

“The needs of the disaster-affected people are more

important than the needs of helpers.”

“I can contribute the most by working all the time.”

“Only I can do x, y, and z.”

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Self Care for Responders

• Mandated rotation where workers are moved from the most highly exposed assignments to varied levels of exposure
• Enforced support by providing/encouraging regular supervision/regular case conferences
• Peer partners and peer consultation
• Monitor providers who meet certain high-risk criteria

(especially those with shared trauma experience)

• Conduct trainings on stress management practices

Agency Management Structures

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Self Care for Responders

Individual Care During Response

Make every effort to avoid:

• Working too long by oneself without checking in
• Working “around the clock” with few breaks
• Feeling like you are not doing enough
• Excessive intake of sweets and caffeine

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Self Care for Responders

Provider Care Following Response Deployment

• Expect a readjustment period upon returning home
• Discuss the situation with coworkers and

management

• Participate in formal help if extreme stress persists
• Ask for help in parenting, if you feel irritable or have

difficulties adjusting

• Prepare for worldview changes that may not be

mirrored by others in your life

• Increase experiences that have spiritual or

philosophical meaning to you

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https://www.appi.org/Products/Trauma-Violence-and-PTSD/Disaster-Psychiatry-Second-Edition

Model for Adaptive Response to Complex, Cyclic Disasters

https://marccd.info/

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Key Resources at Vibrant

Disaster Distress Helpline: Call or text 

1-800-985-5990 to connect with a trained crisis counselor.

�SAMHSA’s Disaster Distress Helpline provides 24/7, 365-day-a-year crisis counseling and support to people experiencing emotional distress related to natural or human-caused disasters and En Española

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https://www.nctsn.org/resources/pfa-mobile

Questions?

Sander Koyfman, MD 917-582-2455 sander.koyfman@gmail.com

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Grant Brenner, MD DrBrenner@granthbrennermd.com

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April Naturale, VP Disaster Services, Vibrant Emotional Health ANaturale@vibrant.org

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