In the past few years, Nepal has faced a series of devastating natural disasters that have significantly impacted the country. Among these, the April 2015 earthquake stands out as one of the most catastrophic, causing nearly 9,000 deaths and injuring around 22,000 people¹. More recently, in August 2024, a 6.4 magnitude earthquake struck Jajarkot in the Karnali Province. This earthquake claimed 153 lives, with 101 fatalities reported in Jajarkot alone, and left numerous others injured. The quake caused extensive damage to infrastructure, including the destruction of 213 school buildings in the area². Rescue and rehabilitation in such sudden and devastating incidents require significant human and financial resources. The 2015 earthquake led to a surge of volunteers and human resources from other organizations in the rescue and rehabilitation of the affected and displaced. Many volunteers from neighboring and foreign countries came in to offer their help and support during the 2015 earthquake. Mental health becomes one of the critical part of activities by the first responders. Like any other First Aid skills everyone should be equipped with the skills of Psychological First Aid (PFA).

The concept of Psychological First Aid (PFA) originated during and after World War II, largely in response to the need for immediate, front-line mental health interventions for soldiers^3,4. The idea was to provide quick, practical assistance to reduce the emotional distress experienced by those exposed to traumatic events, aiming to prevent the development of more severe psychological conditions such as Post-Traumatic Stress Disorder (PTSD). National Center for Post Traumatic Stress Disorder (NC-PTSD) a section of the United Statges Department of Veteran Affairs formally developed Psychological First Aid (PFA) as a technique designed to reduce the occurrence of post-traumatic stress disorder in 2006. Since then, many organizations such as the International Federation of Red Cross and Red Crescent Societies, Community Emergency Response Team (CERT), the American Psychological Association (APA) and many others have endorsed it.

After the National Institiute of Mental Health conference in 2011 marked a rapid adoption and proliferation of Psychological First Aid ensued in the coming days and years⁴.

Psychological first aid is also consistently recommended in international treatment guidelines for posttraumatic stress disorder (PTSD) and as an early intervention for disaster survivors^5,6,7,8.

Since 9/11 there has been a proliferation of different frameworks and variations based on the target population some of which are psychological first aid, community-based psychosocial support, disaster behavioral health first aid, mental health first aid, and stress first aid. For ease and brevity, we will use the term, “psychological first aid,” and the generic abbreviation, “PFA,” throughout this commentary⁹.

The formalization of PFA as we know it today, however, gained significant momentum in the early 2000’s. This development was driven by the recognition that victims of natural disasters, terrorism, and other large-scale emergencies needed immediate psychological support. The increased frequency of such events, along with a growing body of research on trauma and stress, highlighted the importance of early intervention to stabilize emotional distress and promote recovery.

The World Health Organization (WHO), the National Center for PTSD, and other organizations have since developed guidelines and training programs for PFA. These guidelines emphasize the importance of providing psychological support in a way that is non-intrusive, compassionate, and appropriate to the cultural and social context of those affected.

The rise in the adoption of PFA can be attributed to its practicality and effectiveness in helping people cope with the immediate aftermath of trauma, thereby reducing the risk of long-term mental health issues.

These events have placed enormous strain on Nepal’s emergency response and recovery efforts, underscoring the need for continued preparedness and resilience in the face of natural disasters​. Natural disasters such as earthquakes, landslides, and floods can have profound and long-lasting mental health implications on affected populations. The psychological impact can be immediate, but the effects often persist long after the physical wounds have healed. Key mental health issues include:

Principle of Psychological First Aid (PFA) meet four basic standards. They are: (1) Consistent with research evidence on risk and resilience following trauma; (2) Applicable and practical in field settings; (3) Appropriate for developmental levels across the lifespan; and (4) Culturally informed and delivered in a flexible manner¹⁰.

This guide contains the following sections: (1) Introduction and Overview; (2) Preparing to Deliver Psychological First Aid; (3) Core Actions; (4) Contact and Engagement; (5) Safety and Comfort; (6) Stabilization; (7) Information Gathering; (8) Practical Assistance; (9) Connection with Social Supports; (10) Information on Coping; and (11) Collaborative Services¹⁰.

What is the difference between PFA and counseling or Individual Psychotherapies?

Traditional psychological therapies and counseling are based on sympdtom reduction and target either brief relief from symptoms of psychiatric disorders or bring about lasting change in the pattern of thinking and behaving or personality restructuring. However, as the name suggest, Psychological First Aid are strategies to reduce strong emotional reaction to immediate psychological trauma to life threatening situation such as brought by natural disaster or any other form of threat to personal wellbeing.

Psychotherapies and counseling are provided by trained mental health professional however, PFA can be provided by anyone, such as a family member, friend, teacher, supervisor, co-worker if he or she is aware of the basic principles of PFA.

PFA’s are based on the five “essential elements” generated through consensus conference of disaster mental health experts convened in 2004 and later summarized in a landmark publication by Hobfoll and 19 co-authors^9,11.

Inter-Agency Standing Committee (IASC) of the United Nations wrote that most people experiencing acute psychological distress following exposure to stressful events are “best supported without medication” and that “all aid workers, and especially health workers, should be able to provide very basic psychological first aid”

One of prominent figure in mental health states “A little help, rationally directed and purposely focused at a strategic time, is more effective than extensive help given at a period of less emotional accessibility” (Rapoport 1965, p. 30).

The main goal of PFA is an evidence-informed intervention designed to reduce the initial distress caused by traumatic events and to foster short- and long-term adaptive functioning and coping. The goal of PFA is to provide immediate emotional and practical support to individuals affected by a crisis. It is a humane, supportive response to those suffering and is delivered in the immediate aftermath of a traumatic incident.

Principles of Psychological First Aid (PFA)

1. Safety: Ensure physical and emotional safety of the individuals affected.
2. Calm: Help people to calm down and manage their feelings of anxiety and fear.
3. Connection: Help individuals to connect with their loved ones and support networks.
4. Self-Efficacy: Encourage people to take an active role in their recovery and make decisions about their immediate needs.
5. Hope: Provide information that fosters hope and promotes the understanding that recovery is possible.
6. Practical Assistance: Address immediate practical needs to reduce stressors and provide comfort.

Steps to Perform Psychological First Aid

1. Prepare and Approach

• Ensure Personal Safety: Before approaching, assess the situation to ensure that it is safe for both you and the affected individuals. Consider your own emotional readiness and understand your role.
• Introduce Yourself: Approach in a calm and respectful manner, introduce yourself, and explain your role. Ask for permission before providing assistance, respecting their need for space and autonomy.

2. Establish a Connection

• Listen Actively: Show empathy through attentive listening. Allow the affected individuals to express their feelings without interrupting or offering unsolicited advice.
• Be Present: Maintain a calm, composed demeanor. Your presence alone can provide a sense of stability and support.
• Observe and Assess: Pay attention to the person’s emotional state, body language, and behavior. Look for signs of shock, confusion, fear, or distress.

3. Ensure Safety and Provide Comfort

• Create a Safe Environment: If possible, move the affected individuals to a quieter, safer space away from the immediate scene of the trauma.
• Comforting Presence: Offer words of reassurance such as, “You are safe now,” or “We are here to help you.” Avoid making promises you cannot keep or providing false hope.
• Normalize Reactions: Explain that their reactions—such as crying, confusion, or fear—are normal responses to an abnormal situation. This can help reduce their sense of isolation or abnormality.

4. Offer Practical Assistance

• Assess Immediate Needs: Ask about any immediate needs—such as water, a blanket, contacting a family member, or taking a break. Fulfilling these needs can help alleviate immediate stress.
• Help Prioritize Needs: Assist in identifying what immediate actions are necessary. For example, “Would you like to sit down for a moment, or is there someone you want to call first?”
• Provide Accurate Information: If they ask for information about what happened or what will happen next, provide clear, factual, and simple information without overwhelming them.

5. Encourage Connection and Social Support

• Facilitate Contact with Loved Ones: Help the affected individual connect with their family, friends, or other support networks. This could involve making phone calls or arranging transportation.
• Involve Community Resources: If applicable, connect them with other forms of support such as community groups, religious leaders, or counselors.
• Peer Support: Encourage supportive interactions among affected individuals, if appropriate. Shared experiences can provide comfort and a sense of solidarity.

6. Encourage Adaptive Coping Strategies

• Promote Self-Care: Encourage the individual to engage in simple self-care activities, such as resting, eating, or breathing exercises. Remind them of the importance of looking after themselves.
• Set Small, Manageable Goals: Help them focus on what they can control by setting small, achievable tasks, such as calling a loved one or sitting down to rest.
• Empower Decision-Making: Support them in making their own decisions about their next steps, helping them regain a sense of control.

7. Provide Information and Referral

• Explain Available Resources: Provide information about the resources available to them, such as counseling services, support groups, or hotlines.
• Encourage Follow-up: If needed, suggest follow-up with a mental health professional or a counselor for ongoing support.
• Avoid Overloading: Be careful not to overwhelm the individual with too much information. Offer information in small, manageable portions and prioritize their immediate needs.

8. End the Interaction Respectfully

• Summarize the Conversation: Briefly recap what was discussed and the next steps agreed upon. Ensure the individual knows what to expect next and who to contact if they need further support.
• Express Continued Availability: Let them know that they can reach out for help in the future if needed. Provide contact information if appropriate.
• Respect Their Wishes: If the individual does not want further assistance, respect their decision while ensuring they have the information, they need to seek help later if they change their mind.

Important Considerations

• Cultural Sensitivity: Be aware of cultural differences and respect the individual’s cultural background and preferences.
• Non-Intrusive: PFA should be delivered in a non-intrusive, compassionate manner. It is not about probing into personal details or forcing someone to talk about their trauma.
• Confidentiality: Maintain confidentiality and ensure that the individual’s privacy is respected throughout the process.

What Not to Do in Psychological First Aid

• Do Not Force Discussion: Avoid pressuring individuals to talk about the event or their feelings if they are not ready.
• Avoid Making Assumptions: Do not assume you know what the person is feeling or what they need. Always ask and listen.
• Do Not Give False Reassurance: Avoid saying things like “Everything will be fine” if you are not sure. Instead, focus on the present moment and what can be done immediately.
• Avoid Blaming or Judging: Refrain from any comments that might seem like blame, judgment, or criticism of how someone is reacting to the event.

References

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