Psychological First Aid and the Role of Scientific Evidence in Christians' Provision of Disaster Spiritual and Emotional Care.
Schruba, Alice N. ; Davis, Edward B. ; Aten, Jamie D. 等
Psychological First Aid and the Role of Scientific Evidence in Christians' Provision of Disaster Spiritual and Emotional Care.
Natural and man-made disasters are an ever-present part of the
broken world we inhabit. When disasters strike, Christians and Christian
humanitarian aid organizations (e.g., Mennonite Disaster Service, World
Vision, Food for the Hungry, and Samaritan's Purse) are normally
there to respond and provide early psychological, spiritual, and
practical assistance. However, sometimes well-meaning Christians offer
assistance with little awareness of what scientific evidence indicates
is and is not effective in helping disaster survivors. The recent
upsurge in the frequency and intensity of disasters has made it all the
more important for Christians to be trained in scientifically informed
principles and practices of disaster mental health if they are going to
provide effective care to disaster survivors (Aten, O'Grady,
Milstein, Boan, & Schruba, 2014; Aten et al., 2017).
The purpose of this article is to help address this need by
offering an overview of Psychological First Aid (PFA; APA, 1954; Brymer
et al., 2006a), which is currently considered the most evidence-informed
approach for providing early psychosocial help to disaster survivors. We
first give a historical and empirical overview of PFA and another widely
used intervention--Critical Incident Stress Debriefing (CISD; Mitchell,
1983). Then we explore implications for Christians who provide disaster
spiritual and emotional care.
A Historical and Empirical Overview of PFA and CISD
First Edition of Psychological First Aid
The first edition of PFA was developed by the American Psychiatric
Association, at the request of the United States Federal Civil Defense
Administration. The American Psychiatric Association published their
manual Psychological First Aid in Community Disasters in 1954. The
manual focused on techniques that relief workers could use to evaluate
how well disaster-affected individuals were functioning after the
disaster and help them re-establish a sense of mental stability. Four
principles were intended to guide the use of this initial PFA version:
(a) every individual has the right to his or her own feelings, (b) the
relief worker should accept the survivor's limitations, (c) the
relief worker should determine the survivor's abilities and engage
him or her in useful coping activities as quickly as possible, and (d)
relief workers should accept their own limitations when providing
relief. Some of these principles are still reflected in the contemporary
version of PFA, which was published over 50 years later (Brymer et al.,
2006a). The initial PFA version was quite popular and well-utilized when
it was first released, but its popularity and use steadily waned,
perhaps partly because of its matter-of-fact terminology and the
directive manner in which it encouraged relief to be provided. Also, the
initial version of PFA focused on the short-term psychological
re-stabilization of disaster-affected individuals, rather than on
alleviating possible longer-term psychological effects (e.g., PTSD) as
well.
Critical Incident Stress Debriefing
As the popularity of this initial PFA version waned, the disaster
response community recognized the need to find other ways to treat the
mental health needs of disaster survivors and other trauma-exposed
people. One intervention that emerged to fill this gap was CISD
(Mitchell, 1983), developed by Jeffrey T. Mitchell in the 1980s. CISD
was originally intended for use with emergency response workers, helping
reduce their risk of adverse mental health effects (e.g., PTSD,
depression, and anxiety). However, it gradually was used with disaster
survivors as well (Rose, Bisson, Churchill, & Wessely, 2002; Van
Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002).
CISD typically consists of a single, 1-to-3-hour session (delivered
within one week of a potentially traumatic event) in which groups or
individuals are led through seven stages. Its overarching goals are to
reduce psychological distress and prevent psychological problems.
Participants explore their thoughts and feelings related to the
traumatic event, discuss common trauma reactions, learn about adaptive
coping strategies, and prepare for reentry (Everly & Mitchell, 1995;
Litz, Gray, Bryant, & Adler, 2002; Rose et al., 2002; Van Emmerik et
al., 2002).
In the 1990s, the efficacy of CISD began coming under scientific
scrutiny. Since then, meta analyses have repeatedly found that CISD is
not effective either in reducing psychological distress or in preventing
PTSD and other negative psychological outcomes (e.g., depression,
anxiety; Bisson, McFarlane, Rose, Ruzek, & Watson, 2009; Rose et
al., 2002; Van Emmerik et al., 2002). In fact, a few studies (e.g.,
Hobbs et al., 1996; Mayou et al., 2000; Sijbrandij et al., 2006) have
even suggested CISD may exacerbate PTSD and other forms of emotional
distress, complicating survivors' recovery. Because of these
various findings, the International Society for Traumatic Stress Studies
has concluded: "The current evidence suggests that individual
[CISD] should not be used following traumatic events ... and that there
is unlikely to be a significant beneficial effect of group [CISD];
therefore, its use is not advocated" (Foa, Keane, Friedman, &
Cohen, 2009, p. 540; see also ISTSS, n.d.).
Psychological First Aid Field Operations Guide
As the popularity and use of CISD waned, an updated version of PFA
was developed, specifically for use in disaster response. This version
was developed through collaboration between the National Center for PTSD
(https://www.ptsd.va.gov/) and the National Child Traumatic Stress
Network (http://www.nctsn.org/), and its culminating publication was the
Psychological First Aid Field Operations Guide (2nd ed. [PFA Guide];
Brymer et al., 2006a). This PFA version is described as "an
evidence-informed modular approach to help children, adolescents,
adults, and families in the immediate aftermath of disaster and
terrorism" (Brymer et al., 2006a, p. 5). It is intended to reduce
initial psychological distress following a disaster and to foster
adaptive short-term and long-term functioning and coping. The PFA Guide
is based on four main standards: (a) consistency with scientific
research on trauma risk and resilience, (b) ease of applicability and
usefulness in the field, (c) appropriateness for all developmental
levels, and (d) cultural responsiveness and flexibility. People
providing PFA engage in eight "core actions" with disaster
survivors, usually in the days or weeks after a disaster: (a) establish
contact and compassionate engagement, (b) foster safety and comfort, (c)
help with emotional stabilization (if needed), (d) gather information
about current needs and concerns, (e) provide practical assistance in
addressing those needs and concerns, (f) facilitate connections with
sources of social support, (g) offer information on common stress
reactions and adaptive coping strategies, and (h) link the survivor with
available services they need now or in the near future. The PFA Guide
includes detailed instructions on providing each of these helping
actions, and it offers recommendations for behaviors to engage in,
behaviors to avoid, guidelines to follow when delivering and preparing
to deliver PFA, and tips for working with specific cultural groups
(e.g., children/adolescents, older adults, and persons with
disabilities; Brymer et al., 2006a).
This contemporary version of PFA has many strengths that represent
improvements over its PFA predecessor and over CISD. For example, its
principles and techniques are based on scientific evidence, expert
consensus, and field testing. Moreover, it emphasizes the delivery of
interventions that are individually tailored, pragmatically flexible,
developmentally appropriate, and culturally responsive. Lastly, it
consists of a manualized protocol that has detailed instructions and
user-friendly handouts for providers and survivors to use (Brymer et
al., 2006a).
Even so, the contemporary version of PFA has some limitations. Most
notably, it does not yet have enough empirical support for it to be
considered a truly evidence-based intervention for disaster mental
health. That is, its efficacy and effectiveness have not yet been
demonstrated through rigorous and systematic outreach research (Foa et
al., 2009; Shultz & Forbes, 2014; Vernberg et al., 2008), despite
promising evidence from pilot studies (e.g., Everly, Lating, Sherman,
& Goncher, 2016).
PFA continues to evolve as a disaster mental health intervention.
One exciting development is the PFA Mobile app
(http://www.nctsn.org/content/pfa-mobile), which is a technology-based
platform intended to assist disaster workers in providing PFA. The PFA
Mobile materials are adapted from the PFA Guide. Through PFA Mobile,
providers can learn about PFA, assess their readiness to offer PFA in
the field, find PFA interventions to use to help survivors with
particular needs and stress reactions, assess and track disaster
survivors' needs and concerns, and access a variety of PFA
resources.
Another promising development is increasing empirical evaluation of
PFA training effectiveness. Indeed, a few studies have found preliminary
evidence that PFA training increases providers' knowledge, skills,
and confidence in offering mental health care following a disaster, both
among trained behavioral health professionals and trained lay volunteers
(Akoury-Dirani et al., 2015; Allen et al., 2010; McCabe et al., 2012).
Yet one more development is that the PFA Guide has been translated
into a variety of languages (e.g., Spanish, Japanese, Chinese, and
Norwegian) and adapted for use in particular contexts (e.g., PFA for
schools, PFA for Medical Reserve Corps members) and with particular
populations (e.g., PFA for families and youth experiencing
homelessness). Of particular interest to the Journal of Psychology and
Christianity readership, one of these PFA adaptations is the
Psychological First Aid Field Operations Guide for Community Religious
Professionals (Brymer et al., 2006b). In this adapted PFA Guide,
community religious professionals (defined as "all people who
consider themselves religious/spiritual leaders or act on behalf of
their own faith tradition," Brymer et al., 2006b, p. 7) learn an
adaptation of PFA that incorporates religious/spiritual and existential
themes and includes: (a) clarification of the distinctions among
religious, spiritual, and existential terminology; (b) exploration of
how to worship with survivors from a different faith; and (c)
recommendations for talking with children and adolescents about their
religious/spiritual concerns and including them in religious/spiritual
activities (Brymer et al., 2006b). This PFA Guide for Community
Religious Professionals is an excellent resource for helping Christian
religious professionals and lay volunteers who are providing disaster
spiritual and emotional care. Likewise, it can serve as a helpful
resource for mental health professionals and workers who find themselves
working with survivors who are wrestling with significant
religious/spiritual concerns (e.g., religious/spiritual struggle, such
as religious/spiritual doubt or anger toward God) and/or wanting to draw
on religious/spiritual sources to help them cope (e.g., their faith
community, religious leaders, or perceived relationship with God).
Implications for Christians Involved in Providing Disaster
Spiritual and Emotional Care
This historical and empirical overview has several implications for
Christians who are involved in providing disaster spiritual and
emotional care, which refers to any services provided to disaster
survivors in order to (a) promote their mental or spiritual health and
(b) mitigate mental or spiritual distress. Perhaps most notably,
Christian religious professionals and lay volunteers need to have at
least basic familiarity with the scientific evidence on disaster mental
health interventions. For example, they need to be aware that some
commonly utilized interventions (e.g., the PFA Guide) are considered
scientifically informed and credible, whereas others (e.g., CISD and
other forms of psychological debriefing) have been shown to be either
ineffective or even detrimental. In other words, not all interventions
will produce positive--or even neutral--results; some interventions may
even be harmful. Relying on evidence-informed interventions and
principles (e.g., the PFA Guide) will not only maximize the possibility
disaster survivors will experience positive mental and
religious/spiritual outcomes, but it also will minimize the possibility
they will experience psychological or religious/spiritual harm.
This point is especially important in light of the fact that many
people get involved in disaster response efforts out of a sincere,
well-intentioned, and admirable desire to help, but they may not fully
consider whether their responses are in fact helpful. To illustrate,
following the Sandy Hook Elementary School shooting, in which twenty
children and six staff members were tragically murdered in December
2012, people inundated the town of Newtown, Connecticut with gifts and
donations, including 65,000 stuffed animals, half a million letters, and
tens of thousands of dollars of toys. Although well-intentioned, this
generous outpouring actually created a huge burden for the Newtown
community. After all, what might a town of 27,000 people do with more
toys and stuffed animals than residents (Kix, 2015; Maynor, 2015)? One
moral of this story is that people's admirable desire to help
disaster survivors needs to be channeled in thoughtful and appropriate
ways--ways that actually meet the physical, mental, and
religious/spiritual needs of disaster-affected individuals, families,
and communities. Sometimes that might involve sending tangible gifts and
donations, but more often than not, it will mean a different response,
such as donating money to a well-respected disaster-response agency
(e.g., American Red Cross, Salvation Army, United Way, or other members
of National VOAD; https:// www.nvoad.org/) or volunteering through such
an agency (if feasible).
For Christians seeking to get involved by actually providing
disaster spiritual and emotional care to survivors, it is important for
them to receive the appropriate training needed to offer competent,
effective, and culturally responsive mental and spiritual health care,
without doing harm. Such training can often be received through the
aforementioned disaster-response agencies, or it can be received through
web-based platforms (e.g., the PFA Online course;
https://learn.nctsn.org/course/index.php) or academic/faith-based
settings (e.g., the Wheaton College Humanitarian Disaster Institute;
https://www.wheaton.edu/hdi). Christians can also draw on
evidence-informed resources that can help guide their provision of
disaster spiritual and emotional care. Such resources include the ones
we have reviewed above (e.g., the PFA Guide and its adaptations; the PFA
Mobile app), as well as resources available through the National Center
for PTSD (https://www.ptsd.va.gov/public/types/ disasters/index.asp),
the National VOAD (https://www.nvoad.org/resourcecenter/member-resources/), the Humanitarian Disaster Institute (https://
www.wheaton.edu/hdi/resources/), and other scientifically reputable
sources.
Conclusion
In this paper, we have reviewed the historical and scientific
evidence for two well-utilized disaster mental health
interventions--Psychological First Aid (which is considered
evidence-informed and scientifically credible) and Critical Incident
Stress Debriefing (which is considered scientifically unsupported). Then
we discussed a few implications for Christians who provide disaster
spiritual and emotional care. Our main take-away message is that
scientific evidence needs to play a key role in informing
Christians' provision of disaster spiritual and emotional care. The
PFA Guide (Brymer et al., 2006a, 2006b) is currently considered the most
evidence-informed disaster mental health intervention, and Christians
would benefit from receiving training in it and incorporating it into
their provision of disaster spiritual and emotional care.
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Alice N. Schruba
Edward B. Davis
Jamie D. Aten
Wheaton College
David C. Wang
Biola University
David N. Entwistle
Malone University
David Boan
World Evangelical Alliance
This publication was made possible through the support of a grant
from the John Templeton Foundation (Grant #44040). The opinions
expressed in this publication are those of the authors and do not
necessarily reflect the views of the John Templeton Foundation.
Correspondence concerning this article should be addressed to Alice N.
Schruba, Psychology Department, 501 College Ave, BGC Mezzanine, Wheaton,
IL; a.n.schruba@gmail.com
Authors
Alice Schruba (Psy.D, Wheaton College) is a postdoctoral fellow at
Alexian Brothers Behavioral Health Hospital. Dr. Schruba's
professional interests focus on the integration of psychological science
and spiritual care within acute contexts, including hospital and
disaster settings.
Edward B. Davis (Psy.D., Regent University) is an Associate
Professor of Psychology at Wheaton College (IL). His research focuses on
the psychology of religion and spirituality, especially relational
spirituality, God representations, disasters, and positive psychology.
Jamie D. Aten (Ph.D. in Counseling Psychology, Indiana State
University) is the Dr. Arthur P. Rech and Mrs. Jean May Rech Associate
Professor of Psychology and the Founder and Executive Director of the
Humanitarian Disaster Institute at Wheaton College. Dr. Aten's
primary professional interests include the psychology of
religion/spirituality and disasters, spiritually oriented disaster
psychology, and psychology in disaster ministry.
David C. Wang (Th.M., Regent College), Ph.D. (University of
Houston) is Associate Professor of Psychology at the Rosemead School of
Psychology, Biola University in La Mirada, CA, and Editor of the Journal
of Psychology and Theology. His research focuses on trauma/traumatic
stress, spiritual formation, mindfulness, integration, and various
topics related to multicultural psychology and social justice.
David N. Entwistle (Psy.D, Biola University) is Professor of
Psychology at Malone University in Canton, Ohio. Dr. Entwistle's
interests include the integration of psychology and Christianity,
coping, religious coping, and psychosocial issues in cystic fibrosis and
other chronic illnesses.
David Boan (Ph.D. in Clinical Psychology, Biola University) is the
Director for Humanitarian Advocacy for the World Evangelical Alliance.
He is a graduate of the Rosemead Graduate School at Biola University and
an adjunct faculty member at Wheaton College (IL) and Northwest Nazarene
University (ID).
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