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).