C 2010)

Journal of Traumatic Stress, Vol. 23, No. 4, August 2010, pp. 509513 (

BRIEF REPORT

Perceptions of Psychological First Aid Among Providers

Responding to Hurricanes Gustav and Ike
Brian Allen, Melissa J. Brymer, and Alan M. Steinberg
University of California, Los Angeles

Eric M. Vernberg
University of Kansas

Anne Jacobs
University of Kansas

Anthony H. Speier
Louisiana Ofce of Mental Health

Robert S. Pynoos
University of California, Los Angeles
Psychological First Aid (PFA), developed by the National Child Traumatic Stress Network and the Department of
Veterans Affairs National Center for Posttraumatic Stress Disorder, has been widely disseminated both nationally
and internationally, and adopted and used by a number of disaster response organizations and agencies after
major catastrophic events across the United States. This study represents a rst examination of the perceptions of
providers who utilized PFA in response to a disaster. Study participants included 50 individuals who utilized
PFA in their response to Hurricane Gustav or Ike. Findings indicated that participation in PFA training was
perceived to increase condence in working with adults and children. PFA was not seen as harmful to survivors,
and was perceived as an appropriate intervention for responding in the aftermath of hurricanes.
All too often, experts in acute interventions tend to be clearer
about what not to do as opposed to endorsing a specic course of
action (Litz, 2008); however, challenges remain even as empirically
informed guides became available. Policy reviews of efforts to address mental and behavioral health needs of disaster survivors often
note that research-informed approaches are underutilized (Disaster
Mental Health Subcommittee of the National Biodefense Science

Board, 2008). Barriers to a greater widespread use of postdisaster evidence-based mental health approaches include difculties
training sufcient numbers of responders on these approaches in
a short period and continued use of intervention procedures that
are not well-dened, have been shown to have little positive impact, or simply have not been evaluated. This study represents the
rst evaluation of the use of an evidence-informed postdisaster
intervention as utilized by responders who were deployed in the
aftermath of hurricanes that struck Louisiana and Texas in 2008.
With support from the Substance Abuse and Mental Health
Services Administration, the Psychological First Aid (PFA) Field
Operations Guide was developed by the National Child Traumatic
Stress Network and the National Center for Posttraumatic Stress
Disorder (PTSD) to provide an evidence-informed, operationalized modular approach to assist children, adults, and families in
the immediate aftermath of disaster and terrorism (Brymer et al.,
2006). It is designed to reduce the initial distress caused by traumatic events and to foster short- and long-term adaptive coping. Principles and techniques of PFA meet four basic standards:
consistent with research evidence on risk and resilience following
trauma, applicable and practical in eld settings, appropriate for

Brian Allen, Melissa J. Brymer, Alan M. Steinberg, National Center for Child Traumatic
Stress, University of California, Los Angeles; Eric M. Vernberg, Anne Jacobs, Clinical Child
Psychology Program, University of Kansas; Anthony H. Speier, Deputy Assistant Secretary,
Louisiana Ofce of Mental Health; Robert S. Pynoos, National Center for Child Traumatic
Stress, University of California, Los Angeles.
Brian Allen is currently afliated with the Department of Psychology at Sam Houston State
University.
This work was supported by the Substance Abuse and Mental Health Services Administration
(SAMHSA), U.S. Department of Health and Human Services (HHS). The views, opinions,
and content are those of the authors, and do not necessarily reect those of SAMHSA or HHS.
Correspondence concerning this article should be addressed to: Brian Allen, Department
of Psychology, Sam Houston State University, Box 2447, Huntsville, Texas 77341. E-mail:
BJA009@shsu.edu.

C 2010 International Society for Traumatic Stress Studies. View this article online at

wileyonlinelibrary.com DOI: 10.1002/jts.20539

509

510

Allen et al.

developmental levels across the lifespan, and culturally informed

and delivered in a exible manner. This PFA guide was developed
after extensive review of available materials and resources on acute
postdisaster mental health response, crisis and acute trauma intervention, and the relevant scientic literature (Pynoos & Nader,
1988; Raphael, 1986; Reyes, 2006; Ruzek et al., 2007; Young,
2006).
The PFA Field Operations Guide is based on ve underlying
principles, including promotion of safety, calming, self- and community efcacy, connectedness, and hope (Hobfoll et al., 2007).
It includes in-depth descriptions of how to accomplish eight core
actions: contact and engagement, safety and comfort, stabilization,
information gathering, practical assistance, connection with social
support, information on coping, and linkage with collaborative
services. Although PFA is evidence-informed, rigorous research related specically to PFA is lacking (Vernberg et al., 2008). This
study sought to learn from those who provided PFA after Hurricanes Gustav, Ike, or both in regard to their perceptions of, and
satisfaction with, PFA.
Participants completed a standardized full-day PFA training
course conducted by staff from the National Child Traumatic Stress
Network. The PFA training consisted of reviewing the underlying
principles informing PFA and the eight core actions. In addition,
trainees were engaged in skill-building exercises related to the core
actions and addressing personal and professional issues of provider
self-care in delivering PFA. All participants received a copy of the
PFA Field Operations Guide and a set of standardized PFA PowerPoint training slides. Participants included in this study attended
one of three trainings that occurred during the week of August 18,
2008, in Shreveport, Alexandria, and Lafayette, Louisiana. Hurricane Gustav made landfall in Louisiana on September 1, 2008,
with Hurricane Ike following closely behind. This study examined
whether those participants who responded to these hurricanes used
PFA, how satised they were utilizing PFA, and their perceptions of
which core actions were most helpful to them and to the survivors.
The data collected are strictly the perceptions of the providers and
are not objective indices of the utility of PFA.

METHOD
Participants
The survey Web site link was sent to 259 individuals who participated in the PFA trainings. Of these, 115 individuals completed
the survey for a response rate of 44%. Seventy-ve of the individuals who responded to the survey responded to either Hurricane
Gustav or Ike, and 50 of these individuals utilized PFA in their
response. These 50 individuals are included in the present study.
The sample was overwhelmingly female (82%), with 88% between the ages of 30 and 59. The respondents were primarily
doctorate and masters-level mental health, addictive disorder, and

developmental disabilities professionals (66%); other respondents

included rst responders, health and public health workers, and
social services workers. The majority of respondents had previous
experience responding to a disaster (72%). Psychological First Aid
was most often provided in a shelter (78%), although other settings were also employed, including hospitals (12%), survivors
homes (10%), community centers (8%), and telephone crisis
lines (8%).

Measures
After completing basic demographic questions, participants were
asked to identify no more than three core actions of PFA they
found most helpful to survivors and no more than three core
actions they found most helpful to them in serving survivors. In
addition, they were asked to identify any core actions they viewed
as harmful to survivors and any core actions they found unhelpful
to them in carrying out their response activities. Participants also
rated the level of condence the PFA training provided them in
working with adults, the level of condence the PFA training
provided them in working with children, and the appropriateness
of PFA for meeting the needs of the survivors with whom they
worked. These ratings were made on a Likert-type scale ranging
from 1 (none) to 5 (a great deal). Finally, respondents were asked to
evaluate their overall satisfaction in providing PFA on a Likert-type
scale ranging from 1 (very dissatised ) to 5 (very satised ).

RESULTS
Provider Perceptions of Psychological First Aid
To examine provider perceptions of PFA training, respondents
were asked to evaluate the impact of the training on their condence to provide PFA to adults and children. They were also asked
to rate the appropriateness of PFA for the population with which
they worked, and their overall satisfaction with PFA. Table 1 indicates that participation in PFA training was perceived to increase
their condence somewhat to a lot in working with both adults
and children. Reports from respondents also indicate that PFA was
perceived as being an appropriate intervention for responding in
the aftermath of hurricanes and that they were satised overall in
providing PFA.
Zero-order correlations were computed to examine the relationships between the variables of condence in working with
adults, condence in working with children, appropriateness of
PFA, and overall satisfaction with PFA (Table 1). Although condence working with adults and condence working with children
were signicantly correlated, respondents reported signicantly
more condence working with adults, paired samples t(49) =
3.45, p < .01. The strongest correlation was between ones condence in working with adults and overall satisfaction with PFA,
indicating that the more condence the training provided one in

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

511

Perceptions of Psychological First Aid

Table 1. Means, Standard Deviations, and Relationships among Condence and Satisfaction With PFA (n = 50).
Item
1. Condence working with adults
2. Condence working with children
3. Appropriateness of PFA
4. Overall satisfaction with PFA

.66
.72
.74

.54
.51

.72

SD

3.56
3.18
3.74
4.10

0.86
1.00
0.80
0.68

Note. PFA = Psychological First Aid.

p < .01.

working with adults, the greater perceived overall satisfaction with

PFA. This is in contrast to the weaker, although signicant, correlation observed between ones condence working with children
and satisfaction with PFA. Similarly, perception of appropriateness
of PFA for working with survivors was more strongly related to
condence working with adults than to condence working with
children. Irrespective of ones condence in working with different
populations, overall satisfaction with PFA was signicantly related
to perception of the appropriateness of PFA for working with
hurricane survivors.
Additional analyses were conducted to determine if perception
of the appropriateness or overall satisfaction with PFA was inuenced by previous disaster response experience or occupation as
a behavioral health professional. A Students t test failed to nd
any signicant differences of perceived appropriateness of PFA regardless of whether this was the individuals rst disaster response,
t < 1, or if the individual was a behavioral health professional,
t < 1. A signicant difference did emerge on perception of overall
satisfaction with PFA. Respondents who reported Hurricane Gustav or Ike as being their rst disaster response demonstrated more
satisfaction with PFA (M = 4.21, SD = .53) than did respondents
with previous disaster response experience, (M = 3.75, SD = .97);

t(48) = 2.13, p < .05, 2 = .09. There were no differences on

satisfaction based on the respondents occupation, t < 1.

Provider Perceptions of Core Actions

Respondents were asked to identify no more than three of the PFA
core actions they found most helpful to the survivors with whom
they worked. Table 2 indicates that the most often endorsed core
action was safety and comfort with 72% of respondents reporting
that it was one of the three most helpful core actions for survivors.
Also frequently endorsed were the core actions of practical assistance (44%) and contact and engagement (42%). When asked to
identify which core actions were perceived as being harmful to
the survivors, 96% indicated that none of the core actions were
harmful.
Table 2 depicts a slightly different pattern of responses in regard
to identifying a maximum of three core actions that were most
helpful to them as providers. The most often endorsed core action
was contact and engagement (64%); safety and comfort (42%) and
practical assistance (42%) were also frequently endorsed. Similarly,
94% of the respondents did not identify any core actions that were
unhelpful to them in their response activities.

Table 2. Perceptions of PFAs Impact on Survivors and Providers Based on Top Three Rankings of Core Actions (n = 50)
Impact on survivors
Core action
Contact & engagement
Safety & comfort
Stabilization
Information gathering
Practical assistance
Connect with social supports
Information on coping
Linkage with collaborative services
None of the core actions

Impact on providers

Helpful %

Harmful %

Helpful %

Unhelpful %

42
72
18
38
44
16
14
22
2

4
0
2
2
0
0
0
0
96

64
42
26
30
42
22
14
28
2

4
2
0
0
2
0
0
0
94

Note. PFA = Psychological First Aid.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

512

Allen et al.

DISCUSSION
This study represents the rst examination of the perceptions of
providers who utilized the National Child Traumatic Stress Network/National Center for PTSD Psychological First Aid in response to a disaster. The occurrence of Hurricanes Gustav and
Ike shortly following a series of PFA trainings in Louisiana provided an excellent opportunity to collect data on the perceptions
of those who trained in PFA and implemented the interventions
core actions. In addition, the diversity of professional occupations
and previous disaster response experience among the responders
allowed for an examination of how these factors may inuence
ones perceptions of PFA.
Overall, the perceived utility of PFA was high. Responders
found PFA benecial in their response activities and were pleased
with their experience in providing PFA; however, differences
emerged depending on whether the survivor being assisted was
a child or an adult. Responders reported feeling more condent
providing PFA to adults than to children. Many reasons may be
offered to explain this nding. For instance, the responders may
have had more previous experience working with adults, received
prior mental health or other professional training focused on adult
populations, or lacked motivation to work with children. Alternatively, responders may have felt the PFA training did not adequately prepare them to work with children or families, as many
times providers will be working with parents and children together
in these settings. Based on these ndings, it is recommended that
role plays and training activities focus on how to work with children of different developmental levels and with families that have
multiple children.
Great efforts were taken during the development and review
of PFA to ensure the guide did not gravitate towards a therapy
manual. The nding that no signicant differences emerged between behavioral health and nonbehavioral health professionals
in perceptions of appropriateness of PFA or overall satisfaction
is reassuring. In addition, providing information on coping, the
most psychological of the PFA core actions, was perceived as one
of the least helpful core actions. Psychological First Aid does not
appear too mental health-focused and is easily accessible by nonbehavioral health professionals. Furthermore, the nding that the
majority of providers rated contact and engagement as the most
helpful core action suggests the skills offered through PFA are
distinct even from the basic listening and rapport-building skills
commonly taught in behavioral health professions.
People with no prior disaster response experience were more
satised with PFA than people with previous disaster response experience. There are several possible reasons for this nding. The
structure of PFA seems to resonate with rst-time responders. Experienced responders may show a greater reliance on and/or give
more credit to their experience and trainings prior to PFA. The
differences between PFA and the current standard of care also
need to be explored. Future studies should examine the contri-

bution of mental health training to perception and implementation of PFA in more depth. For instance, doctoral-level behavioral
health professionals may differ from masters-level professionals
in perceptions and utilization; alternatively, ones discipline (e.g.,
psychology, counseling, social work) may also be inuential.
It is noteworthy that providing for immediate safety and comfort, making effective contact and engaging with survivors, and
giving practical assistance were rated by responders as the most
helpful PFA interventions for survivors. This supports the position that acute interventions postdisaster are best designed to
establish a supportive relationship with survivors so as to help address their immediate safety, needs, and concerns, rather than be
focused on more mental health type interventions that involve
dealing with disaster-related experiences and psychological reactions. This is surprising, as the respondents were predominantly
behavioral health professionals.
This study provides preliminary evidence that PFA is viewed as
a helpful resource by disaster responders; however, this study had
substantial limitations. There may have been a favorable response
bias or investment in PFA or alternative interventions among those
that completed the survey; nonrespondents may have differing
perceptions of PFA than respondents; and it is not clear how closely
providers adhered to the PFA protocol. It is important to stress that
the results reect the perceived utility of PFA from the providers
perspectives, as opposed to a more objective measure of the actual
utility of PFA in the eld. This study suggests the PFA training
helped to build providers condence in using PFA for adults,
but more attention should be directed toward child and family
issues. Future studies should explore why some responders did
not use PFA, what barriers were encountered in the eld, survivor
satisfaction with PFA, and the use of PFA with other disasters. It
will be important to conduct systematic research to move towards
a truly evidence-based approach to disaster mental health and to
more objectively evaluate the effectiveness of PFA. We recommend
research efforts focusing on positive adaptation and coping among
survivors, rather than symptoms, to reect specic goals, strategies,
and techniques that comprise the PFA core actions. It will be
important to measure delity in the delivery of PFA core actions
and link these to possible improvement in positive adaptation of
survivors in the acute aftermath of disasters. Future studies of PFA
training should include examination of participants knowledge
and implementation of PFA in drills, scenario-based activities, or
through eld observations.

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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

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