The term "psychological first aid" has appeared more and more frequently since the terrifying events of September 11, 2001. Soon after 9/11, the National Institute of Mental Health called together two conferences that considered the evidence for use of various approaches to large groups of traumatized people. The New York Times this morning referred to "psychological first aid" in discussing the plight of Haitian earthquake survivors.
One important concern in the development of "psychological first aid" (PFA) is that it is possible for mishandling of survivors' concerns to do harm-- to intensify distress and to create symptoms that last longer and cause more problems than they need to. This was evident in the days following 9/11, when would-be helpers streamed into New York City, not all of whom knew what they were doing. A special problem arises when people who want to help believe that trauma is relieved by catharsis-- the re-experiencing and expression of feeling about fearful events. As Jill Littrell's research has shown, this is not the case unless there is also help in processing disturbing memories.
Properly done, PFA is of great use to families of young children. Older infants, toddlers, and preschoolers may have very little understanding of a catastrophe, but they respond in age-associated ways to the event. Many of those ways have to do with observing their parents' psychological reactions. In normal circumstances, young children literally look to their parents for cues that will explain whether an unusual event is "all right" or "scary". This process, called social referencing, involves the child glancing at the parent's face to see whether the parent looks relaxed or frightened as he or she encounters something strange to the child. If the parent's face is happy and relaxed, the child approaches and explores the new situation; if the parent looks frightened, the child backs off, looking serious. This has even been shown experimentally in research that presented to crawling babies a transparent Plexiglas surface which they had to crawl over to get to a parent on the other side. (It looked to the babies as if there was a considerable drop they would have to cross to get there.) Parents were trained either to look fearful or to smile and look relaxed. When the baby approached the "drop", he or she looked at the parent's face; if the parent looked frightened, the baby did not try to cross, but if the parent smiled, the baby crawled right onto the transparent surface.
Social referencing occurs in everyday life, especially when there are new and strange experiences. But traumatized parents may not be able to give the referencing child the cues she is looking for. An expression of terror, a "thousand-yard stare", or an inability to respond to the child's bids for engagement all make it vastly more difficult for the child to cope with frightening circumstances.
These facts suggest that when children are with their families, they are likely to be helped most when the older members of the family receive PFA. PFA to young children as individuals may be difficult to deliver, and in addition may not be of help when the child is constantly being signaled by his parents' or others' faces that something is terribly wrong.
PFA as it is presently used by the American Red Cross was recently described by Dr. Heather Shibley in the Brown University Child and Adolescent Behavior Letter. Dr. Shibley noted the need for good preparation of PFA teams, including an understanding of the local culture, of ethnic diversity, and of the damage that has caused psychological distress. When entering the area, the PFA team would approach people, give them food and drink, and use this contact to decide whether individuals were overwhelmed emotionally. Further work with the emotionally overwhelmed would involve taking them to a private area before discussing their situation.
An important technique of PFA is the use of grounding techniques. Survivors may be experiencing flashbacks, intrusive thoughts about the disaster, and a sense of shock. Grounding techniques attempt to fight these preoccupations and bring the individual to awareness of the present moment-- a time when the disaster is no longer occurring (although its aftereffects may be present in abundance). Examples of grounding techniques would be asking survivors to describe things present in their environment, or to hold something sensorily intense, like an ice cube. With respect to families with children, we might expect that grounding techniques would help parents to notice young children's communications and respond to them appropriately, rather than having the child's sounds and expression "blanked out" by overwhelming memories and thoughts.
Among other techniques, PFA workers try to facilitate the coping abilities of parents and others who take care of children. One aspect of this approach is to educate adults on the normality of children's responses to disaster, such as separation anxiety, nightmares, and "regressive" behaviors like loss of toilet habits. Such education helps allay adult concerns that their children are permanently damaged by their experiences, feelings that would be traumatizing in themselves.
I hope readers will notice that none of these evidence-based techniques involve urging survivors of any age to re-experience the disaster, or to cry or rage in order to "get rid of" feelings that are disturbing them. Instead, as Dr. Shibley has noted, the effort is to create "a sense of calmness, hope, connection, safety, and self-efficacy" to replace the feeling of chaos, despair, and helplessness. Seeking this outcome for parents is probably the best way to assure the recovery of infants and young children.
