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Psychological First Aid: Mental Health Care After Hurricane Sandy

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On a recent Friday, a psychiatrist and a team of medical students traveled to the Far Rockaways in Queens to provide mental health assistance to survivors of Hurricane Sandy. Their work did not involve psychotherapy sessions and diagnoses but rather tending to the immediate needs of survivors.

The medical team arrived in response to a request from "Occupy Sandy Relief," an outgrowth of Occupy Wall Street formed to help survivors of the hurricane.

At the heart of a vast public housing complex outside the community center, the medical team found people lined up expectantly under the watchful eyes of Guardian Angels, a band of ex-gang members who that day were providing equally grassroots security.

Inside, the volunteers met a local community leader who told them that they needed to be ready as the center opened its doors for people to come in to get warm; have a meal; and get supplies like blankets, baby diapers and food for their sodden and freezing homes.

Within less than an hour, a makeshift clinic had risen up in the corner of what had been a children's play area, using the medical supplies and basic medications that Sandy Relief staff had shuttled over.

The medical team saw over 30 adults and children in the chaotic afternoon that followed. The main complaints they heard were of headaches and dizziness, likely from the many mysterious fumes that had filled the air of their stricken buildings, upper respiratory infections that developed amid unheated apartments and waterlogged and moldy mattresses, and unfilled prescription refills.

This type of care, known as "psychological first aid," or PFA, does not resemble typical mental health treatment, but it comes as a result of a changed understanding of what survivors need immediately after disasters. PFA is the best post-disaster mental health response we have, so far, for the pervasive distress that occurs in the wake of a disaster -- what is known as the "normal response to an abnormal event."

PFA emerged as a disaster response out of concerns about the scattershot types of mental health interventions that were provided after 9/11.

One particular concern was whether well-meaning mental health responders were causing more harm than good by psychologically "de-briefing" survivors. Psychological de-briefing encouraged victims to talk about their 9/11 experiences, often too soon, too openly, or too unwillingly. Experience and subsequent studies soon began to suggest that this approach was re-traumatizing some of those who simply needed relief, not recovered memories, that it was no time to open wounds that need to heal.[1]

PFA was developed by professional consensus, drawn from the available evidence base and the collective wisdom of these experts.

From 9/11 and other U.S. and international human-made and natural disasters, mental health experts have accrued a body of knowledge from clinical experience about treatment that is safe and that may be effective in the wake of a traumatic event. They synthesize this knowledge into guidelines for "evidence informed" care that is used to direct professional and public health efforts.

Although evidence gathered in this fashion seldom meets the rigorous parameters of a randomized control study, for disaster mental health, the conditions as well as the financial support for controlled studies are very limited.

Disaster responders, whether mental health professionals or not, need to be familiar with PFA.
PFA does not preclude implementing traditional mental health interventions like psychotherapy (especially cognitive-behavioral therapy) and medication, but it also does not promote them. Instead, it leads with the universe of concerns and actions vital to all who suffer trauma, like medical care, food, shelter, reliable information, and the support of people they know and trust. In this way, PFA is far, far more immediate and broader than the traditional psychological interventions in the quiver of the mental health professional.

The idea is that in the immediate aftermath of a disaster, people will feel better if they are provided with essentials. Some disaster survivors, including those at the Far Rockaways community center, will need specialized mental health care. But first, they need to be free of environmentally-induced headaches, to sleep on dry mattresses, to eat and have their overcharged nervous systems quiet down. Psychological "problems" often have non-psychological solutions.

In many ways, PFA represents the instinctive response of a community to a crisis. It is striking, for instance, that a newspaper called Resources -- Sandy Relief that was distributed in affected areas of south Brooklyn, south Queens, and Staten Island had as its November 7 front page just eight items in stark, large print: "Disaster Unemployment," "Staying Warm," "Emergency SNAP [food stamp] Benefits," "FEMA Disaster Relief," "Cleaning Up," "NY is Hiring!" "Shelters and Care," and "Food and Supplies." These items sound a lot like the core areas of PFA, a remarkable overlap.[2]

Although everyone knows of medical first aid like that provided at the Far Rockaways community center, few know about PFA even when it's happening. The message to affected communities should be clear: Your emotional world can and should be addressed in ways small and sometimes big, even when the world around you has become so demanding of your attention.

Disasters are becoming increasingly frequent around the globe. As we learn from Hurricane Sandy, more evidence-informed practices will emerge. In the meantime, PFA gives relief workers a common sense, safe, readily learnable and demonstrably effective means of responding to the pain and suffering they will encounter.

References:

1. Psychological debriefing for preventing post traumatic stress disorder (PTSD), Rose S, Bisson J, Churchill R, Wessely S, Cochrane Database Review, 2002 (2):CD000560

2. United States Department of Veterans Affairs, http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp

Edited by Elaine Meyer

This article first appeared in the Columbia/Mailman School of Public Health 2x2 Project on Dec. 3, 2012

Craig L. Katz, M.D. is an associate clinical professor of psychiatry and medical education at the Mount Sinai School of Medicine, where he serves as a faculty advisor for medical students and directs the Program in Global Mental Health. Dr. Katz co-founded Disaster Psychiatry Outreach (DPO) in 1998 and was its president through 2011.

Lloyd I. Sederer, M.D. is adjunct professor at Columbia University's Mailman School of Public Health, medical director for the New York State Office of Mental Health, and medical editor of Mental Health for the Huffington Post/AOL. His website is www.askdrlloyd.com

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