Logistic and Structural Considerations for the Use of Psychological First Aid in Humanitarian Emergencies

.......................................................................................2 Acknowledgments...........................................................................3 Introduction....................................................................................5 Research Methodology........................................................................7 Literature Review..............................................................................9 Analysis.......................................................................................14 Training Factors......................................................................14 Evidence Limitations.................................................................20 Policy Considerations................................................................23 Recommendations....................................................................26 Conclusion....................................................................................27 Abbreviation List.............................................................................29 References....................................................................................30 PFA USAGE IN HUMANITARIAN EMERGENCIES JOHNSON 5 Introduction Global mental health is a relatively new field with an increasing number of obstacles. One of the main challenges is the increasing number of humanitarian emergencies and the increasing duration of these crises, with children, internally displaced persons, refugees, and women and girls continuing to be especially vulnerable populations (UN Office for the Coordination of Humanitarian Affairs, 2018). Because rates of mental health disorders like depression, anxiety, and post-traumatic stress disorder can double in emergency situations, it is crucial that mental health and social support are addressed comprehensively and appropriately during humanitarian emergencies (World Health Organization [WHO], 2019). Prior to 2002, the standard intervention to address trauma-related stress in the immediate aftermath of a crisis was debriefing, during which a group or individual survivors of a traumatic event are encouraged to talk about the emotional, physical, and social difficulties they have been facing in the wake of the traumatic event. However, in response to several systematic reviews concluding that debriefing in the first 2 weeks after a crisis may negatively impact survivors, the World Health Organization Department of Mental Health and Substance abuse no longer recommends the use of debriefing as an immediate mental health and social support intervention (WHO, 2012). Since the decline in using debriefing after crises, psychological first aid (PFA) has become the standard tool for providing immediate psychosocial support in humanitarian emergencies. PFA is defined as a humane, supportive response to suffering, including listening carefully, addressing basic needs, encouraging social support, and protecting survivors from further harm (Sphere Association, 2011). This approach differs from debriefing in multiple aspects: there is less of an emphasis on telling the traumatic story to the provider, and more of an emphasis on meeting people where they stand, emotionally and physically. As outlined by PFA USAGE IN HUMANITARIAN EMERGENCIES JOHNSON 6 Psychological First Aid: Guide for field workers (2011), there are three action principles within PFA: look, listen, and link. In this way, when PFA providers are in the field during a humanitarian emergency, they are prepared to look for and identify people who may be distressed (including assessing physical symptoms of distress), engage in meaningful conversation with them in order to assess their needs, and then guide them towards other resources to meet those needs, whether they require services for further mental health care, social support, or addressing other basic needs. These principles are straightforward and adaptable, meaning that PFA can be used in a wide variety of situations and by people who are not mental health professionals, which makes PFA a promising tool for use in humanitarian situations because of the multitude of settings they encompass and the potential lack of mental health professionals in the area. However, ensuring that responders utilize PFA as effectively as possible in humanitarian emergencies and implement it appropriately for the populations served is crucial to ensuring proper social support services during these crises. However, there is little quantitative research available on the effectiveness of PFA, except for a recently conducted randomized control trial that found it significantly decreased symptoms of anxiety and negative affect while also promoting positive affect scores (Despeaux, Lating, Everly, Sherman, & Kirkhart, 2019), let alone research conducted on facilitating factors and barriers to PFA in emergency settings (Fox et al., 2012). This leaves a gap in the literature that a comprehensive, qualitative analysis of the logistic and structural considerations for the usage of PFA in humanitarian emergencies could address. This qualitative analysis will address this gap by incorporating both primary qualitative data from formal interviews with PFA experts and reviewing the current literature on these aspects of PFA. PFA USAGE IN HUMANITARIAN EMERGENCIES JOHNSON 7 Research Methodology This analysis of the logistic and structural considerations for PFA in humanitarian contexts usage uses a qualitative methodology, integrating primary data from individual, formal interviews with experts in the field and secondary data from academic and organizational resources relevant to the topic. The interviews conducted for this analysis were formal, semi-structured interviews. The interviewees were selected based on their previous contribution to research evaluating PFA, experience in training PFA providers, developing PFA guidelines, or providing PFA in humanitarian emergencies themselves. The questions aim to gather information on the interviewee’s professional experience with PFA and how their experiences relate to PFA’s effectiveness, especially regarding impacts on self-efficacy among providers, improving training efforts, the development of the research, the use of PFA at a policy level, and perceptions of PFA among providers and recipients. The interviewees included were Alison Schafer, Donatella Paioro, and Caroline Schlar. Alison Schafer is currently a technical officer at the WHO and has contributed to multiple academic papers and technical guidelines regarding PFA, including the development of Psychological First Aid: Guide for field workers, a guidebook developed by the WHO, War Trauma Foundation, and World Vision (WHO et al., 2011). Donatella Paioro and Caroline Schlar are staff psychologists at Médecins San Frontiers (MSF) Geneva, both of whom have experience with PFA training for work in humanitarian emergencies. The literature review component of this analysis includes both academic and organizational sources. The academic secondary sources were identified through searching PFA USAGE IN HUMANITARIAN EMERGENCIES JOHNSON 8 academic databases for academic articles regarding the structural and logistic factors impacting the use of psychological first aid in humanitarian emergencies. Nine sources were identified in this manner to be included in the literature review section (Allen et al., 2010; Fox et al., 2012; Dieltjens, Moonens, Praet, De Buck, & Vanderckhove, 2014; Schafer, Snider, & Sammour 2016; Lee, You, Choi, Youn, & Shin, 2017; Birkhead & Vermeulen, 2018; Akasaka & Kawashima, 2019; Horn et al., 2019; Despeaux, Lating, Everly, Sherman, & Kirkhart, 2019). The organizational resources were identified by searching prominent humanitarian aid organizations engaged in mental health and psychosocial support in humanitarian emergencies and identifying their PFA guidelines and reports. Two sources were identified in this way and included in the literature review (International Medical Corps, 2010; World Health Organization, War Trauma Foundation, & World Vision International, 2011). Ethical Considerations In order to ensure that the methodology of this analysis was ethically sound, the interviewees were only asked to speak in a professional capacity, verbal consent was obtained to reference all conversations included in the analysis, and no members of vulnerable populations were recruited to participate. Because of this, the School for International Training’s local review board reviewed an expedited human subjects review application and approved it without modifications. Additionally, none of the interviews were recorded, and all interviewees are aware that they can withdraw their participation at any time. All participants have received copies of the final draft to confirm the accuracy of the responses represented in the analysis. PFA USAGE IN HUMANITARIAN EMERGENCIES JOHNSON 9 Limitations This analysis has several limitations, including a small sample size regarding the formal interviews, a brief period between the interviews and the submission of the final draft, and the difficulty in recruiting experts to participate. These limitations potentially hinder the generalizability of the results and the depth of the analysis.