A traumatic event involves exposure to a perceived or actual threat of death, serious injury or violence. Examples of such events include severe accidents, fires, robberies, physical attacks, terrorist attacks, natural disasters and any form of sexual and gender-based violence. The word “exposure” could be a direct experience, witnessing something traumatic or learning about a loved one experiencing such an event. A traumatic event is usually unexpected, unavoidable and dangerous.
How a person experiences and reacts to a traumatic event is extremely unique. Some may experience psychological distress and feelings of shock immediately after an event but eventually adapt well to daily life. Others may have persistent, intense post-traumatic stress reactions that disrupt their ability to function from day-to-day. Common reactions include intrusive behaviour, avoidance, dissociation, negative mood and arousal symptoms. Specific stressors (such as level of experienced pain), individual characteristics and conditions (such as the level of social support) impact a person’s ability to cope.
Guidelines
- Providing support (through listening, being empathetic, maintaining contact and connecting to other resources) to those who have experienced a traumatic event may decrease post-traumatic stress. *
- Actively expressing emotions (expressive coping) may result in a decrease of post-traumatic stress. *
- Single session psychological debriefing may be harmful to those who have experienced a traumatic event. *
Good practice points
- The following interventions are recommended to support those who have experienced a traumatic event:
> Engage in conversation.
> Listen to the person’s concerns.
> Offer empathetic support.
> Maintain contact as long as the first aid provider can and calm the person in distress.
> Connect to additional support resources or networks. - Providing psychosocial support may help during or in the immediate aftermath of a distressing event, even in the days, weeks, months and even years after an event has taken place.
Education considerations
Context considerations
- People can experience a crisis on a global, local and personal level.
- Programme designers should be aware of the support networks in their area and link to these resources in the educational material.
Learner considerations
- Consider the different types of vulnerabilities learners are most likely to encounter. For example, are learners most likely to provide support to young children? In this case, education should focus on the particular vulnerabilities of children and acknowledge the link to potential mental and emotional health challenges children may face later on in life as a result of a traumatic event. Conversely, if learners will interact more with older adults who have experienced multiple bereavements and traumas (including significant changes in their health), learners should be aware that this group of people may have increased loneliness, isolation, anxiety and depression.
- Each individual will come to the learning environment with their own set of experiences and personal history. It is likely that they have experienced elements of trauma, distress and loss. It is important for facilitators to acknowledge this at the beginning of the session and plan for any disclosures or emotional moments.
Facilitation tips
- Emphasise the importance of self-care. Learners must understand that supporting others in crisis can be overwhelming. They need to learn to recognise their own cues and have strategies in place to maintain their own emotional, mental and physical health.
- Communicate that, if written as an equation, vulnerability = threat – resilience. A person’s vulnerability can be measured by the crisis they endure and whether this outweighs their capacity or resilience to cope with it.
- Facilitate a discussion on the types of trauma people may face. How can learners support individuals after a traumatic event? Does anyone have experience doing so?
- Help learners recognise that there are different types of loss. Some provide closure while others are left unresolved (ambiguous loss).
- Acknowledge the diversity and uniqueness of individual experiences and how these affect the way people respond to and cope with trauma.
- Facilitate a discussion on the stigmas of post-traumatic stress and how people behave differently to trauma.
- Provide information on local support networks and how learners can contact them.
- Have learners practise active listening. This involves listening to the verbal and nonverbal (such as facial expression and body language) cues of a person.
- Explain that during or immediately after a severely distressing event, many people react by going into what is commonly known as a state of shock; they may feel numb, in disbelief or like time stands still (IFRC, 2018). Physical reactions of an increased heartbeat, sweating, shaking, trembling or shortness of breath may also accompany these feelings. Some people feel dizzy or nauseous and may find it difficult to think clearly or grasp the situation at hand. These reactions can last for minutes or hours during or after an event but can have a more sustained effect on some. (Note this type of ‘shock’ is an emotional response and is different to clinical shock caused by a failure in the circulation system.)
Facilitation tools
- Have learners work together to build case studies in which they have to support individuals in coping with a traumatic event.
- Be sure to correctly define sexual and gender-based violence. For more information, see the additional resource Sexual and gender-based violence.
- Show video(s) explaining empathy and sympathy. Have learners discuss and attempt to use empathetic responses in different scenarios or conversations when supporting individuals.
- Have learners share their own experiences of being listened to. Explore the good qualities of an active listener and discuss some attitude or behaviours to be avoided when recalling personal experiences.
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NOTE
A tool commonly used in psychological first aid is Look, Listen, Link.
See Psychological first aid for details of this.
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NOTE
It is incredibly important to create and maintain a safe learning environment. Learners should feel safe to share and discuss their ideas and experiences without fear of judgement.
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Scientific foundation
Systematic review
Critical incident stress debriefing
A single-session debriefing is when people are encouraged to share their emotions and thoughts after experiencing a traumatic event. Two meta-analyses found that a single session debrief neither prevented the onset of post-traumatic stress nor reduced psychological distress, compared to control groups (Rose et al., 2009; van Emmerik et al., 2002). As a result, the NICE guidelines from 2005 do not recommend using single-session debriefing after a traumatic event.
Communication and social support
An evidence summary developed by the Centre for Evidence-Based Practice (CEBaP) in 2019 identified seven cross-sectional studies about communication and social support (De Brier et al., 2020; Dockx et al., 2020). Evidence is of very low quality and results are considered imprecise due to limited sample size. The review could only identify associations and no causal relationship because of the nature of the study type:
- Evidence showed a statistically significant association between communication and post-traumatic stress in sexually assaulted women. Positive communication (defined as a mutual discussion, expression and negotiation between spouses) led to a decrease in post-traumatic stress, while negative communication (defined as a pattern where one partner attempts to discuss a problem while the other avoids or ends the discussion) led to an increase in post-traumatic stress.
- Among the two specific groups of neglected children and survivors of traffic accidents, evidence showed that good family and mother-child communication resulted in a statistically decreased risk of post-traumatic stress disorders.
- Evidence showed no statistically significant association between communication and post-traumatic stress for people who were kidnapped or their family members.
- Evidence showed a statistically significant association between talking about a terrorist attack and an increase in post-traumatic stress. Conversely, two smaller studies could not demonstrate a statistically significant association between talking with others and a decrease in post-traumatic stress for victims of intimate partner violence or a terrorist attack.
Communication-based coping strategies
In the same evidence summary, two cross-sectional studies were identified that looked at coping strategies (De Brier et al., 2020). The evidence is of very low quality and results are considered imprecise due to limited sample size. Again, the review could only identify associations, no causal relationships:
- There was a statistically significant association between expressive coping and a decrease in post-traumatic stress in sexually abused women.
- There was a statistically significant association between social-emotional coping after an occupational accident (e.g., explosion) and an increase in post-traumatic stress.
Psychological first aid
Psychological first aid is a method of helping people in distress to feel calm and supported in coping with their challenges. It addresses both the emotional and social needs of individuals, with the intention of helping people use their resources, enhance their resilience and make informed decisions. There are a limited number of studies that researched the effectiveness of psychological first aid as a complete programme. Two existing systematic reviews on psychological first aid both concluded that there is a lack of controlled studies to support it (Dieltjens et al., 2014; Fox et al., 2012). However, as it is unlikely to have adequate representation of randomised controlled trials using interventions for traumatic events, interventions need to be informed by good practices and psychological first aid is supported by expert opinion.
Non-systematic review
Psychological first aid intervention principles
Psychological first aid, provided by trained people, is widely supported by expert opinion and rational conjecture as a tool to help people who have experienced a traumatic event(s) (Shultz & Forbes, 2014).
Through observation and expert experience, there is a widespread consensus and support for the five intervention principles that should guide and inform any psychosocial support intervention and prevention efforts at the early to mid-term stages of an emergency. These principles facilitate survivors’ short-term adjustment and long-term adaptation after a crisis (Hobfoll et al., 2007). The five principles involve the promotion of:
- calm
- hope
- connectedness
- a sense of safety
- a sense of self-efficacy and community efficacy.
First aid for mental health problems
In 2019 the Belgian Red Cross-Flanders developed guidelines to provide first aid to people experiencing mental health problems based on a systematic review of scientific evidence (evidence summaries developed by CEBaP, as mentioned above), expert opinion and the preferences of the target population (Dockx, submitted for publication). The guidelines include specific recommendations to support people exposed to shocking events.
Sexual and gender-based violence
Within the scope of providing first aid, individuals may encounter situations where the injured people have experienced some forms of sexual and gender-based violence, such as genital injuries in both adults and children. Sexual and gender-based violence (SGBV) is a broad term referring to any harmful act that leads to – or is likely to lead to – physical, sexual or psychological harm or suffering to someone on the basis of their gender. Gender-based violence is a result of gender inequality and abuse of power, including but not limited to the imposition of sexual violence, domestic violence, trafficking, forced or early marriage, forced prostitution and sexual exploitation and abuse (IFRC, 2015). It was estimated that about one-third of women experience some type of SGBV in their lifetime (WHO, 2017). It is also crucial to consider SGBV committed against men, boys, and sexual minority groups despite the lack of data on its occurrence globally. SGBV can take different forms and happen in diverse situations and contexts across the world and is now a focus of humanitarian challenges (ICRC, 2015; IFRC, 2015).
Reactions to trauma
The IFRC Reference Centre for Psychosocial Support (2018) found that during or immediately after a severely distressing event, many people react with a feeling of shock (numb, in disbelief or like time stands still). They may also have physical reactions such as an increased heart rate, sweating, trembling or shortness of breath. Some people feel dizzy or nauseous and may find it difficult to think clearly or grasp the situation at hand. These reactions can last for minutes or hours during or after an event. In some cases, people may be severely impaired by their reactions. In other instances, people may remain relatively calm and actively stick to their routines, especially if they have already had the chance to develop practices for the emergency. Particularly in the first hours and days after the event, the reactions may vary a lot between people, but they also may change rapidly on an individual basis. A rapid change commonly appears as “loud” reactions like shouting or crying and “silent” reactions like feeling numb or being unable to recognize the full impact of the event.
Reactions after an initial state of shock vary depending on each person’s perceived severity of the event. If the event was traumatic and frightening, the person might feel relieved that they survived, but also guilty, sad or angry if others were hurt or killed. Sometimes there can be fear that the frightening event will happen again, such as aftershocks after an earthquake or the possibility of further violence in a situation of armed conflict. In this state, it can be challenging to make decisions and to communicate clearly with others.
Many people have physical reactions in the first few days after a distressing event like physical pains and may lose their appetite or ability to sleep. If a person’s life has changed dramatically due to a distressing event, it may be difficult to carry out everyday activities and focus on next steps. Some people may feel enormously angry with other people and the world. In contrast, others may experience a sense of deep sadness and grief or hopelessness about the future and lose interest in interacting with others or doing things they used to do. Withdrawal, disappointment, avoiding others and feeling misunderstood are also common reactions to a crisis.
References
Systematic reviews
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders (2018). Evidence summary Traumatic event – Communication (available via publication by De Brier et al., 2020).
De Brier N, Borra V, Dockx K, Scheers H, Stroobants S, De Buck E, Lauwers K & Vandekerckhove P. (2020). Best Available Evidence on Communicative First Aid Interventions by Laypeople for Preventing and Relieving Posttraumatic Stress Disorder–Related Symptomatology Following Traumatic Events. Journal of Traumatic Stress. DOI https://doi.org/10.1002/jts.22625
Dieltjens, T., Moonens, I., Van Praet, K., De Buck, E., Vandekerckhove, P. A. (2014). Systematic literature search on psychological first aid: lack of evidence to develop guidelines. PLoS One, 9(12), 114714.
Dockx, K., Stroobants, S., Scheers, H., Borra, V., Brier, N. D., Verlinden, S., Kaesemans, G., De Buck, E., Lauwers, K., Vandekerckhove, P. (2020). Providing first aid to people experiencing mental health problems: development of an evidence-based guideline [unpublished manuscript]. Frontiers in Public health.
Fox, J. H., Burkle, F. M., Bass, J., Pia, F. A., Epstein, J. L., & Markenson, D. (2012). The effectiveness of psychological first aid as a disaster intervention tool: research analysis of peer-reviewed literature from 1990-2010. Disaster medicine and public health preparedness, 6(3), 247-252.
Rose, S., Bisson, J., Churchill, R., & Wessely, S. (2009). Psychological debriefing for preventing post-traumatic stress disorder (PTSD) (Cochrane Library, Issue 4). Oxford, England.
van Emmerik, A. A. P., Kamphuis, J. H., Hulsbosch, A. M., & Emmelkamp, P. M. G. (2002). Single session debriefing after psychological trauma: A meta-analysis. The Lancet, 360(9335), 766–771.
Non-systematic reviews
Belgian Red Cross-Flanders. (2019). Luister! Eerste hulp bij psychische problemen [Listen! First aid for mental health problems]. Rode Kruis-Vlaanderen.
Dockx, K., Stroobants, S., Scheers, H., Borra, V., Brier, N. D., Verlinden, S., Kaesemans, G., De Buck, E., Lauwers, K., Vandekerckhove, P. (submitted). Providing first aid to people experiencing mental health problems: development of an evidence-based guideline. Frontiers in Public health.
Hobfoll, S.E., Watson, P.E., Ruzek, J.I., Bryant, R.A., Brymer, M.J., Pynoos, R.S. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70, 283-314.
International Committee of the Red Cross. (2017). Guidelines on Mental Health and Psychosocial Support. Geneva; Switzerland.
IFRC Reference Centre for Psychosocial Support. (2018). A Guide to Psychological First Aid for Red Cross and Red Crescent Societies. Denmark: Copenhagen.
Inter-Agency Standing Committee, (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC.
International Committee of the Red Cross and the International Federation of Red Cross and Crescent Societies. (2015). Background Report on Resolution 3: Sexual and gender-based violence: Joint action on prevention and response. (p.2). 32nd International Conference of The Red Cross and Red Crescent, Geneva, 2015 December 8-10. Retrieved from http://rcrcconference.org/app//uploads/2015/04/32IC-Background-report-on-Sexual-and-gender-basedviolence_EN.pdf
International Federation of Red Cross and Red Crescent Societies. (2015). Sexual and gender-based violence – A two-day psychosocial training. Training guide. Retrieved from https://pscentre.org/wp-content/uploads/2018/03/SGBV-A-two-day-psychosocial-training-final-version.pdf
National Institute for Clinical Excellence. (2005). Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care. National Clinical Practice Guideline No. 26. London: National Institute for Clinical Excellence.
Shultz, J. M., & Forbes, D. (2014). Psychological first aid: Rapid proliferation and the search for evidence. Disaster Health, 2(1), 3-12.
World Health Organization (2017). Violence against women. November 29. Retrieved from http://www.who.int/mediacentre/factsheets/fs239/en/
World Health Organization, War Trauma Foundation and World Vision International (2011). Psychological first aid: Guide for field workers. WHO.
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Published: 15 February 2021
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