Thesis

REPUBLIC OF TURKEY
ISTANBUL GELISIM UNIVERSITY
RECTORATE Dean's Office of
the Faculty of Health Sciences
Assist.Prof. Nurten Elkin Head of department

Department of Health Sciences

Field of Child Development

Are there effective approaches to apply PFA

by short-timed trained non-professionals on
group of children or adolescents at once

Undergraduate Thesis Project

Beran Çubukçu

Supervisor
Prof. Dr. Ünal Erdem ELLİ

Istanbul – 2024

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 THESIS INTRODUCTION FORM

NAME AND SURNAME : Beran Çubukçu

OF THE AUTHOR

LANGUAGE OF THE : English

THESIS

NAME OF THE THESIS :Are there effective approaches to apply PFA by short-timed
. trained non-professionals on group of children or adolescents
at once.

INSTITUTE : Istanbul Gelisim University Institute of Graduate Studies

DEPARTMENT : Health Sciences

TYPE OF THE THESIS : Undergraduate

DATE OF THE THESIS : 06.06.2024

THESIS SUPERVISORS : 1. Prof. Dr. ÜNAL ERDEM ELLİ

2. Prof. Dr. TALAT SARIKAVAK

Signature

Name SURNAME
Beran Çubukçu

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DECLARATION

I hereby declare that in the preparation of this thesis / project, scientific ethical
rules have been followed, the works of other persons have been referenced in
accordance with the scientific norms if used, there is no falsification in the used
data, any part of the thesis /project has not been submitted to this university or
any other university as another thesis/project.

Name Surname
Beran Çubukçu

DATE
03 /06 / 2024

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ABSTRACT

When someone is injured outdoors, a practical reaction from the surroundings is to

provide First Aid to this human until they reach the hospital. Which means we need
people who knows how to apply First aid. but when it is huge accidents with lots of
injuried individuals, the care rely more on providing first aid to everyone than
delivering the injured to hospitals. The review is speaking about even a larger
circumstances disaster that reaching the hospitals is not possible or available since
disasters diminish all kinds of resources and accessibility to it. In this review, I
presented about disasters and it’s types. Consequences of the after math of such highly
stress environments on an individual vary from PTSD, becoming dysfunctional,
depressed, having higher risks of developing psychopathologies. The method of this
research was using a wide range of timeline due to limitation in human resources, the
methods were evaluated according to 5 criterias. Inspections of 6 PFA approaches
were inspected according to criterias specified. Generally the criterias were trying to
find the best practice among the methods. A method relied on Social Support was
found to be best practice among the 6 reviewed methods. The findings could answer
the main research question, that we can find effective, easy to learn, easy to apply,
Psychological first aid at such situations. Recommendations and Limitations were
mentioned. The limitation mainly were: due to limit in resources of the researcher,
searching for further in-depth in those reviewed methods and other methods, could
could not be pursued.

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TABLE OF CONTENTS

ABSTRACT.................................................................................. i
TABLE OF CONTENT……….................................................. ii

FIRST CHAPTER
1.1. Key words………..............................................………… 9
1.2. Introduction………..............................................……… 9
1.2.1.Definitions of Disaster, PFA, PTSD ....…………. 9
1.2.2. Five Evaluation criterias ..................…………… 10
1.2.3. Research importance.........................……………12

SECOND CHAPTER

2.0. Methodology/Approach……..............................................13

THIRD CHAPTER

Findings

3.1.Eye Movement Desensitization and Reprocessing method..15

3.2. Massage Therapy.................................……………………15
3.3. Johns Hopkins’ RAPID-PFA................………………...…16
3.4. The Sphere Handbook..........................……………………18
3.5. Mental Health and Disasters....................……………….…19
3.6. Critical Incident Stress Debriefing…………..………….…20

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 FOURTH CHAPTER

4.0. Discussion/Conclusion..................………………………..22

FIFTH CHAPTER
Others

5.1. Recommendation for further research.........…………….23

5.2. Limitation......................…………………………..…….23
5.3. To cite this review..................…………………….…….23
5.4. References..................………………………….……….24
5.5. Annotated bibliography..................………………..…….30

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 1.1. Key words

Psychological first aid - PTSD support for Children - crisis intervention - PFA & PTSD -
psychosocial support - Psychological first aid and PTSD - Traumatic event support options
- Disasters’ young victims - Does PFA work ? - What does PFA prevent ? - duration of
PFA - Community disaster situation - PFA models

1.2. Introduction

1.2.1. Disasters are inevitable to occur anywhere and anytime on this earth whether
natural, technological, or man-made ones. Causing negative psychological, physical,
material, or/and other types of effects on a bunch of people at once which makes it more
difficult to control, because in most cases damage has occurred to existing resources and
remained resources don't match the sudden various basic needs. In 2008, Galea & others’
literature research suggested that “many people will have transient stress reactions in the
aftermath of mass violence, and such reactions may occur, occasionally, even years later.’’
and that those people need support to return to normalcy. The formation of these
distressess responses is often determined by pre-, during-, and post-disaster circumstances.
The study focuses on PFA limiting the distress and increasing adaptive functionality after
the event a.k.a post-disaster circumstances. PFA (Psychological First Aid) is a response
tool used for high stress environments. PFA is meant to be an early intervention for
human’s ability to continue functioning as they were supposedly did prior to the occurred
disaster. Techniques vary but mainly have same goals –ones mentioned before. According
to two certified mental health practitioners, Tripathi, D., & Ediea, J. (2021), Techniques
are like–but not limited to– assessing the person, helping them addressing basic needs,
listen, comfort, connect to services (making them more able and adaptive with their
situation); It is social, emotions, non-direct physical support. PTSD (Post-traumatic stress
disorder) is one of the disorders individual may end with having during post disasters (B.
Green & others, 1990). PTSD (Copeland-Linder, 2008; Sher, 2004) is a reaction to
experiencing an unparalleled event or sometimes hearing about it or watching a video
describing it or video documenting this unparalleled event. It causes the individual to
develop an avoiding behavior to any related stimuli to such event, emotional numbness,
trouble concentrating through the day, getting flashbacks, some experience nightmares
(Anna Freud, 2022). PTSD is a reaction due to (Blanco, 2011) intense fear, horror,

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helplessness but not every one who experience directly or indirectly traumatic event
develops trauma towards it (Anna Freud, 2022).

1.2.2.

In this literature review, attempts to find effective approaches capability to reduce

what a disaster can do to human functionality are being searched. It is focusing on any
Psychological First Aid (PFA) approaches that could be applied on children or adolescents
. Aiming to evaluate–at the end–PFA models or approaches based on specific criterias :

(a) Already proven, by other literature, to have positive effect on young

individuals–short & long term. This is done by assessing the affected individuals by using
one of Psychological tests before intervention, immediately after it, and after intervention
with long term. Then comparing the results between tests on ones intervention applied on
plus also results of people who were left without intervention and also suffered from the
same disaster.

(b) The method needs to have proven that it prevents or alleviate some known
negative effects of a disaster on young individuals short & long term ones. Like decreasing
their vulnerability and reversing the increased probability that they have (develop to have)
than average population to suffer other mental disabilities. The claimed negative long-term
consequences of disasters on mental health of individuals can be proved in two steps.
Firstly, People who are exposed to a disaster which is an intense stressor–relatively to
average human–are ,according to B. Green & others (1990), linked to higher PTSD
incidence rates than normal population under normal circumstances. Each 3 people of ones
affected with PTSD or trauma, one of them continued to suffer from PTSD-symptoms for
over 3 years when an intervention was absent (Παναγιώτης Κωστάρας a.k.a Panagiotis
Kostaras , 2018). Secondly, In 2007, Stam has highlighted in his paper’s conclusion that
the physiological disturbances that PTSD were characterized by were contributing to
disability development. Moreover, Dückers added (2016) that his research suggested that
PTSD makes human more vulnerable to mental illness.

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In summery to pass this criteria they need to be proved to decrease the possible added risk
of mental disabilities. Since PTSD were linked to mental disability vulnerability, so did
this program made them less vulnerable, statistic or data needed of long term effect to
prove that between on number of people who had trauma and developed ptsd, then went
through the program , to be compared with people who went through the same without the
program being applied on them. Where there less mental disabilities in them in long term
consequences, did it actually reduced their vulnerability?

(c) Can be applied by a staff who "mainly not totally" consists of non-professionals
after being trained for anytime that is less than a week and can expand but only if
education was given during the days the intervention is being applied, which means
getting psychoeducation shall not stall the intervention process more than a week.

The reason why non-professionals are needed to apply this programs, because non-
professionals are basically any capable adult which is a more available source so they can
apply PFA on a wide range of children or adolescents in critical times like post the event.
But if the program needed professionals only to apply the program, there will be shortage
in human resources that matches the current need. Because one of the characteristics of a
disaster is it affect everyone in the area. This criteria is needed especially when the PFA
program needed human direct interaction with few children or adolescents at a time, for
long time, then it would be impossible to use the countries’ professionals only for support.

One other reason why we need non-professionals, such PFA programs are applied
during lack of resources, especially money, existing financial resources do mainly get
invested in the physical needs like housing or nutrition and hardly utilized in human
psychological needs when it isn’t abundant source. So such programs need volunteers to
volunteer for such help, not every professional individual dedicated his/her life studying
and working on a field would have the volunteering soul for just giving their expertise,
time for the sake of humanity, this is not a fairy world we are living in.

Furthermore, for such action, it needs capable/available volunteers at the critical

moment who weren’t affected hugely so they still are functioning, but during a disaster

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some of the professional's or their relatives may be hugely affected from the event which
disable some from joining such voluntrous act for days or weeks. Which reduce the
possibilities of availability of professionals ready to close the gap of need in the area. But
if we looked for any ready to volunteer capable adult, would be much easier to find,
available, accessible. More practical to have a handbook to help the available
non-professional to intervene, than using only professionals at such critical times.

(d) Uses less resources as much as possible as : Human professional resources like
psychiatrist, therapist, or counselors, or Medicine, or, devices like electronics, etc or time:
like the mission needs to finish in less than 4 months and not to use any more time
resource, or other resources ,especially ones known to be limited during most of disasters.

(e) Could be applied on large amount of the communitys’ children or adolescents

at once_not a one to one therapy kind of approach_ this aligns with point ‘d’ uses less
resource but benefiting more people. Emphasizing that 10 personnels aren’t to be trained
to help 10 kids only, the approach needs to be helping for each staff member, at least 5
children to be benefited. So if staff were 15, at least a number of 75 children/adolescents
shall be intervened through the intervention duration mentioned (4 months or less).

1.2.3.

This will contribute to communities by presenting them one or two approaches

from 6 diverse available PFA models that will be mentioned. Those two are ones that meet
most elements in the above criterias that aimed to reach most effectiveness and
applicability. Which can be in handy trying to handle part of upcoming disastrous
situation. Potential audience need to review this research is people in : potential disastrous
areas like wars, volcanos areas, people who can reach affected people worldwide,
earthquakes area, also health care professionals, etc. This research is important because it
tries to find ways to limit human’s distress and trauma, both were linked to vulnerability to
mental illness ( Dückers ,2016). So the research is aiming for humanity to reach a more
peaceful, productivity, functionality state.

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 2.0. Methodology/Approach

This study employed a literature review methodology to partially examine existing

research and scholarly contributions–like books or posts & reports on an organization’s
website– on PFA. This literature mainly followed Aristotle's approach of synthesizing a
data (Teddlie, 2008), which followed a pragmatic way in which qualitative data is going to
be included to summarize each PFA method and what it provides from data to be used on
ground with children or adolescents, but also contains some quantitative data specifying
which of the methods had higher rates of saving individuals mentalities and future, by
giving them higher resiliencies in their life.

The paper’s design method showed descriptive analysis of data, explaining

components of various PFA methods. It measured central tendencies for how long each
program takes to be applied on the child. It included written data from researches that used
cohort studies on affected individuals and how the application of one, of to be mentioned
PFA methods, affected them. It has been studied whether the methods used evidence based
practices in it’s program or not. The findings had a pattern, first it was mentioned general
information about the method, then followed by it, researches on that method. Then the
next method was mentioned and so on.

Researcher’s strategy was to find any established PFA program through google chrome
and study specific factors across each method, then see if any literature examined their
actual benefit, effectiveness, compare methods according to their time to apply and
amount of people needed to apply program on specific amount of children or adolescents
and other criterias explained in the introduction. Websites that where inspected through
chrome were Google scholar, Pubmed, Elicit, and others. Guiding slides to perform and
write thesis was by Gelesim university’s Thesis writing guide. Guiding individual for
ensuring the process is going on and general director, Lecturer Elli Ü. at Istanbul Gelisim

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university in Turkiye. Guiding individual for ensuring the mental capacities don’t get
bellow baseline was definitely one of the methods used through this research and
recommended for the vulnerables.

The sample used when selecting PFA methods, is whatever found from decent, full , clear
programs of PFA on internet through 2 months of searching. It included literature
published between 1974-2022. I choose sample of PFA according to ones available in
English, easy to reach, accessable, complete, clear, applicable on children and/or
adolescents. No specific location of invention programs were chosen accordingly, neither
according to any other standards than ones mentioned before.

Size of method review, Here 6 PFA methods were reviewed. Each PFA method is
listed in the findings as a separate paragraph combined with each paragraph related
evidence of research on there efficacy if found, has been tested and statistics were
collected.

In the discussion part evaluation has been carried out on the PFA methods,
evaluating which ones answered our research questions best and fulfilled most criterias
needed , according to the data items mentioned in the Introduction from ‘A’ to ‘E’ and by
which efficacy measure will be measured giving a number from 0-10. 2 points for each
data item, in which zero was to the PFA program that didn’t include such data in the
evaluated criteria, 2 if it fulfilled the criteria, 1 when it included it but not at satisfactory
level. For example as for Item ‘A’ a program will take a zero if it was only a theory and
wasn’t applied on real life and also a zero if applied successfully in disastrous areas but
data weren’t synthesized and posted to public to see the efficacy, also it would take a zero
if it was applied in real life but no data proves it was positively effective through short and
long term (data available but not proving to reach the criteria). The program took a zero
also when there was data showing it had a negative effect on the individual to apply the
program. The program will be evaluated with one point if there was data proving it had a
short term positive effect on individuals. On the other hand, the program that had proven it
had a positive effect on individuals short and long term, to be granted a full score in
criteria ‘A’ which is two points.

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 The main source of the data is primary one when it included reviewing programs
since it was extracted from original written formats by professionals who directly took
initiatives developing such programs. While when it is about a program efficacy and
applicability tests review, data used is a secondary one, since it was other researchers who
directly involved in observation and they the one did the data analysis, like catastrophe
experts' papers or opinion published in mass media, encyclopedias and internet.

3.0. Findings

3.1. Eye Movement Desensitization and Reprocessing method

Chemtob and his peers (2002) studied PTSD treatments on 32 children who went through
a disastrous event. The event was a powerful Hurricane striking the Hawaiian Islands
named Hurricane Iniki. The studied an intervention strategy called Eye Movement
Desensitization and Reprocessing (EMDR). EMDR is to do intentional sight movements
while remembering the stressful event, with other tap and sound stimulations. It try to
reorder how the memories were stored in the patient’s brain. The patient goes through
eight phases to practice EMDR trying to reprocess the trauma (Shapiro, 2018, pp. 83).
Chemtob and his colleagues applied this using one-to-one therapies sessions. Their
method needed Phd trained therapist to apply EMDR although many internet users
reported doing it to themselves.The efficacy of self treatment or treatments through non
trained professional needs to be further studied in literature. Chemtob and his team
concluded some positive results to their study, which contains an observable, reported
reduction of depressive, anxiety, traumatic symptoms than the controlled group who were
affected from same crisis (Hurricane Iniki) but their intervention was delayed than the first
group by a month to be able to compare between one who received intervention and one
who didn’t. So they only reported comparing such symptoms after one month.

3.2. Massage Therapy

Hurricane Andrew which occurred in 1992, hit Bahamas, Florida, and Louisiana. Field,
Seligman, & Scafidi (1996) released a research paper on testing massage therapy for
children in primary school, they studied on 60 child with mean age of 7.5 years. The
control group were being exposed to video attention sessions. They used for measures; for

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depression, CES-D by Radloff (1977); for PTSD, Posttraumatic Stress Disorder Reaction
Index by Frederick (1985). The method was messaging neck, waist, back for 30 minutes,
twice a week. Each child received 10 message sessions. The message personnel kept silent
through whole session, children where asked to keep quite and just relax. One of their
foundings that girls were observed to have higher PTSD symptoms than boys. After the
intervention on the message group, they showed promising results than the control group,
showing decrease in depressive, anxiety symptoms, reported being happier. After doing a
biochemical assay, they had lower salivary cortisol levels after therapy than before, it was
also reported they appeared more relaxed.

3.3. Johns Hopkins’ RAPID-PFA

A model for PFA, designed by George Everly and Jeffery Lating at the Johns Hopkins
Bloomberg School of Public Health. The model is named RAPID. This model is being
taught to any adults who seeks learning it. A 2-day workshop if the individual was
in-site–in Baltimore, originally was 6 hours but extended to 12 hours training later
(Psychological First Aid, 2020). Also the training is available online, a 6 hours one,
recommended to be finished in at most 3 weeks but could be finished in less than a week.
The online training is provided by the John Hopkins university on Coursera platform, for
free if people wanted it without certified certificate. Both courses (in-site and off-site) are
being taught by George Everly the Professor of Psychology (George Everly | Coursera,
n.d.) at Loyola University in Maryland, Baltimore, USA. Just the in-site one is the
extended and include the long format. RAPID is designed to be applied for situations of
mass disasters but also workplaces, public health settings, military.

RAPID contents

Each letter stands for a specific technique and they are in order. The ‘R’ for Rapport and
Reflective listening. To be present, empathic, develop history knowledge of the affected
human, adhere, be sensitive, build a trust bridge. The ‘A’ stands for assessing the needs. It
is through a psychological & Physiological lens but not a clinical professional assessment,
instead common sense based assessment, based on what survivor perceived and their
narration. An appraisal of social adaptability, demonstration of focusing on factors that
foster rapid recover, like focusing on affective expression, emotional state, behaviors,
cognition. Assessing by getting a background in terms of what happened to this individual

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and their reactions to this particular event. Then categorizing if they are under Eustress,
distress, or dysfunctional. .The third letter, ‘P’ for Prioritizations, is creating a hierarchy
based on ones who needs greatest help to the least from affected population. Prioritization
is done through the A-B-C model of psychological triage to detect behavioral or
Psychological crisis. The ‘I’ for intervention. This gives the trainee strategics and tactics
for what to do to stabilize distress. But as George said in one of his classes ‘Remember the
goal, PFA is a compassionate and supportive presence. It’s not a therapy. So don’t feel the
need to fix someone’s problem. This is first aid not a surgery. ’ (Everly G, n.d). Enlisting
them for social support. Allow catharsis and ventilation but if you felt their stories is
transmitted with heavy behavioral reactions, making them unstable, mission termination
shall start. Distract them or suggest that this isn’t best time and move on. Intervention
stage is also for encouraging them for some tasks to pursue as he said ‘give them work to
do, and that seems to help them stay stable. It helps resilience’. ‘I’ contains explanatory
guidance or education factor, reassurance, and installation of hope. The ‘D’ for
disposition. For following up and connect to resources and insure continued care
accessibility.

Research validations on RAPID method

Wang, L.et al (2021) found that RAPID‐PFA were most influential in mitigating acute
distress and dysfunction, they help recognition of whether to facilitate access to further
mental health support and facilitate self-care practicing. A randomized clinical trial by
Everly and his colleges (2016) showed that this method had an ability to accelerate
recovery toward baseline, reduce anxiety, have a calming effect over the baseline. Unlike
the CISD method to be mentioned in last paragraph, This research didn’t find any
evidence for RAPID method to have an iatrogenic effect. It was found it promote personal
and community resilience. Prof. George Everly seemed to have join multiple studies on his
own developed method, so most of the studies had his contributions in it. Another study
(Everly, Barnett, & Links, 2012) stated that the method has been derived from valid
sources as, clinical applications and content validation. A study on trainees for the course
showed (George S. Everly, Jr.,Christina M. Kennedy, 2019) that 78% of the sample said
they became more confident in building rapport with others. 82% agreed that the training
made them better listeners (according to their narration, perceptions, own judgments).
20% could use the training experience in disastrous environments.

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3.4 The Sphere Handbook

The Sphere project (Sphere Association, 2018) a Humanitarian Charter and Minimum
Standards in Disaster Response started in 1997, developed by various NGOs to create an
international minimum standard set for essential humanitarian response among various
domains. Their core principles are; enhancing humans’ safety, dignity, rights and reduction
of any further exposure of harm; accessibility and no discrimination; finally the third
principle–which resonate most with this review–is that they assist people to recover from
psychological and physical deprivation responding to any event that hindered such.
Among the four standards they discussed and composed standard responses, which were
water supply, sanitation and hygiene promotion; food security and nutrition; shelter and
health settlement; and finally health. The forth standard is what we are mentioning and
caring to discuss in this paper (Health). Chapter four (health) in their handbook discussed
Communicable diseases; Child health; Injury and trauma; Sexual and reproductive health
care; Noncommunicable diseases; Palliative care; and eventually Mental health, the last
item Mental health standard response will be specifically one trying to answer our
hypothesis.

The book writers emphasized that their intervention isn’t clinical intervention but
rather basic, humane, supportive one. Reporting that a Single-session psychological
debriefing is ineffective and should not be used. Their approach initially divided the
services needed into four layers in order to meet different needs : Specialized services,
Focused non-specialised supports, Strengthening community and family supports, Social
considerations in basic services and security. They mentioned the when: to take steps
during early stages of crises.

A summary for the approach was to create activities for the community to have
safe spaces for having dialogues, encouraging social support. Also they included listening
carefully but not intrusively pressing individuals to talk about their distress

No timeframe was mentioned in this protocol. They emphasized multiple times the
necessity to train non-specialists. Suggesting that orienting volunteers on how to offer
psychological first aid. They provide training named Sphere NDMA training on their
website, said to be designed to support individuals facilitating Sphere training for

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managerial and operational personnel of National Disaster Management. The handbook
suggested forming teams co-led by a protection humanitarian and health organizationist.

Their PFA protocol didn’t mention criterias like for how long such intervention
needed to be sustained neither did it mention for which exact environments it was
recommended for. They didn’t mention for how long shall the non-specialist be oriented
for.

Studies reviewing the Sphere Handbook

Henderson SE and her peers (2015) conducted a review based on case studies reviewing
the Sphere. Their review concluded that the handbook lacked sufficient guidance to ensure
the application of required response. Reflecting on the handbook being used in December
2004 pos-disaster occured in India which was caused by an ocean tsunami, they reported
that the standards of mental health and psychosocial did an overall support and were
relevant to the long-term psychosocial interventions after the disaster, the application in
such settings did improve the quality of the response.

One aid worker in the Sphere Evaluation report–trying to emphasis the lack of
sufficient resources–quoted : ‘[The Sphere Project is] less useful (perhaps frustrating) in
the too many emergencies where there isn’t a snowflake's chance [in hell] of coming close
to meeting many of them, so there may be a tendency to dismiss the entirety’.

In the evaluation report by Marci Van Dyke and Ronald Waldman (2004) a survey
they conducted and to only find that respondents felt : the Project is not useful during the
emergency phase.

3.5. Mental Health and Disasters

Yuval Neria, Sandro Galea, Fran H. Norris (2009) collected evidence and gathered it in a
huge book named Mental Health and Disasters, published by Cambridge University Press.
Consists of researches and reviews by others on PFA post a disaster.A Social Support
model, The more Social support an individual had during such time of life–after disaster–
the lower their distress would be in future and more functional they were ( Cassel, 1976;
Cobb , S. 1976; Dalgleish, Trana, Joseph, & Yule, 1986; Udwin, Boyle, Yule, Bolton, &

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O’Ryan, 2000 ). They stated that Social support is a stress-buffer and predictor for better
psychological, physical health. One study by Fleming, Baum, Gisriel, and Gatchel ( 1982 )
studied the social support model and it’s absences effects on residents of Three Mile Island
in USA. Those residents were exposed to a partial nuclear meltdown in 1979. They found
that the residents who had lower perception of social support exhibited higher rate of
symptoms of anxiety, depression, alienation, and global distress than other group who
responded to have a higher social support. A partially related study instead of studying the
social support, studied the support (Benight, 2004) on people had floods, fires type of
crises. The one who found to have highest levels of mental distress when tested after a
year of the event, were ones reported having lowest support (perceived one) and collective
efficacy. Cohen, Wills (1985) and Hobfoll (1998) explained mechanism of why Social
support model may be working. They stated that this model infuse the individuals with
self-esteem, optimism, self-efficacy which help them return to their equilibrium state,
emotionally and physiologically. The model specifically help individuals find concret
resources imperative for coping through connectedness to society. Kaniasty and Norris
(2008) made longitudinal study, having data collected for times since 1999 mudslides and
flooding in Mexico. They came up with a conclusion that perceived low social support
was associated with higher PTSD, GAD, depression, and social support is one of the
protective factors regarding those 3.

3.6. Critical Incident Stress Debriefing

Richard A. bryant and Brett Litz (n.d) made a study on one method developed to be used
as PFA, The CISD (Critical Incident Stress Debriefing). The method was developed by a
Clinical Professor of Emergency Health Services, Jeffrey T. Mitchell in 1974 at the
University of Maryland in Baltimore, USA. The intervention was to be used during first
48 hours post a disaster. After Prof. Jeffrey developed CISD, it got integrated to be applied
with other program parts, a program called critical incident stress management (CISM).
Richard and his colleges emphasized that professionals do not use CISD alone as a
technique to relieve. CISM is an integrative, comprehensive, ,multicomponent
intervention program for crisis. CISD is an intervention based on the reaction experience
recipients required to describe. It is like a catharsis to their cognition amd emotional
burdens they hold from the disastrous event moments. It then provide recommendations
on ways for stress reduction. CISD is a seven steps method. One of the initial steps was

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taking practical moves to bring the recipient to safety perception when it is actually safe,
and that those flashbacks can’t harm them like the actual event that passed. Then another
step further would getting them to reduce their hyperarousal state by promoting calmness.
This step is based on an evidence (Shalev & Freedman, 2005 ) that linked the hyperarousal
state as a risk factor for subsequent PTSD. This calmness step has few factors in it to reach
such goal, they teach them to control their breath, adaptive self-talk, and problem solving.
Third step to the CISD, is aiming at making the individuals believe their actions have a
positive impact and their capacities is capable, Self-Efficacy. The paper wrote how this
characteristic or belief, that an average neurotypical human have, is lost in the after math
of experiencing such helpless situation like disaster. This step help try to reattain this
believeness (Hobfoll et al., 2007 ). Next in this approach, Highlight their connectedness to
others. Norris et al. (2002) had strong evidence that social support was one of the buffers
against trauma symptoms. Lastly, giving them a dash of hope. As Antonovsky (1979) said
that optimism is a predictor for positive outcome out of a trauma.

Studies reviewing the Critical Incident Stress Debriefing

Many studies were negative about this technique, failing to find any positive outcome in
long-term. McNally, Bryant, & Ehlers (2003) formed a structured group model to explore
the CISD, only for them to say their study couldn’t find an evidence that CISD prevents
negative outcomes. One literature review by Rose, S., Wessely, S., & Bisson, J. (2002)
reviewed empirical studies on debriefing. The researchers concluded that CISD or such
debriefing techniques when applied in short term after the exposure to a stressful event,
has no relation to reduction of depression, anxiety, or PTSD. Bisson et al., (2002) had
RCTs in his study, stating in his results that by following such individuals,debriefing
didn’t prevent any psychopathology or PTSD. They also had sufficient evidence for it’s
negative effect, and those evidence where enough for him to recommend that such
techniques shall not to be used in the immediate after trauma (Rose, Bisson & Wessely,
2002; Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002; Gray, Maquen & Litz,
2004), as the CISD was said to applied during first 48 hours. One suggestion of why
debriefing have such negative consequences (McNally, Bryant, & Ehlers, 2003) that trying
to ventilate traumatic emotions after math of disaster may hasten arousal and further
strengthen the scary memories and hinder natural recovery.

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 4.0. Discussion/Conclusion

Figure 1 : Evaluating the PFA methods based on the criterias mentioned in the
introduction.

The approach name / A : Existing B : Alleviating C : Can be D : Less E : Not a one to one Sum from
criterias reviews negative effects applied by a resources used : intervention 10
evidence on of a disaster trained staff from time, materials,
short term and volunteers etc.
long term
positive effects

EMDR 2 2 0 2 0 6
(Chemtob , et al,2002)

Massage therapy 1 2 2 2 0 7
( Field, Seligman, &
Scafidi ,1996)

RAPID 1 1 2 2 0 6

Sphere book 1 1 2 0 1 5

Social support (Mental 2 1 2 1 2 8

health and disasters)

CISD 0 0 0 2 0 2

The research was trying to find a practical solution and adaptations to human/nature
post disasters effects. To limit the negative consequences with the least resources. 6
PFA methods were reviewed and the main research question ‘partially’ got a positive
answer. The 6 methods didn’t directly answer all 6 sub-questions or some did but
sometimes the researcher found it hard to find the exact, direct, clear, definite answer,
due to huge number of literature needed to review for the answer to be found and the
limitations of the researcher’s time and brain capacities. So humble conclusions were
made in figure 1, but further research needed to verify them. The most PFA that was
found effective, efficient according to the criterias mentioned in the introduction was
Mental Health and Disasters manual collected by Yuval Neria, Sandro Galea, Fran H.
Norris (2009). But the researcher believe all PFA that took a 6 points or higher did
reach expectations of the sub-questions. In which Massage therapy intervention by
Field, Seligman, & Scafidi (1996) seemed to be easy to apply by non-professionals,
easy to learn, took 6 weeks only and each intervention was 30 minutes. It was
explained that it’s healing effect had root to human need for physical touch (Renee A.
Exelbert, 2022). So the massage therapy seemed remarkable. The most unsolved

22
criteria that it was hard to get definite numbers of how long would this method take
for such effects, that was vague in some methods. The social support method also
seemed vague, they didn’t define what was considered cases had social support and
what weren’t, because mostly everyone knows people, they didn’t define thresholds to
this approach since it meant a lot of things.

5.1. Recommendation for further research

To continue reviewing the rest of the programs listed in the annotated bibliography–or
any more that weren’t listed–and conduct a study that has more reliable conclusion of
which program was really effective among wide sample than the ones used here. Also
it is recommended to ask or email researchers who directly observed and wrote
reports on statistics of such programs. To know what have they seen from subjective
experiences and actual benefits of the program they used and they saw it being
applied. investigate if those researchers had enough expertise to actually draw a
conclusion and according to which experience where they comparing that this
program is a better option than the other. It is also recommended to have a pilot
research after finishing the suggested literature review, using the program that was
nominated to be one of the best. Using it in the nearest affected disastrous area (we
are on earth there is always a disaster somewhere). Then actually seeing whether what
the literature review concluded was right or not.

5.2. Limitation

The sample of programs used here where few, so generalizing the data wasn’t
possible. Also the program with the highest score can’t be considered one of the best
practice approaches ‘for sure’, since few programs were examined due to limitations
in human resource and time resources while conducting this study.

5.3. To cite this review :

Çubukçu, Beran. (2024) "Are there effective approaches to apply PFA by short-timed
trained non-professionals on group of children or adolescents at once" [Unpublished
paper]. Health and Sciences department, Istanbul Gelisim University.

23
 5.4. References

Galea S., Tracy M., Norris F., & Coffee, S.E. (2008). Financial and social
circumstances and the incidence and course of PTSD in Mississippi during the first
two years after Hurricane Katrina. Journal of Traumatic Stress, 21, 357–368.

Tripathi, D., & Ediea, J. (2021). Psychological first aid. GYMHA.

https://gymha.org/psychological-first-aid-course/

Kostaras, P. / Κωστάρας, Π. (2018). Μελέτη συννόσησης μετατραυματικής και

καταθλιπτικής διαταραχής.

Green, B.L., Grace, M.C., Lindy, J.D., Gleser, G.C., & Leonard, A.C. (1990). Risk
factors for PTSD and other diagnoses in a general sample of Vietnam veterans. The
American journal of psychiatry, 147 6, 729-33 .

Teddlie, C., Johnson, R.B. (2008). Methodological Thought Before the 20th Century.
In C. Teddlie & A. Tashakkori (Eds.). Foundations of Mixed Methods Research:
Integrating Quantitative and Qualitative Approaches in the Social and Behavioral
Sciences, 47. Thousand Oaks, CA: Sage.

Sher, L. (2004). Recognizing post-traumatic stress disorder. QJM : monthly journal of

the Association of Physicians, 97 1, 1-5 .

Copeland-Linder, N. (2008). Posttraumatic stress disorder. Pediatrics in review, 29 3,

103-4; discussion 104 .

Anna Freud. (2022, December 7). What is PTSD? | UK Trauma Council [Video].
YouTube. https://www.youtube.com/watch?v=5iocOm_ixLU

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Stam, R. (2007). PTSD and stress sensitisation: A tale of brain and body Part 1:
Human studies. Neuroscience & Biobehavioral Reviews, 31, 530-557.

Dückers, M.L., Alisic, E., & Brewin, C.R. (2016). A vulnerability paradox in the
cross-national prevalence of post-traumatic stress disorder. The British journal of
psychiatry : the journal of mental science, 209 4, 300-305 .

Sphere Association. The Sphere Handbook: Humanitarian Charter and Minimum

Standards in Humanitarian Response, fourth edition, Geneva, Switzerland, 2018.
www.spherestandards.org/handbook pp.339-343

Henderson SE, Elsass P, Berliner P. Mental and social health in disasters: the Sphere
standards and post-tsunami psychosocial interventions in Asia. Disasters. 2016
Jul;40(3):432-51. doi: 10.1111/disa.12159. Epub 2015 Nov 17. PMID: 26574293.

Yuval Neria, Sandro Galea, Fran H. Norris. H. Mental Health and Disasters, United
States of America, Cambridge University Press 2009.
https://myemotionalhealthin.com/wp-content/uploads/2020/04/yuval-neria-md-sandro
-galea-md-fran-h.-norris-mental-health-and-disasters-2009.pdf

Marci Van Dyke, Ronald Waldman, The Sphere Project Evaluation Report January
2004

https://www.unscn.org/web/archives_resources/files/Evaluation_report.pdf

Fleming , R. , Baum , A. , Gisriel , M. , & Gatchel , R. ( 1982 ). Mediating inf uences

of social support on stress at T ree Mile Island . Journal of Human Stress , 8 , 14 –22.

Cassel , J. ( 1976 ). T e contribution of the social environment to host resistance .

American Journal of Epidemiology , 104 , 107 –123.

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Cobb , S. ( 1976 ). Social support as a moderator of life stress . Psychosomatic
Medicine , 38 , 300 –314.

Udwin , O. , Boyle , S. , Yule , W. , Bolton , D. , & O’Ryan , D. ( 2000 ). Risk factors

for long-term psychological ef ects of a disaster experienced in adolescence:
Predictors of PTSD . Journal of Child Psychology and Psychiatry and Allied
Disciplines , 41 , 969 –979.

Dalgleish , T. , Joseph , S. , T rasher , S. , Tranah , T. , & Yule , W. ( 1996 ). Crisis

support following the herald of free-enterprise disaster: A longitudinal perspective .
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Benight , C. ( 2004 ). Collective ef cacy following a series of natural disasters .

Anxiety, Stress & Coping: An International Journal , 17 , 401– 420

Shalev , A. Y. , & Freedman , S. ( 2005 ). PTSD following terrorist attacks: A

prospective evaluation. American Journal of Psychiatry , 162 (6), 1188 –1191.

Hobfoll , S. E. , Watson , P. , Bell , C. C. , Bryant , R. A. , Brymer , M. J. , Friedman ,

M. J. , et al. ( 2007 ). Five essential elements of immediate and mid-term mass trauma
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Norris , F. H. , Friedman , M. J. , Watson , P. J. , Byrne , C. R. , Diaz , E. , & Kaniasty

, K. ( 2002 ). 60,000 disaster victims speak: Part I. An empirical review of the
empirical literature, 1981–2001. Psychiatry , 65 , 207 –239

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Richard A. bryant and Brett Litz (2009), Mental Health and Disasters ,Cambridge
University Press, pp. 321 - 335.

Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing Therapy: Basic

Principles, Protocols, and Procedures (3rd ed.). New York, NY: The Guilford Press

Chemtob, C. M., Nakashima, J., & Carlson, J. G. (2002). Brief treatment for
elementary school children with disaster-related posttraumatic stress disorder: A field
study. Journal of Clinical Psychology, 58(1), 99–112.
https://doi.org/10.1002/jclp.1131

Field T, Seligman S, Scafidi F, (1996), Alleviating Posttraumatic Stress in Children

Following Hurricane Andrew. Retrieved from JOURNAL OF APPLIED
DEVELOPMENTAL PSYCHOLOGY.

Bryant, R. A., & Litz, B. (n.d.). Mental Health Treatments In The Wake Of Disaster.
Mental Health and Disasters, 321–335. doi:10.1017/cbo9780511730030.01

George S. Everly, Jeffrey M. Lating. The Johns Hopkins guide to psychological first
aid. Baltimore, Johns Hopkins University Press, 2017.

Everly, G.S., Jr., Lating, J.M., Sherman, M., & Goncher, I. (2016). The potential
efficacy of psychological first aid on self-report anxiety and mood. A pilot study.
Journal of Nervous and Mental Disease, 204, 233-235.

Wang, L., Norman, I., Xiao , T., Li, Y., & Leamy, M. (2021). Psychological First Aid
Training: A Scoping Review of its Application, Outcomes and Implementation .
International Journal of Environmental Research and Public

Health. https://doi.org/10.3390/ijerph18094594

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Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing
post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002
;(2):CD000560. doi: 10.1002/14651858.CD000560. PMID: 12076399.

McNally, R. J., Bryant, R. A., & Ehlers, A. (2003). Does Early Psychological
Intervention Promote Recovery From Posttraumatic Stress? Psychological Science in
the Public Interest, 4(2), 45–79. doi:10.1111/1529-1006.01421

Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis.
Psychological Bulletin, 98(2), 310–357. doi:10.1037/0033-2909.98.2.310

Hobfoll, S. E. (1998). Stress, culture, and community: The psychology and

philosophy of stress. Plenum Press. https://doi.org/10.1007/978-1-4899-0115-6

Everly GS Jr, Barnett DJ, Links JM. The Johns Hopkins model of psychological first
aid (RAPID-PFA): curriculum development and content validation. Int J Emerg Ment
Health. 2012;14(2):95-103. PMID: 23350225.

Psychological first aid. (2020, May 3). Coursera.

https://www.coursera.org/learn/psychological-first-aid?

George Everly, Jr., PhD, Instructor | Coursera. (n.d.). Coursera.

https://www.coursera.org/instructor/georgeeverly
Everly G., Jr PhD. (n.d.). Module 5 Introduction [Video]. Coursera.
https://www.coursera.org/learn/psychological-first-aid/lecture/UCG7i/module-5-intro
duction

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Kaniasty, K., & Norris, F.H. (2008). Longitudinal linkages between perceived social
support and posttraumatic stress symptoms: Sequential roles of social causation and
social selection. Journal of Traumatic Stress, 21, 274–2810.

Renee A. Exelbert(2022)The healing power of touch may be the missing link. THE
WELL. https://www.the-well.com/editorial/the-healing-power-of-touch

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 5.5. Annotated bibliography

World Health Organization, War emergencies conditions in

Trauma Foundation and World Vision non-specialized health settings.

International (2013). Psychological https://interagencystandingcommittee.o

first aid: Facilitator’s manual for rg/sites/default/files/migrated/2020-11/
orienting field workers. IASC%20Guidelines%20on%20Menta

WHO: Geneva. l%20Health%20and%20Psychosocial

https://iris.who.int/bitstream/handle/10 %20Support%20in%20Emergency%20

665/102380/9789241548618_eng.pdf? Settings%20%28English%29.pdf

sequence=1 IASC Guidelines on Mental Health and

A PFA method developed by the Psychosocial Support in Emergency

collaboration of World Health Settings. Another PFA method that

Organization, War Trauma Foundation wasn’t mentioned in the review due to

and World Vision International. resources limitations for the researcher.

A minimal set of multi-sectoral

World Health Organization and United interventions to safeguard and enhance

Nations High Commissioner for people's psychological and mental

Refugees. mhGAP Humanitarian health.

Intervention Guide (mhGAP-HIG):

Clinical management of mental, https://www.tandfonline.com/doi/pdf/1
neurological and substance use 0.1080/21665044.2015.1110292?_gl=1
conditions in humanitarian *1axzyjq*_ga*NDk2NTU1MTI1LjE3
emergencies. MTM2MTkzNTQ.*_ga_0HYE8YG0
Geneva: WHO, 2015. M6*MTcxMzYxOTM1NS4xLjEuMTc
https://iris.who.int/bitstream/handle/10 xMzYxOTM4MC4wLjAuMA..&_ga=
665/162960/9789241548922_eng.pdf? 2.84521758.68735574.1713619354-49
sequence=1 6555125.1713619354

mhGAP Humanitarian Intervention

Guide. practical and easy-to-use tools, A report about the implementation and
evidence-based manual for the impacts of Psychological First Aid
management of humanitarian (PFA), mentioned IASC method.

30
https://internationaltraumacenter.com/ raise trainee capacities to provide
what-we-do/post-traumatic-stress-man Psychological First Aid (PFA) to
agement-ptsm-services/ individuals affected by crises events.

PTSM a cognitive based group

intervention model for PFA, for youth Brymer M, Jacobs A, Layne C, Pynoos
of 9 years and older. R, Ruzek J, Steinberg A, Vernberg E,
Watson P, (National Child Traumatic

https://www.mindwise.org/trainings/ps Stress Network and National Center

ychological-first-aid-post-traumatic-str for PTSD), Psychological First Aid:

ess-management/ Field Operations Guide, 2nd Edition.

July, 2006. Available on:
Training for adults who want to learn
https://www.nctsn.org/sites/default/file
the PTSM approach.
s/resources//pfa_field_operations_guid
e.pdf and www.ncptsd.va.gov.
https://corpslakes.erdc.dren.mil/emplo Kathi A. Borden, Susan J. Simonian
yees/cism/pdfs/Debriefing.pdf book on a PFA method.
Jeffrey T. Mitchell stating about
Critical Incident Stress Debriefing
Vernberg, E. M., Steinberg, A. M.,
(CISD), the Required Conditions for
Jacobs, A. K., Brymer, M. J., Watson,
the Application of the method.
P. J., Osofsky, J. D., Layne, C. M.,
Explanations of why researches had
Pynoos, R. S., & Ruzek, J. I. (2008).
negative outcomes, referencing
Innovations in disaster mental health:
researches that had positive outcomes
Psychological first aid. Professional
when few principles were realized.
Psychology: Research and Practice,
39(4), 381–388.
https://doi.org/10.1037/a0012663 or
https://psycnet.apa.org/record/2008-10
899-001
https://tembo.msf.org/course/info.php?
Evaluation research for previous Kathi
id=33
A. Borden, Susan J. Simonian’s
Médecins Sans Frontières / Doctors approach.
Without Borders’ PFA method. This is
a link for the online training. Which

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