Psychological First Aid Manual

IFMSA – Egypt IFMSA-Egypt is a full member of the International Federation of Medical Students' Association (IFMSA) which is the only official body of medical students worldwide made up of 123 countries spanning all continents. It is a NonGovernmental Association related to the World Health Organization (WHO).

IFMSA-Egypt is represented by medical students from a wide range of medical schools all over Egypt.

IFMSA-Egypt consists of 25 Local Committees in all medical schools around Egypt.

International Federation of Medical Students’ Associations (IFMSA) The IFMSA was founded in 1951 in Copenhagen as a result of the post-war wave of friendship among international students and has evolved to represent more than One Million medical students from all continents and over 123 nations.

The IFMSA is affiliated to the United Nations system as a nonpolitical and nongovernmental organization, and is recognized by the World Health Organization as the official international forum for medical students since 1969.

Since 1951, IFMSA exists to serve as a forum for sharing ideas and expertise among medical student organizations pertaining to public health, medical education, reproductive health and human rights. IFMSA also serves as an action platform to formulate policies and co-ordinate activities by its member organizations.

IFMSA aims to serve medical students all over the world through its member organizations, to promote and facilitate international co-operation in professional training and to contribute to the development of culturally aware and socially responsible physicians.

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SCOPH The Standing Committee on Public Health (SCOPH) brings together medical students from all over the world to learn, build skills, cooperate, explore and share ideas to address all issues related to Public Health, including Global Health issues, health policies, health promotion, and education activities.

Medical students of the IFMSA formed the Standing Committee on Students’ Health (SCOSH) in 1952, driven by a strong will to take an active part in preventing and making policies concerning health problems. During the following years, the wide variety of activities led to the change of SCOSH to Standing Committee on Health (SCOH) in 1963. In 1983 the name of the Committee changed once more to Standing Committee on Public Health (SCOPH).

During these six decades, SCOPHeroes have implemented, maintained and improved a wide variety of community-based projects on a local, national and international level. Through these activities, we are pursuing our vision of a healthy society and we are developing our own potential of being complete and skillful health professionals.

Vision Medical Students attain the optimal skills and knowledge to contribute to their full potential towards the making of healthier communities in their capacity as medical students and as future healthcare providers.

Mission The Standing Committee on Public Health promotes the development of medical students worldwide regarding Public Health issues through an international sharing knowledge network, projects management, community-based learning, capacity building, advocacy, exchanges placements and access to external learning opportunities.

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SCOME Medical Education should be a concern of every medical student as it shapes not only the quality of future doctors but also the quality of healthcare. The International Federation of Medical Students’ Associations (IFMSA) has a dedicated organ which aims to implement an optimal learning environment for all medical students around the world the Standing Committee On Medical Education (SCOME). Through all our joint efforts we work to create sustainable changes around the world, for ourselves as medical students, for the generations to come and for our future patients and our communities who are in fact the final beneficiaries of our education.

History SCOME was one of IFMSAs first standing committees from the beginning of its foundation in 1951. It acts as a discussion forum for students interested in the different aspects of medical education in the hope of pursuing and achieving its aim. Today, SCOME works mainly in medical education capacity building.

SCOME provides several platforms and methods to educate medical students worldwide on various medical education issues. Through this knowledge, it empowers them to advocate to be a part of the decision-making chain. SCOME believes in medical students as important stakeholders in creating, developing and implementing medical education systems.

Vision Medical students attain an optimal professional and personal development to reach their full potential as future doctors for better healthcare worldwide.

Mission Our mission is to be the frame in which medical students worldwide contribute to the development of medical education. Students convene in SCOME to share and learn about medical education in order to improve it as well as benefit the most from it on a personal and professional basis.

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Index 1-PFA definition and history

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2-Who , When and Where

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3-PFA Principles

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4-Out-Breaks

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5-Remote PFA

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6-Where to seek help

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Psychological First-Aid: According to the Sphere Project (2011) and IASC (2007), Psychological First Aid (PFA) describes a humane, supportive response to someone who is suffering and may need support.

It involves: •

Providing non-intrusive, practical care and support.

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Assessing needs and concerns.

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Helping people to address basic needs (food and water, information).

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Listening to people, but not pressuring them to talk.

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Comforting people and helping them to feel calm.

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Helping people connect to information, services and social supports.

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In the case of Ebola disease, information is vital: those providing PFA can help

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to dispel myths, share clear messages about healthy behavior and improve

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One's understanding of the disease.

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Protecting people from further harm.

PFA is not: •

It is not something that only professionals can do.

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It is not professional counseling.

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It does not necessarily involve a detailed discussion of the event that caused the distress (as in “psychological debriefing”).

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It is not asking someone to analyze what happened to them or to put time and events in order.

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It is not about pressuring people to tell you their feelings and reactions to an event but rather being available to listen to people.

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Overall, PFA involves helping people to: •

Feel safe, connected to others, calm and hopeful.

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Have access to social, physical and emotional support.

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Feel able to help themselves, as individuals and communities.

Figure: the place of PFA in overall mental health and psychological response.

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Psychological First-aid Beginning: PFA is not a new intervention. Rather, it is better conceptualized as documenting and operationalizing good common sense – those activities that sensible, caring human beings would do for each other anyway.

The term Psychological First Aid was first coined by Drayer, Cameron, Woodward, and Glass (1954) in a manuscript they wrote for the American Psychiatric Association on request of the U.S. Federal Civil Defense Administration. The purpose of the manuscript was to provide guidance for managing in the aftermath of community disasters. By the 1970s the principles and foundations of crisis (psychological) intervention were being utilized in disaster work with adults. By 1990 emergency organizations such as the Danish Red Cross were applying the principles as a preferred model for early intervention following exposure to a traumatic event. The principles have continued to gain widespread international acceptance, culminating in their inclusion in international guidelines.

WHO PFA is for distressed people who have been recently exposed to a serious crisis event. You can provide help to both children and adults. In Egypt one of the places that give PFA is "Red Crescent". However, not everyone who experiences a crisis event will need or want PFA. Don't force help on people who do not want it, but make yourself easily available to those who may want support.

There may be situations when someone needs much more advanced support than PFA alone. Know your limits and get help from others, such as medical personnel (if available), your colleagues or other people in the area, local authorities, or community and religious leaders. In the following box we have listed people who need more immediate advanced support. People in these situations need medical or other help as a priority to save life.

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People who need moreimmediate advanced Support: •

People with serious, life-threatening injuries who need emergency medical care.

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People who are so upset that they cannot care for themselves or their children.

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People who may hurt themselves.

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People who may hurt others.

WHEN Although people may need access to help and support for a long time after an event, PFA is aimed at helping people who have been very recently affected by a crisis event. You can provide PFA when you first have contact with very distressed people.

This is usually during or immediately after an event. However, it may sometimes be days or weeks after, depending on how long the event lasted and how severe it was.

WHERE You can offer PFA wherever it is safe enough for you to do so. This is often in community settings, such as at the scene of an accident, or places where distressed people are served, such as health centers, shelters or camps, schools and distribution sites for food or other types of help. Ideally, try to provide PFA where you can have some privacy to talk with the person when appropriate. For people who have been exposed to certain types of crisis events, such as sexual violence, privacy is essential for confidentiality and to respect the person’s dignity.

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HOW Action principles of PFA: Principle

LOOK

LISTEN

LINK

Actions •

Check for safety

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Check for people with obvious urgent basic needs

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Check for people with Serious distress reactions

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Approach people who may need support

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Ask about people's needs and concerns

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Listen to people and help them to feel come

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Help people address basic needs and access services

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Help people cope with problems

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Give information

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Connect people with loved ones and social support

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RAPID Model 1. Reflective listening: refers to the ability to utilize active listening techniques, establish empathy, and determine important aspects of the survivor’s experience.

2. Assessment: entails, first, screening to answer the binary (yes-no) query of whether there are indicators to warrant exploration into a person’s capacity for adaptive mental and behavioral functioning and, second (if necessary), a brief assessment of dimensional factors that are likely to facilitate or impede rapid recovery of adaptive functioning, for example, the ability to understand and follow directions, the ability to express emotions in a healthful and constructive manner, social adaptability, and the ability to access interpersonal resources; 3. Prioritization (of assessed functional needs): is essentially a triage task intended to guide an acute intervention plan for more severe physical, psychological, and behavioral reactions. Beyond physical and medical priorities, the focus is on the ability of the survivor to perform basic activities of daily living; 4. Intervention (once physical and medical needs are addressed): is applied, as needed, using stress management and/or cognitive/behavioral techniques to reduce acute distress; 5. Disposition: involving the determination if survivors have regained the functional capacity to engage in the basic activities of daily living, or need referral and transitioning to other clinical or social supports (possibly with continuing advocacy and liaison needs).

Although not part of the RAPID acronym, but “Self Care” is very important. Remember that Primary civilian victims experience adverse reactions to disaster, but first responders and others in the helping professions may also be vulnerable to similar adverse reactions!

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DO AND DON'T DO's •

Be honest and trustworthy.

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Respect

people’s

right

DON'Ts • to

make

their

•

•

• •

Don’t make false promises or give false information.

Be aware of and set aside your own biases and •

prejudices.

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for helping them.

own

decisions.

Don’t ask the person for any money or favor

Don’t exaggerate your skills.

Make it clear to people that even if they refuse help •

Don’t force help on people, and don’t be

now, they can still access help in the future.

intrusive or pushy.

Respect privacy and keep the person’s story • • confidential, if this is appropriate.

Don’t pressure people to tell you their story.

Behave appropriately by considering the person’s •

Don’t judge the person for their actions or

culture, age and gender.

feelings.

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Don’t share the person’s story with others.

Definition of outbreaks An outbreak is when an illness happens in unexpected high numbers. It may stay in one area or extend more widely. An outbreak can last days or years. Sometimes, experts consider a single case of a contagious disease to be an outbreak. This may be true if it’s an unknown disease, if it’s new to a community, or if it’s been absent from a population for a long time. Disease outbreaks are usually caused by an infection, transmitted through person-to-person contact, animal-to-person contact, or from the environment or other media. Outbreaks may also occur following exposure to chemicals or to radioactive materials. For example, Minamata disease is caused by exposure to mercury. Occasionally the cause of an outbreak is unknown, even after thorough investigation.

An epidemic: is when an infectious disease spreads quickly to more people than experts would expect.

A pandemic: is a disease outbreak that spreads across countries or continents. It affects more people and takes more lives than an epidemic. The World Health Organization (WHO) declared COVID-19 to be a pandemic when it became clear that the illness was severe and that it was spreading quickly over a wide area.

The number of lives lost in a pandemic depends on:

▪ How many people are infected ▪ How severe of an illness the virus causes (its virulence) ▪ How vulnerable certain groups of people are ▪ Prevention efforts and how effective they are

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Stressors in outbreaks:

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Acute stress: The response to a single experience that creates heightened demands for a limited period of time Chronic stress: the cost of daily living: bills, kids, jobs… stress we tend to ignore or suppress

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Traumatic stress: The reaction to situations that are shocking and emotionally overwhelming, often involving actual or threatened death, serious injury or betrayal.

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But there is also a good type of stress which is Eustress, it is stress in daily life that has positive elements: being challenged at work, birth of a child, pushing oneself physically, etc.

The outbreak of diseases may be stressful for people. Fear and anxiety about a disease can be overwhelming and cause strong emotions in adults and children. Coping with stress will make you, the people you care about, and your community stronger.

Stress during an infectious disease outbreak can include:

▪Fear and worry about your own health and the health of your loved ones ▪Changes in sleep or eating pattern ▪Difficulty sleeping or concentrating ▪Worsening of chronic health problems ▪Worsening of mental health conditions ▪Increased use of alcohol, tobacco, or other drugs ▪Everyone reacts differently to stressful situations

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Effect of outbreaks on mental wellbeing People can experience a wide range of reactions in response to outbreaks. They can feel overwhelmed, confused or very uncertain about what is happening. They can feel fearful and anxious, or numb and detached. Some people may have mild reactions, whereas others may have more severe reactions. In general, how someone reacts depends on many factors, including: 1. The nature and severity of the event; 2. Their experience with previous distressing events; 3. The support they have in their life from others; 4. Their physical health; 5. Their personal and family history of mental health problems; 6. Their cultural background and traditions; 7. Their age (for example, children of different age groups react differently).

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People tend to feel anxious and unsafe when the environment changes. In the case of infectious disease outbreaks, when the cause or progression of the disease and outcomes are unclear, rumors grow and close‐minded attitudes eventuate. the level of anxiety rose significantly when the SARS outbreak occurred.

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For example, in Hong Kong, about 70% of people expressed anxiety about getting SARS and people reported they believed they were more likely to contract SARS than the common cold. Anxiety and fear related to infection can lead to acts of discrimination. People from Wuhan were targeted and blamed for the COVID‐19 outbreak by other Chinese people and Chinese people have since been stigmatized internationally, for example, use of the term ‘China virus’ and the use of terms such as ‘Wuhan virus’ and the ‘New Yellow Peril’ by the media.

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Fear is known (for centuries and in response to previous infectious outbreaks such as the plague), yet a common response to infectious outbreaks and people react in many and individualized ways towards the perceived threat.

Hypervigilance, for example, can arise because of fear and anxiety and, in severe cases, result in post‐traumatic stress disorder (PTSD) and/or depression Fear of the unknown, in this case, the spread of the disease and the impact on people, health, hospitals, and economies, for example, raises anxiety in healthy individuals as well as those with pre‐existing mental health conditions.

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Individuals, families, and communities experience feelings of hopelessness, despair, grief, bereavement, and a profound loss of purpose because of pandemics. Feelings of loss of control drive fear and uncertainty as the trajectory of the pandemics is constantly evolving; so is the advice on the action to take to stop the spread of a pandemic. Perceived mixed messaging from government or health officials can also lead to public confusion, uncertainty, and fear.

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People’s responses to fear and intolerance of uncertainty lead to negative societal behaviors. Uncertainty increases feelings of alarm resulting in behaviors targeted at reducing uncontrollable situations which people fear. For example, we have seen people clearing shelves of supermarkets resulting in global shortages of food and essentials such as toilet paper.

This behavior is purported to occur for two reasons: 1. because the threat of COVID‐19 is perceived as a ‘real’ threat and expected to last for some time 2. as a means to regain control.

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While outright panic as a result of this pandemic is unlikely, it can occur as a consequence of mass quarantine. The current state of the COVID‐19 illness already paints a picture of inevitable and large‐scale quarantine – some of which are already occurring. In the case of mass quarantine, experiencing social isolation and an inability to tolerate distress escalate anxiety and fear of being trapped and loss of control, and the spread of rumors.

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Rumors fuel feelings of uncertainty and are extricably linked to issues such as panic buying and hoarding behavior. Anxiety related to this pandemic is also compounded by people being reminded of their own mortality that can lead to an ‘urge to splurge’, that is an increase in spending as a means to curb fear and regain control.

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Throughout history, people have sought to allocate blame to someone in order to calm their fear of disease outbreaks. This fear and othering are often present with pandemics. For example, the 2014 Ebola outbreak was considered an African problem resulting in discrimination against those of African descent, while the 2009 H1N1 flu outbreak in the USA saw Mexican and migrant workers targeted for discrimination. Misinformation, public anxiety, and rumors must be addressed by Government and Health officials, that help mitigate the adverse effects of stigmatization and help provide protection of vulnerable populations.

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Ultimately, to apportion blame in any circumstance can damage everyone involved and can reduce individual and community resilience both in the short and long term. Fear and guilt can also occur as a result of being infected by the virus. Infected people, while also the target of discrimination, also experience self‐blame or guilt. Unfortunately, this feeling culminated in the suicide death of a health worker recently who feared she had contaminated seriously ill people she cared for while infected by COVID‐19.

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Example on using (PFA) in outbreaks as (Ebola): Ebola virus disease is a severe, infectious disease that can be fatal (the case fatality rate of the 2014 outbreak in West Africa is about 50%). It can be spread only by direct contact with the body fluids or tissues of a person who is sick with the disease or who has died.

▪(PFA) role in Ebola outbreak In the case of Ebola disease, information is vital. So, those providing (PFA) can help to dispel myths, share clear messages about healthy behavior and improve people’s understanding of the disease.

(PFA) also helped people suffering in other ways as a consequence of the Ebola disease outbreak. This may include people who have lost multiple family members and loved ones to Ebola, particularly orphans who need extra care and protection. PFA may also be useful for people who may be stigmatized by their communities, such as:

People who have recovered from Ebola Health care providers treating people with Ebola; Frontline workers of Ebola operations (e.g., people involved in dead body management)

▪ Effects of (PFA) during Ebola outbreak:

According to a study, which took place in Ebola-affected West Africa, aimed to investigate whether and how PFA strengthens the provision of mental health support to acutely distressed people in humanitarian crises There are some findings:

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Those trained in PFA during the Ebola outbreak reported very positive personal changes (e.g. learning to understand reactions of others and manage one’s own emotions; improved use of self-care strategies; improved relationships with friends, family and colleagues as they began to use the skills).

The prospective study showed that PFA training increases understanding of helpful ways to respond to someone who is distressed. The health care workers who participated in the PFA training showed an increase in knowledge of how to respond to a person in distress and gave more appropriate responses to hypothetical scenarios, compared to those who did not participate. These changes were maintained up to six months after the training.

In the context of the Ebola outbreak, the rapid scale-up of PFA training had established valuable knowledge among non-specialists. However, training participants still had challenges in the following areas:

1) How to calm a person without making false promises, telling own / others stories, telling the person how they should feel, etc.

2) Supporting a person to identify their own coping strategies and resources (strengthening self-efficacy) – rather than giving advice or trying to solve the problem

3) Putting the ‘link’ action principle into practice.

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Remote PFA The outbreak of COVID-19 has created concern and worry among the general population worldwide. Many become anxious and afraid, and those who are directly affected in different ways by the virus may be in greater panic, fear and worry.

Psychological first aid (PFA) is a method of helping people in distress so they feel calm and supported to cope better with their challenges. Due to mandatory social distancing nowadays, psychological first aid must be remotely provided through phone calls or online platforms. However, keeping socially connected and closely in dialogue with others is vital. It is important to support the infected people to find ways to keep in touch with others, even though being in social distancing or quarantine. Remote PFA will assist those who need help to manage their situation and make informed decisions. The basis of Remote psychological first aid during the outbreak is: caring about the person in distress and showing empathy. It involves paying attention to reactions, active listening and, if needed, practical assistance, such as problem solving, help to access basic needs or referring to further options for assistance. In this way, remote PFA helps to normalize worry and other emotions, and also promotes healthy coping and provides feelings of safety, calming, and hope.

Helpers will use the PFA action principles of Look, Listen and Linkwhen offering remote support. A PFA helper will follow these action principles, knowing that when they are used in practice they overlap. For remote PFA offered without any physical contact the following points describe the principles: Look refers to how to assess: • • •

The current situation Who seeks support?

What are the risks, the needs andexpected emotional reactions of affected people?

Listen refers to how to: • • • • • • •

Begin the conversation Introduce the helper Pay attention and listen actively Accept feelings Calming someone in distress Ask about needs and concerns Help find solutions to needs and problems.

Link refers to how to assist with: • • •

Accessing information Connecting with loved ones and social support tackling practical problems Accessing services and other help.

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Advice on how to keep your mental well-being during outbreaks: Fighting the psychological effect of the global pandemic requires fair estimation of our emotions: •

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Do not underestimate the cognitive and emotional load that this pandemic brings, or the impact it will have on your productivity, at least in the short term. Difficulty concentrating, low motivation and a state of distraction are to be expected.

Adaptation will take time. Go easy on yourself. As we settle into this new rhythm of remote work and isolation, we need to be realistic in the goals we set, both for ourselves and others in our charge.

Create clear distinctions between work and non-work time, ideally in both your physical workspace and your head space. Find something to do that is not work and is not virus-related, something that brings you joy.

Working in short bursts with clear breaks will help to maintain your clarity of thought.Knowing the facts about COVID-19 and stopping the spread of rumors can help reduce stress and stigma.

Understanding the risk to yourself and people you care about can help you connect with others and make the outbreak less stressful.

During times of increased social distancing, people can still maintain social connections and care for their mental health. Virtual communication (like phones or video chats) can help you and your loved ones to feel less lonely and isolated.

This pandemic will cause a lot of stress for many of us, and we cannot be our best selves all the time, but we can ask for help or reach out when help is asked of us.

Connect with family, friends, and others in your community. Take care of yourself each other and know when and how to seek help. Call your healthcare provider if stress gets in the way of your daily activities for several days in a row.

Available organizations and numbers of hotlines that cares with mental well-being in Egypt: 1. The General Secretariat for Mental Health of the Egyptian Ministry of Health 08008880700 / 0220816831 2. Egyptian Rec Crescent for metal support 15322/02 23492106 3. Al.Abassia Hospital for mental health 2262237 – 0152028565 4. Al khanka Hospital for mental health 44698437 5. Portsaid Hospital for mental health 0663655907 6. Helwan Hospital for mental health 25547387 - 25547368 7. Benha Hospital for mental health 0133213275 – 0133232506

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8. Assiut Hospital for mental health 882180443 - 0882180443 9. Al Mamora Hospital for mental health 0882180443 – 0882180443

For further readings and references, check this link

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