By Britt T. Gonsoulin, M.D., M.P.H, Psychological First Aid Team Lead

Here, in the Seattle area, memories of early January provide a stark contrast to the current reality. It is hard to imagine a recent time when minds were not continually occupied with questions like, Is it safe at the grocery store? Should the kids go to swim lessons? What kind of disinfectant should I use? Is this more than just the sniffles? Did I wash my hands when I came home? What will tomorrow bring?

For me, like so many of us living in areas affected by COVID-19, uncertainty pervades the conscious mind, provoking a constant, insidious rumination, the kind that can take a toll on our psychological health if left unchecked. We face an uncertain path in the months to come and this necessitates a conversation.

As humans, we are accustomed to the notion and application of First Aid when it comes to cuts, bruises, sprains, and strains. But, the concept and embodiment of ​Psychological​ First Aid is less tangible for many of us. As volunteers, caregivers, or simply concerned citizens, we may feel the urge to forego our own self-care needs as we prioritize helping others, which is why we should be well versed in Psychological First Aid.

Psychological First Aid (PFA) is ​NOT​ mental health care as we imagine it: either going to see a trained mental health professional to talk to about symptoms OR providing mental health counseling to another. On the contrary, it is a ​STANCE​ that anyone and everyone can embody. When skillfully delivered, PFA builds resilience for individuals and communities. It diminishes the need for higher level, formal mental health interventions across a group of affected people. And it is vital that healthcare workers be well versed in it.

So, what exactly is PFA and how can you employ it? What is the equivalent of a mental bandaid when the mind is suffering?

The World Health Organization outlines a basic approach to PFA(1) represented in three words: look, listen, link. We should all memorize these words, just as we memorize stop, drop, and roll, and other helpful cues. As we practice our fire drills, we must also practice look, listen, link.

Step One: LOOK

Pause what you are doing, look at (or observe) your situation, and ask:
Am I physically safe? If not, take steps toward safety. Once achieved, ask: Are others safe? If not, take steps to remedy their safety. Once achieved, ask: What signs of stress can I observe in MYSELF and OTHERS?

A full discussion of signs of stress would deserve another conversation, but common signs in adults and children appear in several areas: altered thought patterns, feelings/emotions, behaviors, spiritual practices, and physical symptoms. Much like a grief response, observable signs of stress run the gamut from primarily physical symptoms (physiologic arousal, change in vital signs) to anger/irritability, sadness/hopelessness, denial, acceptance, or—as is often the case in children—acting out or withdrawing.

Exh. 1 Common stress reactions in adults

It is important to note that in the presence of a prolonged disaster event (such as an evolving COVID-19 pandemic), distinct mental health challenges arise when compared to an isolated, time-limited disaster (an earthquake, for example). In such prolonged disasters, stress responses may not subside in the typical 2-3 week period after onset. Instead, there may be a protracted acute phase and a delay in reaching the recovery phase (see image below). Thus, it is vitally important to monitor signs of stress in self and others and take action to mitigate them on a daily basis, minimizing the potential for trauma and long-term burnout.

This is a good moment to talk about coping. We all cope in different ways, sometimes adaptive and sometimes not. It goes without saying that we should encourage adaptive coping strategies for ourselves and others. If we see someone engaged in non-adaptive coping, we may seek to better understand their state of mind and gently encourage adaptive coping.

Adaptive coping	Non-adaptive coping
Moderate exercise Good nutrition Social connection (virtual or in-person) Playing games Watching a favorite show Listening to music Journaling Meditation	Excessive alcohol consumption Excessive exercise Isolation Denial Blame Risky behaviors Drug use Avoidance

The take-away point here is that practicing the PFA skill of “looking” or observing for signs of stress is an essential first step to promoting long-term resilience and meaning-making within a community.(2) It prepares that population for implementation of the next PFA skill: listening.

Step Two: LISTEN

Use your presence of mind and your listening ears to embody a calm, compassionate connection to another. Too often, in times of stress, our actions and thoughts speed up. We may express or carry ourselves forcefully, and this forceful energy, while well-meaning, subconsciously perpetuates sympathetic arousal states (or stress states) in those around us. This is a good moment to define the term “vicarious trauma”(3), which can occur when someone in the presence of a traumatized person may begin to feel and experience the trauma physiologically in themselves. In simple terms, our nervous systems take cues from one another.

Conversely, when we take time to ground ourselves, listen, and respond in a calm and compassionate manner, parasympathetic tone (the relaxation response) improves and can be vicariously experienced by others. The implications of this phenomenon within a post-disaster setting are not hard to comprehend. We have the ability to subconsciously influence those around us in a positive manner. Not surprisingly, vicarious resilience can aid in a smoother recovery from trauma or disaster.(4) Grounded, calm, and compassionate listening enables us to embody the final principle of PFA, which is to “link.”

Step Three: LINK

We are social creatures and our social bonds are tested during times of stress. Stress induces flight or fight responses, changing the way we relate to one another in subtle ways. Linking ourselves and others to resources calms stress-dominant arousal states and contributes to physiologic and psychic stability. These “resources” I speak of are more basic than one would think: having available fresh drinking water, toothbrushes and toothpaste for those working long shifts or displaced from home, a quiet place to rest or take a break, healthy snacks to eat, a calm person to talk to, a book to read, games to play.

When responding to large-scale emergencies, meeting our basic needs for self-care and nutrition are often overlooked or even celebrated if you are a volunteer or caregiver. But long-term psychological health can not be sustained in such circumstances. If you notice yourself neglecting your own needs, please begin the practice of meeting them. Ask someone to help you meet them. If you see others around you doing the same, say, “I notice that we are not taking care of ourselves as we should. Would you like to take a water break with me?”

However basic, such gestures of acknowledgment and connection go a long way in balancing fight or flight states and reducing the sense of isolation within our personal struggles. So go ahead, offer someone a (disinfected) bottle of water, designate a dark room in your home for relaxation and rest (soft music there, maybe?), and do your best to put your proverbial oxygen mask (N95?) on first, so to speak.

In summary, caring for our basic psychological needs during an uncertain time is paramount to sustaining a non-traumatizing response to disaster within our communities. Embodying a stance of Psychological First Aid within ourselves strengthens self-care and vicarious resilience and prevents the harm of vicarious trauma.

While this article is by no means comprehensive (and does not spend adequate time addressing challenges specific to the COVID-19 pandemic, such as social distancing and isolation, the possibility for hopelessness or despair, unique challenges of parents, etc.-) I hope that it encourages us all to familiarize ourselves with PFA and implement healthy psychological practices.

Finally, it should also be noted that, as in the case with First Aid, sometimes cuts and sprains need more than basic first aid. If you observe yourself or others to be suffering with severe symptoms of stress or experiencing hopelessness, despair, or suicidal thoughts, please seek the support of a trained mental health professional. We must remember that we are only human.

Britt Gonsoulin, M.D., M.P.H.

I am a dual-trained medical and public health physician practicing in the Seattle area. I work in the area of Disaster Mental Health Responses, promoting personal and community resilience in the city of Bainbridge Island. I also practice General Adult Psychiatry and Collaborative Care Psychiatric Consultation.

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2 ​Vernberg, E. M., Steinberg, A. M., Jacobs, A. K., Brymer, M. J., Watson, P. J., Osofsky, J. D., Layne, C. M., Pynoos, R. S., & Ruzek, J. I. (2008). Innovations in disaster mental health: Psychological first aid. ​Professional Psychology: Research and Practice, 39​(4), 381–388. https://doi.org/10.1037/a0012663

3 ​Cohen, K., & Collens, P. (2013). The impact of trauma work on trauma workers: A metasynthesis on vicarious trauma and vicarious posttraumatic growth. ​Psychological Trauma: Theory, Research, Practice, and Policy, 5​(6), 570–580. ​https://doi.org/10.1037/a0030388 

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Image "No Joke" by Steve Corey is licensed under CC BY-ND 2.0.