Development of mental health first aid guidelines on how a member of the public can support a person affected by a traumatic event: a Delphi study

Literature search

The aim of the literature search was to find statements about helping someone who has experienced a traumatic event which would be input for the expert panels to consider. The focus for the search was to find statements which instruct the reader on how to respond immediately after a traumatic event (or the disclosure of a past trauma), how to offer assistance in the short and medium term, and how and when to access professional help for a traumatised individual.

The literature search was conducted across three domains: the medical and research literature, the content of existing crisis intervention guidelines and relevant courses for the public, and lay literature. The lay literature included books written for the general public, particularly consumers' and carers' guides, websites and pamphlets.

The medical and research literature was accessed through searches of PsycInfo and PubMed. This was not a systematic review. No judgment was made about the quality of the evidence or the methods. Any claim about an action that might be effective when assisting someone who has experienced a traumatic event was considered for inclusion in the list of items to be assessed by the panel members (for further details see "Questionnaire development" below).

The search term was 'trauma*' and all records for the 20 years leading to the search date were reviewed. The search term 'trauma*' generated far too many records, including large numbers of records relevant only to physical trauma, but all attempts to narrow the search were found to exclude too many possibly relevant records. Papers were therefore excluded first on the basis of their titles and then on the basis of their abstracts.

Papers were read if they described actions to prevent to development of PTSD after a traumatic event, described risk and protective factors that were modifiable post-trauma (e.g. social bonds and social isolation can be acted on and enhanced after someone has experienced a traumatic event; whereas pre-event trait anxiety cannot), or included guidelines for treating patients who had recently been exposed to trauma (a total of 194 papers). Statements meeting our criteria were drawn from 32 of the 194 relevant records, as most of the advice given in these papers was very clinically orientated, or required extensive training, to be applicable.

To find appropriate websites, we used the search engines Google [26], Google Australia [27], and Google UK [28] using the search term 'traumatic event'; the first 50 websites listed by each were reviewed; beyond the first 50 websites, quality declined rapidly. Since most websites were listed by more than one search engine, only 63 websites were reviewed. The websites were read thoroughly, once again looking for statements which suggested a potential first aid action (what the first aider should do) or relevant awareness statement (what the first aider should know). Any external links to other websites were followed and the same process applied to each of them.

It emerged that there was a great deal of information about how to assist children who had been affected by traumatic events. It was therefore decided that an additional search of websites should be conducted to find statements about helping children. The process was repeated, using the search terms 'traumatic event' and 'children'. This time, 55 websites were identified by the three Google search engines, of which 45 had not appeared in the original search.

The fifty most popular books on the Amazon [29] website which listed the word 'trauma' or 'posttraumatic stress disorder' in the title or keywords were selected. This site was chosen because of its extensive coverage of books in and out of print, including works about mental health aimed at the public. Books which were autobiographical in nature, self-help workbooks constituting a program of self-treatment and clinical manuals were excluded. The remaining books were read to find useful statements. The majority of these were carers' guides, which do contain advice relevant for first aid, but focussed on general caring for a mentally ill family member.

Any relevant pamphlets were sought and read, and statements were taken from these as well. The majority of the pamphlets were written and distributed by organisations focussing on specific sorts of traumas, such as sexual assault or violent crime, and generally directed the reader to appropriate authorities and support organisations. There were also a large number of pamphlets and fact sheets focussing on specific large-scale traumas, which were frequently written in response to a specific event, such as Hurricane Katrina in 2005, and the shootings at Virginia Polytechnic Institute in 2007. While these documents did contain a lot of specific advice about where to get practical or emotional help after such an event, there was also information relevant to first aid givers about how to support people affected by such events. Most of these pamphlets were obtained from websites, but where these were not available online, a request was made for relevant materials from large mental health and community organisations.

Guidelines written for professionals responding to traumatic events were reviewed and relevant statements were drawn from these. While a small number of relevant statements were found in these documents, they frequently emphasised the policies and procedures relevant to the specific organisation for which they were developed.

Only one training course for members of the public was found to be relevant, as most training in critical incident response is designed for professional responders such as paramedics and the police. Material from the Mental Health First Aid Program [30] was reviewed and statements drawn from it.

Questionnaire development

The questionnaire on possible first aid actions was developed by first grouping statements into categories: immediate assistance after a traumatic event; communicating with a traumatised person; discussing the traumatic event; assisting after a large-scale traumatic event; after-care for large-scale traumatic events; coping strategies in the weeks following the event (talking and actions); and when to seek professional help.

The categories for the children's statements were slightly different, and included: immediate assistance after a traumatic event; communicating with a traumatised child; children at large-scale traumatic events; advice for parents and guardians in the weeks following the event; dealing with avoidance behaviour and temper tantrums; legal issues if a child discloses abuse; and when to seek professional help for a child.

Similar or near-identical statements were frequently derived from multiple sources, and they were not repeated in the questionnaire. A working group comprised of the authors of this paper and colleagues working on similar projects convened at each stage of the process to discuss each item in the questionnaire. The role of the working group was to ensure that the questionnaire did not include ambiguity, repetition, items containing more than one idea or other problems which might impede comprehension. The working group made no judgements about the value of the first aid actions in the statements, since that was the role of the expert panels.

The wording of each item was carefully designed to be as clear, unambiguous and action-oriented as possible. For example, 'the first aider should talk about what happened' is highly ambiguous. It is better to specify 'the first aider should encourage the person to talk about the traumatic event', or 'the first aider should tell the person that if they want to talk about the event, the first aider is prepared to listen'. All statements were written as an instruction as shown in the above examples. The only items which were not included in the questionnaire were those which were so ambiguous that the working party was not able to agree on the meaning of the statement, those which were deemed too clinical or relevant only to a specific professional group, and those which called upon 'intuition', 'instinct' or 'common sense', as these cannot be taught.

All participants answered the questionnaire via the Internet, using an online survey website, Surveymonkey [31]. Participants were able to stop filling in their questionnaires at any time and log back in to continue, without the risk of losing the completed section of their questionnaire. Using the Internet also made it very easy for the researchers to identify those who were late in completing questionnaires and send reminders, with no need to send extra copies of the questionnaire. No questions were inadvertently missed, as the web survey was set up so that each question was mandatory. In addition, such survey software allows for branching, so participants who did not feel qualified to answer questions about assisting children who had experienced trauma were not asked to complete those sections of the questionnaire.

Expert panel recruitment

Participants were recruited into one of three panels: professionals (clinicians and researchers), consumers (people who had experienced a traumatic event, some of whom had post-traumatic stress disorder) and carers (family members or loved ones of consumers who have a primary role in maintaining their wellbeing). Consumers and carers had public roles, either in advocacy, as the authors of books or websites or as speakers on the topic. The professional panel had 37 experts, the consumer panel 13, and the carer panel 4. The carers were also consumers themselves, and because of the small numbers, the consumer and carer panels were combined into one panel of 17.

All panel members were from developed English speaking countries (Australia, Canada, New Zealand, The United Kingdom and The United States). Only participants from developed English speaking countries were sought, as these countries were known to have comparable cultures and health systems. It was also felt that a guaranteed degree of fluency was important because some items vary from each other in important, but very subtle ways, which might escape the notice of a non-native speaker.

Participants were recruited in a number of ways. Professionals recruited were those who had publications in the areas of traumatic stress, PTSD, or treatment of patients who had experienced traumatic events. When letters were sent (by email) to professionals asking them to be involved, they were also invited to nominate any colleagues who they felt would be appropriate panel members. Those active in clinical practice were also asked to consider any former patients who might be willing to be involved and also met our other criteria.

No attempt was made to make panels representative. The Delphi method does not require representative sampling; it requires panel members who are information- and experience-rich. This may be one reason that consumers and carers were difficult to recruit. To be included on the panel, they needed experience beyond their own; for example, involvement in facilitating mutual help support groups or advocacy roles.

It is not possible to report accurately the rate of acceptance or rate of refusal, as it is not known how many of the invitations were received. Changes and errors in email addresses, email filtering programs and other factors make it impossible to report how many of the invitations were read by the person they were addressed to. However, we can report that 190 email invitations were initially sent out. Some of those approached may have passed the information on to others. Some approaches were made to organisations, and may or may not have been read by the relevant individuals. Reasons for refusal included being too busy (this project represented a significant time commitment), no longer working in the area, or working in a related area of less relevance to the project (e.g. brain imaging studies). As the research was to be conducted online, only email contact was initiated.

The 37 professional participants included 21 academics (researchers, lecturers and professors), 15 psychologists, 8 psychiatrists, 7 managers of mental health services or clinical research centres, 2 social workers, 2 nurses, 2 public health policy and program professionals in disaster planning, 1 drug and alcohol therapist working with victims of trauma who abuse drugs, and 1 attorney (also a clinical psychologist). Some participants had multiple roles in research, teaching and clinical work.

Consumers were recruited from advocacy organisations and referral by clinicians. They were also identified if they had written websites offering support and information to other consumers. Carers were recruited through carers' organisations, but were difficult to recruit for this study.

The Delphi process

Three rounds of questionnaires were distributed as follows, with each item being rated up to two times. In round 1 the questionnaire, derived from the process described above, was given to the panel members. The questionnaire included space after each of the sections to add any suggestions for additional items.

In each round of the study, the usefulness of each item for inclusion in the mental health first aid guidelines was rated as essential, important, don't know or depends, unimportant, or should not be included. The options don't know and depends were collapsed into one point on the scale because operationally, they are the same response; most of the items were, very reasonably, noted to be useful in some cases and not others, meaning they could not be generalised in guidelines, which is also true of items participants did not feel confident to rate.

The suggestions made by the panel members in the first round were reviewed by the working group and used to construct new items for the second round. Suggestions were accepted and added to round 2 if they represented a truly new idea, could be interpreted unambiguously by the working group, and were actions. Suggestions were rejected if they were near-duplicates of items in the questionnaire, if they were too specific (for example, "Should make sure that the child will be picked up from school"), too general ("just be there"), or were more appropriate to therapy than first aid ("reframe memories of trauma into life lessons, get to the real root of anger, fear, create learnings from experience").

Items rated as essential or important by 80% or more of the professional and consumer/carer panels were considered to have met consensus for inclusion in the guidelines. If they were endorsed by 80% or more of one of the panels, or by 70-80% of both panels, they were re-rated in the subsequent round. Items which met neither condition were considered to have met consensus for rejection from the guidelines and were not re-rated because previous research by our group has shown that major changes in ratings do not occur in the next round. Before the second and third rounds of the study, each participant was sent a summary of the results of the previous round, listing which items had been accepted, which had been rejected, and which were to be re-rated. It is important to note that only items that approached consensus for the criterion for inclusion were submitted for re-rating by the panels. When an item was to be re-rated by the panellists, they were provided with their own response and a table outlining how many people in each group had endorsed the item. They were told that they did not have to change their responses when re-rating an item, but that if they wished to, they would have the opportunity to do so.

Writing the Guidelines

These statements were incorporated to make the following paragraph:

Avoid saying anything that might trivialise the person's feelings, such as "don't cry" or "calm down", or anything that might trivialise their experience, such as "you should just be glad you're alive."

When the guidelines were in draft form, they were sent to all the panel members for feedback. Only feedback related to readability and structure was sought and incorporated, and these amounted to only minor typographical changes. The guidelines are appended to this article and can be freely distributed (see additional files 1 and 2).

The guidelines as a whole contain three major sections. The first section includes actions that should be taken immediately after an event has occurred, particularly where there has been threatened or actual loss of life or injury. They follow a simple pattern: ensure your own safety first, look after any physical injuries, get emergency assistance if it is not there already, and be clear and calm in your communications. The second section is about assisting in the weeks following the traumatic event. This section includes advice about positive coping strategies (such as encouraging the person to use existing support networks and community resources and avoiding the use of negative coping strategies such as alcohol and other drugs). These two domains of first aid are appropriate to provide for anyone who has experienced a traumatic event. Most people will recover normally from a traumatic event after a given period of time. The third section differentiates between people who are recovering normally and those who are in need of professional assistance, and includes advice about the signs that professional help may be needed (such as intrusive thoughts, difficulty sleeping and nightmares for four weeks or more after the event).

The advice amounts to providing positive social support to those who have experienced a traumatic event and referral to professional helpers for those with lingering symptoms, both of which reflect what is currently known about decreasing the risk of long term mental health consequences of traumatic events.

Limitations

There are a number of limitations in membership of the panels. The panels were not sampled from a defined population list, so the response rate and representativeness are impossible to determine. Furthermore, the size of the panels was small, particularly the carers' panel. It may be that some carers were not present at the time of the traumatic event, or may not feel that they have any expertise, since the event was an isolated incident. Some of the consumers reported that their loved ones were not aware of the traumatic event they had experienced, only of the resulting mental health problems. The professionals' panel was not large, either, but it was very diverse, including respondents with a broad range of professional backgrounds, training, and country of origin.

There was significant attrition after Round 1. Most of the accepted items (40 out of 65, or 62% in the adult study and 55 out of 71, or 77% in the child study) were endorsed in the first round. The attrition rate may have influenced the outcome of some of the marginal items in rounds 2 and 3.

In addition, it is important to note that consensus does not mean validity. Although the feedback from the panel members indicated that the guidelines are considered to be suitable in general, and they do fit with existing knowledge about post-trauma assistance, future research may refine and improve them. The ultimate test of their validity of the guidelines as a whole would be their ability to reduce risk for the development of mental disorders when evaluated in a controlled trial.

All panellists were recruited from developed English-speaking countries, so it is not expected that the guidelines will necessarily be generalisable to other countries or to minority cultures within those countries.

These guidelines are not a comprehensive guide to providing support, as they address only actions which may be useful after a traumatic event. The trauma may have ongoing effects regardless of intervention or the person may show few long term effects and recover quickly. First aid givers may find it useful to use these guidelines in conjunction with the other guidelines in this series, including first aid for depression, first aid for suicidal thoughts and behaviours, and first aid for non-suicidal self-injury [19–25]. These other guidelines can be downloaded from the Mental Health First Aid website [32].

These guidelines may not be suitable for use with people of all cultures. Guidelines have been developed for assisting Australian Aboriginal people who have experienced trauma and loss [33].