Psychological first aid
during Ebola virus disease outbreaks
Provisional version
As knowledge on Ebola-related safety measures accumulates, thisguidance is provisional. Do not upload this document on the internet
but rather create a link to http://tinyurl.com/PFA-Eb, which links
to the latest version of this document on the WHO website.

Psychological first aid during Ebola virus disease outbreaks

I

WHO Library Cataloguing-in-Publication Data
Psychological first aid during Ebola virus disease outbreaks.
1.Crisis Intervention - methods. 2.Disease Outbreaks. 3.Haemorrhagic Fever, Ebola - psychology.
4.Adaptation, Psychological. 5.First Aid - psychology. 6.Stress Disorders, Traumatic - psychology.
I.World Health Organization.
ISBN 978 92 4 154884 7			

(NLM classification: WM 401)

© World Health Organization 2014
All rights reserved. Publications of the World Health Organization are available on the WHO website (www.
who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27,
Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int).
Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial
distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). All reasonable precautions have been taken by the World HealthOrganization to verify the information contained in this publication. However, the published material is being
distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the World Health Organization be liable fordamages arising from its use.
This document is an adaptation of the Psychological first aid: Guide for field workers (World HealthOrganization, War Trauma Foundation, World Vision International, 2011) to include relevant information to
respond to Ebola virus disease outbreaks.
The adaptation was developed by Carmen Valle (CBM) with technical support from Leslie Snider (consultant)
and Sarah Watts (WHO).
Review and finalization of the document was coordinated by Mark van Ommeren (WHO) under guidancefrom Sylvie Briand (WHO) and Shekhar Saxena (WHO).
This document was reviewed by Yolanda Bayugo (WHO), Margriet Blaauw (IASC Reference Group on
Mental Health and Psychosocial Support), Georgina Campbell (University of Makeni), Eliza Cheung (IFRC),
Julian Eaton (CBM), Margaux Mathis (WHO), Thomas Moran (WHO), Carol Nader (WHO), Rafael Obregon(UNICEF), Alison Schafer (WVI), Nahoko Shindo (WHO), Saudamini Siegrist (UNICEF), Pat Omidian (WHO),
Meg Riggs (WHO), Emmanuel Streel (consultant), and Saji Thomas (UNICEF).
Suggested citation: World Health Organization, CBM, World Vision International & UNICEF. Psychological firstaid during Ebola virus disease outbreaks (provisional version). WHO, Geneva, September 2014.
For communication and feedback, please email vanommerenm@who.int, enablingaccessmhs@gmail.com,
alison.schafer@worldvision.com.au or sthomas@unicef.org
Photo Credits
Cover page, pages 20 and 46: Tamsin Evans, CBM. Reprinted with permission.
Photos on pages 4, 12 and 24: World Vision International. Reprinted with permission.

II

Psychological first aid during Ebola virus disease outbreaks

1

pfa guide

Psychological first aid
during Ebola virus disease outbreaks

foreword
Ebola virus disease outbreaks have a significant impact on the wellbeing of thoseaffected, their family, community members and the health workers treating people with
Ebola.
This guide focuses on psychological first aid, which involves humane, supportiveand practical help to fellow human beings suffering serious crisis events. It is written forpeople who can help others experiencing an extremely distressing event.
This guide is an adaptation of the Psychological first aid: Guide for field workers (World
Health Organization, War Trauma Foundation, World Vision International, 2011). It has
been adapted to better respond to the challenges of Ebola virus disease outbreaks. Ebola
poses specific problems for affected people (e.g., stigmatization, isolation, fear, andpossible abandonment), their caregivers and responders (e.g., safety, access to updated
information).
Psychological first aid has been recommended by many expert groups, including theInter-Agency Standing Committee (IASC) and the Sphere Project. In 2009, the World
Health Organization’s (WHO) mental health Gap Action Programme (mhGAP) Guideline
Development Group evaluated the evidence for psychological first aid and psychologicaldebriefing. It concluded that psychological first aid, rather than psychological debriefing,should be offered to people in severe distress following recent exposure to a traumatic
event.
Endorsed by many international agencies, the original Psychological First Aid Guidereflects the emerging science and international consensus on how to support people in
the immediate aftermath of extremely stressful events.

2

Psychological first aid during Ebola virus disease outbreaks

foreword & CONTENTS

Contents
Introduction Understanding Ebola Virus Disease

4

Chapter 1 UNDERSTANDING PSYCHOLOGICAL FIRST AID	

12

1.1

How do crisis events affect people?

13

1.2

What is Psychological First Aid?

14

1.3

Psychological First Aid: who, when and where?

15

Chapter 2 how to help responsibly	

20

2.1

Respect safety, dignity and rights

21

2.2

Be aware of other available emergency response measures

23

2.3

Look after yourself

23

Chapter 3 PROVIDING PSYCHOLOGICAL FIRST AID

24

3.1

Good communication with people in distress

25

3.2

Preparing to help

27

3.3

The Action Principles of PFA: Look, Listen and Link!

28

3.4

People who likely need special attention

40

Chapter 4 CARING FOR YOURSELF AND YOUR COLLEAGUES	

46

4.1

Getting ready to help

47

4.2

Managing stress: Healthy work and life habits

48

4.3

Rest and reflection

49

OFFERING PSYCHOLOGICAL FIRST AID TO GRIEVING PEOPLE	

50

RELAXATION AND BREATHING EXERCISES	

52

CONTACT LIST OF MENTAL HEALTH AND PSYCHOSOCIALRESOURCES IN YOUR AREA

54

Local Alternative Rituals for Safe Mourning
after the Death of a Person with Ebola

55

PSYCHOLOGICAL FIRST AID: POCKET GUIDE	56

Contact List of Ebola Disease Outbreak Services
in Your Areaback cover

Psychological first aid during Ebola virus disease outbreaks

3

INTRODUCTION

UNDERSTANDING EBOLAVIRUS DISEASE

4

Psychological first aid during Ebola virus disease outbreaks

In this chapter we discuss:

INTRODUCTION

A	What is Ebola virus disease?
B	How does it spread?
C	How can it be prevented?

A WHAT IS EBOLA VIRUS DISEASE?
Ebola virus disease is a severe, infectious disease that can be fatal (the case fatality rateof the 2014 outbreak in West Africa is about 50%). However, health care substantially
increases a person’s chance of survival.
Appropriate infection prevention and control measures in treatment centres andhospitals, at community gatherings, during burial ceremonies and at home can help
reduce the spread of the disease. You can protect yourself, your family and yourcommunity by following the advice on these measures below.

Who is at risk of Ebola virus disease?
A person is at risk if they have:»»»»spent time with someone sick with Ebola or;attended a funeral of someone who has recently died with symptoms of Ebola.

Psychological first aid during Ebola virus disease outbreaks

5

Signs, symptoms and course of illness
Ebola starts suddenly with a high fever. A person with Ebola feels very
tired, has a headache and aches in the body, and does not want to eat. The
time from infection with the virus to the onset of symptoms is 2 to 21 days.

The person with the Ebola virus can infect others as soon as they begin to havesymptoms.
Early-stage Ebola disease may be confused with other infectious diseases (e.g., malaria)
because the initial symptoms are nonspecific. These symptoms include a high fever andextreme tiredness, often accompanied by appetite loss, headache, and body pain.
As the disease progresses, people begin to experience vomiting and diarrhoea.
Blood in vomit or stool is seen among severely ill patients, mostly in later stages, and isoften followed by death within days.
In non-fatal cases, the person may improve around days 6-11 and will no longer be
infectious.

6

Psychological first aid during Ebola virus disease outbreaks

INTRODUCTION

Advice for individuals and families
in Ebola-affected areas
What should I do?
CALL FOR HELP IMMEDIATELY
Early treatment increases the chance of survival for the person, andprevents the spread of disease to others.
»»

»»

»»

If you suspect a family member or someone in the community of having Ebola,encourage and support them in seeking appropriate medical attention in an
Ebola Treatment Centre.
If they cannot go to the treatment centre, hospital or health post for any
reason, you should speak with your local community leader immediately orcall the Ebola Hotline for help. Health care workers or anyone who transports
sick people to treatment centres should use personal protective equipment
and observe infection prevention and control measures. Personal protective
equipment includes heavy clothing, gloves, goggles and masks.
If someone in your community has recovered from Ebola, ask this person to
help. As far as is known, once a person has recovered from Ebola, they have
immunity against the virus.

Psychological first aid during Ebola virus disease outbreaks

7

While you are waiting for help you should:
PROTECT YOUR FAMILY
»»

»»
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»»

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8

Provide the sick person with their own space, separate from the rest of thefamily. Provide them with their own plate, cup, cutlery (e.g., spoon, fork),
toothbrush, etc. No item should be shared with others.
Only one family or community member should care for the sick person.
Others should not come into contact with them.
Avoid touching the sick person. All body fluids including stool, vomit,
blood, breast milk, sperm, urine and sweat are dangerous and must not betouched. If you need to touch, you must wear gloves. Make sure the gloves
have no holes. You can get gloves from community helpers and health posts
or from a shop. Put soiled (dirty) clothes, towels and bed linen in a plastic
bag and incinerate (burn them).
A person with Ebola is best cared for in a hospital or Ebola treatment centre.
However, if you provide extended care for a person with Ebola in your home
you will need personal protective equipment. Ask your local health post to
provide this. WHO does not recommend caring for a person with Ebola athome.
Wash hands with soap and water or rub hands with an alcohol-based handsanitizer (community workers may be able to provide this):»» after touching the sick person or anything that belongs to the person;»» after touching a used toilet;»» after touching any blood or body fluids (e.g., faeces, vomit);»» after touching anything that could be contaminated with body fluids,
even if you wore gloves; and»» after removing gloves.

Psychological first aid during Ebola virus disease outbreaks

CARE FOR THE SICK»»INTRODUCTION»»

Provide plenty of drinks for the sick person such as water, soup, tea or locallyavailable beverages. If possible, encourage the sick person to feed little by little,“spoon by spoon”.
Give paracetamol to the person, if they are suffering from fever and pain. Do notgive aspirin or any other pain killer.

DANGER SIGNS
If the patient vomits, has diarrhoea or starts to bleed, they must be transported to a
hospital immediately. These are the danger signs. The patient can infect others andis at risk of dying.
The patient should be moved only by health workers who have personal protective
equipment under the guidance of local authorities.

Psychological first aid during Ebola virus disease outbreaks

9

B 	HOW DOES EBOLA VIRUS DISEASE SPREAD
	AND HOW CAN IT BE PREVENTED?
Unlike infections such as influenza or tuberculosis, Ebola is not airborne. It can be spread
only by direct contact with the body fluids or tissues of a person who is sick with thedisease or who has died, or by contact with anything the sick or dead person has used or
touched, such as soiled (dirty) linen and clothing.
Ebola is spread through:
»»

»»
»»
»»
»»

direct contact with an affected person’s wounds, tissues, and body fluids like stool,
vomit, blood, breast milk, sperm, urine and sweat. These are dangerous and mustnot be touched;contact with an infected person’s soiled (dirty) clothing or bed linen;
unsterilized injections;skin piercing instruments (e.g., syringes or needles) that have been used by aninfected person;
direct physical handling of persons who have died of Ebola.

Since Ebola spreads through direct contact with an infected person, those living with andcaring for a person with Ebola are at high risk of infection. Personal protective equipment
should be used when caring for a patient at home. Appropriate infection prevention andcontrol measures are crucial to reduce the risk of infection.
People with symptoms should avoid all physical contact with others.

10

Psychological first aid during Ebola virus disease outbreaks

»»

»»
»»

INTRODUCTION

Protect yourself after someone has died of Ebola: avoid direct contact andimplement protective measures
People who have died of Ebola are still infectious, and people in direct contact
with their bodies are at risk. Do not touch or move the body of someone who
has died of Ebola. Dead bodies should be handled only by people appropriately
trained and wearing personal protective equipment.
During funerals and burial rituals, do not touch the bodies of the deceased. See
page 55 for ideas about how to safely mourn and honour the deceased person.
Wear gloves when touching a dead person’s soiled clothes, towels and bed linen,
and put them in a plastic bag and incinerate (burn them). It will prevent you fromgetting infected.

Information for those who have fully recovered from Ebola
Health care providers should closely monitor people recovering from Ebola, ideally using
laboratory tests, to be sure that the virus is no longer in the person’s system. Keep in mind
the following information about people who have recovered from Ebola:
»»
»»
»»
»»
»»

As far as is known, the person has immunity against Ebola disease.
The person can no longer infect others.
The person can help the community by taking care of sick people.
Men who recover from Ebola should wear a condom during sexual contact for atleast 3 months after recovery – Ebola is present in the semen up to this time.
Before breastfeeding, the breast milk of women who have recovered from Ebola
should be laboratory tested.

Psychological first aid during Ebola virus disease outbreaks

11

chapter 1

UNDERSTANDING
PSYCHOLOGICAL FIRST AID

12

Psychological first aid during Ebola virus disease outbreaks

In this chapter we discuss:
1.1	HOW DO CRISIS EVENTS AFFECT PEOPLE?
1.2	What is Psychological First Aid?
1.3	PFA: WHO, WHEN AND WHERE?

1.1 	HOW DO CRISIS EVENTS AFFECT PEOPLE?

Although these events affect everyone in some way, people can experience a wide rangeof reactions. They can feel overwhelmed, confused or very uncertain about what ishappening. 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, howsomeone reacts depends on many factors, including:
»»
»»
»»
»»
»»
»»
»»

the nature and severity of the event;their experience with previous distressing events;
the support they have in their life from others;
their physical health;their personal and family history of mental health problems;
their cultural background and traditions;
their age (for example, children of different age groups react differently).

It is also important to remember that Ebola influences how we normally provide support
to each other (e.g., by not being able to touch people) and how we cope with the death of
our loved ones (e.g., by not being able to engage in traditional burials). This can severely
worsen people’s distress.

Psychological first aid during Ebola virus disease outbreaks

13

Chapter 1

Communities can be severely affected by Ebola disease in many ways. People are
separated from their loved ones, due to illness or death. Health workers need to deal witha high workload and a lot of stress. Those associated with Ebola can be vulnerable tosocial stigma, worsening their distress and isolation. Ultimately, whole communities may
experience the fear and suffering that disease outbreaks often cause.

Every person has strengths and abilities to help them cope with life’s challenges.
However, some people are particularly vulnerable in a crisis situation and may needextra help. This includes people who may be at risk of being infected, such as those
who have been in contact with someone sick with symptoms of Ebola (e.g., health careproviders) or people who have attended the funeral of someone who has recently died ofEbola (e.g., relatives of people with Ebola). Other vulnerable people may include those
who need additional support because of their age (children and the elderly), because
they have a mental or physical disability, or because they belong to marginalized groups(including migrants). Children whose parents died of the disease, and Ebola survivors,
may be stigmatised and rejected by their communities. Therefore, they may not receive
the support they need.
See section 3.4 for guidance in helping vulnerable people.

1.2 	WHAT IS 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 needsupport. PFA involves:
»»
»»
»»
»»
»»
»»

»»

14

providing non-intrusive, practical care and support;
assessing needs and concerns;
helping people to address basic needs (food and water, information);
listening to people, but not pressuring them to talk;
comforting people and helping them to feel calm;
helping people connect to information, services and social supports;»» In the case of Ebola disease, information is vital: those providing PFA can help
to dispel myths, share clear messages about healthy behaviour and improve
people’s understanding of the disease;protecting people from further harm (see also section 3.4 on people who likely
need special attention).

Psychological first aid during Ebola virus disease outbreaks

It is also important to understand what PFA is not:
»»
»»
»»
»»
»»

Overall, PFA involves helping people to:
»»
»»
»»

1

feel safe, connected to others, calm and hopeful;have access to social, physical and emotional support; andfeel able to help themselves, as individuals and communities.

WHO (2010) and Sphere (2011) describe psychological debriefing as promoting ventilation by asking a person tobriefly but systematically recount their perceptions, thoughts and emotional reactions during a recent stressful event.
This intervention is not recommended. This is distinct from routine operational debriefing of aid workers used by someorganizations at the end of a mission or work task.

Psychological first aid during Ebola virus disease outbreaks

15

Chapter 1

It is not something that only professionals can do.
It is not professional counselling.
It does not necessarily involve a detailed discussion of the event that caused the
distress (as in “psychological debriefing”1).
It is not asking someone to analyse what happened to them or to put time andevents in order.
It is not about pressuring people to tell you their feelings and reactions to an event,but rather being available to listen to people.

1.3 PSYCHOLOGICAL FIRST AID: WHO, WHEN
	AND WHERE?
Who can benefit from PFA?
PFA is for distressed people recently exposed to a crisis event. You can help bothchildren and adults, although not everyone who experiences a crisis event will need orwant PFA. Do not force help onto people, but make yourself easily available to those
who may want support.
People who may benefit from PFA during an Ebola outbreak include distressed healthcare providers treating people with Ebola, members of the community feeling anxious
about infection, or people experiencing distress even though they have received
confirmation that they do not have Ebola.
However, there may be situations when someone needs much more advanced mental
health support. When providing PFA during a disease outbreak, it is especially important
to help people who have been exposed to the disease and/or have symptoms to access
immediate medical attention. Know your limits and get help from others, such as healthpersonnel (including, where relevant and available, mental health nurses and cliniciansin district hospitals), your colleagues, local authorities, or community and religious
leaders.

16

Psychological first aid during Ebola virus disease outbreaks

People who need more than PFA in terms of mental health support include:
»»
»»
»»

people who are so upset that they cannot care for themselves or their children;
people at risk of hurting themselves;people at risk of hurting others.

»»
»»
»»

people who have recovered from Ebola;
health care providers treating people with Ebola;
frontline workers of Ebola operations (e.g., people involved in dead bodymanagement).

Psychological first aid during Ebola virus disease outbreaks

17

Chapter 1

You may also encounter people suffering in other ways as a consequence of the Ebola
disease outbreak. You can offer PFA and determine if they may need further specialized
support. 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:

When is PFA provided?
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 usuallyduring 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.
During the Ebola outbreak, for example, PFA can be offered:
»»
»»

»»
»»
»»

»»

18

during contact tracing of people who have had contact with a person with Ebola;when delivering survival and hygiene kits to people who recovered but whose
properties (e.g., clothing and bedding) were destroyed during disinfection of theirhome;when supporting a health care provider experiencing distress after a long shift at aclinic;when supporting a family or community that has lost someone to Ebola and issuffering because their loved one cannot be buried according to tradition;
when supporting a child whose parents are in hospital, and who may be feelingconfused and sad (see section 3.4 for further advice on supporting separated
children and adolescents);
when helping members of the community share their frustrations about travel
restrictions.

Psychological first aid during Ebola virus disease outbreaks

Where is PFA provided?
You can offer PFA wherever it is safe enough to do so. This is often in»»»»community settings;
places where distressed people are assisted, such as health centres, shelters or
camps, and schools.

When providing PFA, it is essential to respect a person’s confidentiality and dignity.
Ideally, try to provide PFA where you can have some privacy to talk with the person,
when appropriate and possible, while still adhering to safety precautions. This isimportant not only for confidentiality, but also to avoid the spread of panic or rumours in
the community.
However, during disease outbreaks, there are limits to confidentiality because of theimportance of stopping the spread of the disease. Explain to the person that personalmatters shared with you will be kept confidential, but you are required to report to healthsurveillance teams if the person may have been exposed to Ebola and/or has symptomsof the disease. Also, some families do not want to give up the body of a loved one who
has died at home to health teams for burial. They may not understand the serious risk ofinfection for others in the house.
Be gentle as you talk with people and acknowledge their fears or concerns. Explain
in ways they can understand the importance of informing the authorities of suspectedcases of Ebola – to promote the health and safety of the person, their family and theircommunity. You can tell them that:
»»
»»
»»
»»

early detection and supportive treatments improve the chance of survival;
going to hospital to find out their disease status can help protect their family andthe community from infection;
there is a high risk of infection for anyone in the house who comes in contact witha dead person’s body;there may be support measures available from the government to help people
recovering from the illness (e.g., government assistance and material items andservices given when a person is discharged from hospital).

Psychological first aid during Ebola virus disease outbreaks

19

Chapter 1

In the case of an Ebola (or other contagious disease) outbreak, safety from exposure to
the disease is the most important consideration in where to offer PFA – for yourself, theperson and others. This means taking all relevant precautions to prevent infection, andensuring that the appropriate medical care is offered immediately to people who havesymptoms.

Chapter 2

HOW TO HELP RESPONSIBLY

20

Psychological first aid during Ebola virus disease outbreaks

Helping responsibly involves three main points:
2.1	RESPECT SAFETY, DIGNITY AND RIGHTS
2.2	BE AWARE OF OTHER EMERGENCY RESPONSE MEASURES
2.3	Look after yourself

2.1 	Respect Safety, Dignity and Rights
When you take on the responsibility of helping people affected by a distressing event, it isimportant to respect their safety, dignity and rights. The following principles apply to any
person or agency involved in a humanitarian response, including those providing PFA
during disease outbreaks.

Safety:»»»»Avoid putting people at further risk of harm as a result of your actions.
»» For example, avoid putting them at risk of infection by taking all necessary
safety precautions.
Make sure, to the best of your ability, that the adults and children you help are safeand protect them from physical or psychological harm.
»» For example, many Ebola survivors are discriminated against. Do not expose
them to further stigma. Instead, encourage them to think about how they canhelp others if they can and are willing, by perhaps taking care of sick relatives.

Dignity»»

Treat all people with respect. The situation in areas affected by the Ebola disease
outbreak will be challenging for everybody. Fear, grief and tension are likely toincrease in the community. In these difficult moments, more than ever, it is essential
to treat everybody with respect and contribute to an atmosphere of dignity for all.
»» For example, helpers involved in dead body management must treat thedeceased person with dignity during the burial and ensure respect for theirsurviving family members.

Psychological first aid during Ebola virus disease outbreaks

21

Chapter 2

Respect People’s:Rights»»»»»»

Make sure people can access help fairly and without discrimination.
Help people to claim their rights and access available support.
Act only in the best interest of any person you encounter.

Keep these principles in mind in all of your actions and with all people you encounter,
whatever their age, gender or ethnic background. Consider how you would like to betreated in that situation, and treat people in the same way.

»»

Be honest and trustworthy.

»»»»

Respect people’s right tomake their own well-informed
decisions.

»»»»

Be aware of and set aside yourown biases and prejudices.

»»»»

Make it clear to people thateven if they refuse help now,
they can still access help in
the future.

»»
»»

»»

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22

Respect privacy and keep
personal details of the person’s
story confidential, if this isappropriate.
Behave appropriately byconsidering the person’s
culture, age and gender.

»»
»»
»»

Don’t exploit your relationshipas a helper.
Don’t ask the person for any
money or favour for helping.
Don’t make false promises orgive false information.
Don’t exaggerate your skills.
Don’t force help on people, anddon’t be intrusive or pushy.
Don’t pressure people to tell you
their story.
Don’t share personal details of
the person’s story with others.
Don’t judge the person for theiractions or feelings.

Psychological first aid during Ebola virus disease outbreaks

2.2 	BE AWARE OF OTHER AVAILABLE 				EMERGENCY RESPONSE MEASURESAn important part of offering PFA is to ensure that people have access to the correct
information about Ebola, including what services and supports are available, and how toprotect themselves. This also involves dispelling the many myths that often arise during
frightening disease outbreaks.
Therefore, when offering PFA, it is essential to be aware of what other agencies are doing,
and where and how people who may have the disease should seek help (e.g., know thecontact information for key service providers). It is also important to know and share
information about who is responsible for child protection, case management, food
distribution and health care for people requiring treatment for illnesses other than Ebola.

Chapter 2

2.3 	Look after yourself
Helping responsibly means looking after your own physical and mental wellbeing.
As a helper, you may also be affected by the Ebola outbreak or may have family, friends
and colleagues who are affected. It is essential to pay extra attention to your own
wellbeing and be sure that you are physically and emotionally able to help others. Takecare of yourself first, so that you can best care for others. If working in a team, also beaware of the wellbeing of your fellow helpers, and find ways to support each other.


As a helper, if you begin to exhibit any symptoms of the disease,
do not go to work, as you will risk spreading the disease to co-workers
and the people you are trying to help. Immediately inform your agency,
seek medical care and take all necessary safety precautions to prevent
infecting others.

See Chapter 4 for more information on looking after yourself and your colleagues.

Psychological first aid during Ebola virus disease outbreaks

23

Chapter 3

PROVIDING PSYCHOLOGICALFIRST AID

24

Psychological first aid during Ebola virus disease outbreaks

In providing PFA, consider the following:
3.1	Good Communication with people in distress
3.2	Preparing to help
3.3	PFA action principles: Look, Listen and Link!
3.4	Helping people who are likely to need special attention

3.1 	GOOD COMMUNICATION WITH PEOPLE
	IN DISTRESS
The way you communicate with someone in distress is very important. People who havebeen through a crisis event may be very upset, anxious or confused. Some people may
blame themselves for things that happened and others may be angry, especially if they
are grieving.
Being calm and showing understanding can help people in distress feel more safe andsecure, understood, respected and cared for appropriately.
Someone who has been through a distressing event may want to tell you their story.
Listening to someone’s story can be a great support.

Don’t talk too much. Keeping silent for a while may give the person space andencourage them to share with you if they wish.
To communicate well, be aware of both your words and body language, such as facial
expressions, eye contact, gestures, and the way you sit or stand in relation to the otherperson. Speak and behave in ways that take into account the person’s culture, age,gender, customs and religion.
Culture determines how we relate to people, and what is all right and not all right tosay and do. For example, some people may not be used to sharing their feelings withsomeone outside of their family, or it may be appropriate for women to speak only withother women. You may be helping people from a different cultural background, or from aminority group, or someone who may be marginalized. As a helper, it is important toPsychological first aid during Ebola virus disease outbreaks

25

Chapter 3

However, it is important not to pressure anyone to tell you what they have been through.
Some people may not want to speak about what has happened or their circumstances.
Nevertheless, they may value having you stay with them quietly, knowing you are there if
they want to talk, or being offered practical support like a meal or a glass of water.

be aware of your own cultural background and beliefs, so you can set aside yourbiases. Offer help in ways that are most appropriate and comfortable to the people you
are supporting.
Below are suggestions for things to say and do, and what not to say and do. Most
importantly, be yourself, be genuine and be sincere in offering your help and care.

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»»

26

Try to find a quiet place to talk, andminimize outside distractions.
Respect privacy and keep
personal details of the person’s
story confidential, if this isappropriate.
Keep an appropriate distance fromthe person, depending on their age,gender and culture.
Let them know you are listening;for example, nod your head or say“hmmmm….”
Be patient and calm.
Provide factual information, if you
have it. Be honest about what you
know and don’t know. “I don’tknow, but I will try to find out
about that for you.”
Give information in a way that any
person can understand – keep
it simple.
Acknowledge how they are feelingand any losses or important events
they tell you about, such as the lossof their loved ones. “I’m so sorry. I
can imagine this is very sad for you.”
Acknowledge the person’s
strengths and how they havehelped themselves.
Allow for silence.

»»

»»

»»

»»
»»
»»
»»
»»
»»

»»

»»

Don’t pressure someone to telltheir story (for example, don’t
look at your watch or speak too
rapidly).
Don’t touch the person and/or theirbody fluids, given the infectious
nature of Ebola disease.
Don’t judge what they have or
haven’t done, or how they are
feeling. Don’t say: “You shouldn’t
feel that way,” or “You should feel
lucky you survived.”
Don’t make up things you
don’t know.
Don’t use terms that are too
technical.
Don’t tell them someone else’s story.
Don’t talk about your own troubles.
Don’t give false promises orfalse reassurances.
Don’t think and act as if you
must solve all the person’s
problems for them.
Don’t take away the person’s
strength and sense of being able
to care for themselves.
Don’t talk about people in negative
terms (for example, don’t call them“crazy” or “mad”).

Psychological first aid during Ebola virus disease outbreaks

3.2 	Preparing to help
Learn about Ebola disease from reliable resources – how it is transmitted, why it is so
dangerous and the risks, signs and symptoms. (See Introduction)
Know what other agencies in the area are doing and where people can go to obtain more
information about Ebola, or to talk to someone. Be aware of the procedures for referring
people for immediate medical attention, and where and how people can access othersupport services.
For people who extra need help in coping emotionally and socially with the situation,know the contact information for relevant mental health and psychosocial resourcesin your area (see CONTACT LIST OF MENTAL HEALTH AND PSYCHOSOCIALRESOURCES IN YOUR AREA, page 54).

Chapter 3

Psychological first aid during Ebola virus disease outbreaks

27

3.3 	The Action Principles of PFA:
	Look, Listen and Link!

Look

»»
»»
»»

Check for safety.
Check for people with obvious urgent basic needs.
Check for people with serious distress reactions.

Listen»»»»»»Approach people who may need support.
Ask about people’s needs and concerns.
Listen to people, and help them to feel calm.

Link

»»
»»
»»
»»

Help people address basic needs and access services.
Help people cope with problems.
Give information.
Connect people with loved ones and social support.

Look

»»
»»
»»

Check for safety.
Check for people with obvious urgent basic needs.
Check for people with serious distress reactions.

Take time - even a few moments - to “look” around you before offering help. These
moments will give you a chance to be calm, be safe and think before you act. See thefollowing table for questions to consider and important messages as you “look”
around you.

28

Psychological first aid during Ebola virus disease outbreaks

Look
Safety»»»»People with »»obviousurgentbasic needs »»»»Peopleinserious
distress»»»»

Important message

What dangers
can you see in theenvironment?
Can you be there
without likely harm to
yourself or others?

If you are not certain about thehealth condition of the person you
are talking to, take all necessary
safety precautions to protect
yourself and others from
infection.
Do not make physical contact withthe person or their body fluids
or tissues, or other potentiallycontaminated objects such as theirclothing or bedding.
Let the person know that you are
physically healthy at present andthat it is important for you to takeprecautions to prevent infection.

Does anyone appear
to have symptoms ofEbola?
Who is most at risk inyour area?
Does anybody haveobvious urgent
basic needs, such as
clothing or food?
Who may need help
to be protected fromdiscrimination andviolence?

Know your role and try to gethelp for people who need special
assistance, such as those withobvious urgent basic needs. If theperson has been exposed to thedisease and/or has symptoms,
encourage them to go to a treatment
centre, local health post or Ebola
Care Centre. If they cannot go to ahealth facility, immediately speakwith your community leader or seek
help from appropriately trained
health care workers.

Are there people who
appear extremely
upset, in shock, notable to move on
their own, or are notresponding to others?
Where and who are
the most distressedpeople?

Consider who may benefit from PFA
and how you can best help.

Psychological first aid during Ebola virus disease outbreaks

Chapter 3»»

Questions29People may react in various ways to a crisis event. Examples of psychological distressresponses include:
»»

»»
»»
»»
»»
»»
»»
»»
»»
»»
»»
»»
»»

physical symptoms (shaking, headaches, tiredness, loss of appetite, aches andpains that have a non-medical basis). If there is no fever, these symptoms do notindicate Ebola;
crying, sadness, depression and grief;
anxiety and fear;
being “on guard” or “jumpy”;
worrying that something bad is going to happen;
insomnia and nightmares;
irritability and anger;
guilt and shame (for surviving, infecting others, or for not being able to help orsave others);
confusion, emotional numbness, or feeling unreal or in a daze;appearing withdrawn or very still (not moving);
not responding to others, or not speaking at all;disorientation (not knowing their own name, where they are from, or what
happened);
not being able to care for themselves or their children (not eating or drinking, notable to make simple decisions).

Some people may be only mildly distressed or not distressed at all.
Most people will recover emotionally over time, especially if they receive support fromothers and help in meeting their basic needs. However, people with severe and/or
long-lasting distress may need more support than PFA, particularly if they cannot
function in their daily life or if they are a danger to themselves or others. Ensure thatseverely distressed people are not left alone and try to keep them safe until you cancontact the relevant mental health and psychosocial support resources in your area(see CONTACT LIST OF MENTAL HEALTH AND PSYCHOSOCIAL RESOURCES IN
YOUR AREA, page 54).

Vulnerable People
Remember to look for children, people with other health conditions or physicaland mental disabilities, and people at risk of discrimination, as they are likely toneed special attention for their care and safety.

30

Psychological first aid during Ebola virus disease outbreaks

Listen»»»»»»Approach people who may need support.
Ask about people’s needs and concerns.
Listen to people, and help them to feel calm.

Listening carefully to a person you are helping is essential to understand their situationand needs, to help them feel calm, and to offer them appropriate help. Learn to listenwith your:
»»
»»
»»

Eyes ›› giving the person your undivided attention;
Ears ›› truly hearing their concerns;
Heart ›› with care and showing respect.

Even if you must communicate from a distance because of safety precautions, you canstill give the person your full attention and show that you are listening with care.

1. Approach people who may need support:

»»
»»
»»
»»

Approach people respectfully, keeping a safe distance.
Introduce yourself by name and organization.
Explain that while you can’t touch them, you can listen and care about
how they are feeling. Ask the person how he/she is feeling and coping with thesituation, and if you can provide help.
Be sure to ask about the person’s physical condition, and let them know that you
are physically healthy at present.
If possible, find a safe and quiet place to talk.
Ensure that the person is not putting others at risk of infection.
If the person is very distressed, try to ensure they are not alone until further help
can be found.

Psychological first aid during Ebola virus disease outbreaks

Chapter 3

»»
»»
»»

31

2. Ask about people’s needs and concerns:
»»

»»
»»

Although some needs may be obvious, such as some rest for a nurse who has beenworking long hours in the treatment centre, always ask what people need andwhat their concerns are.
Find out what is most important to them at this moment, and help them work out
what their priorities are.
Ask whether they need anything that can be provided to them from a safe distance(e.g., fresh water, food, clean clothes or bedding).

3. Listen to people and help them to feel calm:
»»
»»
»»
»»

32

Do not pressure the person to talk.
Listen in case they want to talk about what happened.
Offer to sing, read, or tell stories to reassure them they are not alone and ease theirfear.
If they are very distressed, help them to feel calm and try to ensure they are not left
alone.

Psychological first aid during Ebola virus disease outbreaks

Help people to feel calm
Some people in a crisis situation may be very anxious or upset. They may feel
confused or overwhelmed, and may have physical reactions such as shaking
or trembling, difficulty breathing, or feeling that their heart is pounding. The
following are some techniques to help very distressed people feel calm in theirmind and body:
»»
»»
»»
»»

Keep your tone of voice calm and soft.
Try to maintain some eye contact with the person as you talk with them.
Remind the person that you are there to help them. Remind them that they
are safe, if it is true.
If someone feels unreal or disconnected from their surroundings, it may help
them to make contact with their current environment and themselves. You
can do this by asking them to:»» Place and feel their feet on the floor.
»» Tap their fingers or hands on their lap.
»» Notice some non-distressing things in their environment, such as
things they can see, hear or feel. Have them tell you what they see andhear.
»» Encourage the person to focus on their breathing, and to breathe
slowly.

Chapter 3

Psychological first aid during Ebola virus disease outbreaks

33

Link

»»
»»
»»
»»

Help people address basic needs and access services.
Help people cope with problems.
Give information.
Connect people with loved ones and social support.

1. Help people address basic needs and access services
People affected by an Ebola disease outbreak, such as those whose property wasdestroyed during disinfection of their home, may need help in addressing basic needs
and accessing services. As you provide PFA, consider the following:
»»
»»
»»
»»

Try to help the person in distress to meet the basic needs they request, such as
food, water, shelter and information about medical and social services.
Learn what specific needs people have and try to link them to the help available(e.g., survival kits if their property was destroyed).
Ensure vulnerable and marginalized people are not overlooked (see Section 3.4).
Follow up with people if you promise to do so.

2. Help people cope with problems
A person in distress can feel overwhelmed with worries and fears. Help them to consider
their most urgent needs, and how to prioritize and address them. For example, you can
ask them to think about what they need to address now, and what can wait for later.
Being able to manage a few issues will give the person a greater sense of control andstrengthen their ability to cope.

34

Psychological first aid during Ebola virus disease outbreaks

Remember to:
»»

»»
»»
»»

help people identify supports in their life, such as friends or family, who can help
them. If they have lost many relatives and friends to Ebola, help them to think ofadditional supports, such as religious leaders or other members of the community;
give practical suggestions for people to meet their own needs;
ask the person to consider how they have coped with difficult situations in thepast, and affirm their ability to cope with the current situation;
ask the person what helps them to feel better. Encourage them to use positive
coping strategies and avoid negative coping strategies (see the following table).

CopingEveryone has natural ways of coping. Encourage people to use their own positive
coping strategies, while avoiding negative strategies. This will help them to feelstronger and to regain a sense of control. You will need to adapt the following
suggestions to take into account the person’s culture and what is possible in theparticular crisis situation.

Encourage
positive coping
strategies

»»
»»
»»

Discourage
negative coping
strategies

»»
»»
»»
»»
»»
»»

Chapter 3

»»
»»
»»
»»

Get enough rest.
Eat as regularly as possible and drink water.
Talk and spend time with family, friends or othercommunity members.
Discuss problems with someone you trust.
Do activities that help you relax (walk, sing, pray).
Do physical exercise.
Find safe ways to help others in the crisis and get
involved in community activities.
Don’t take drugs, smoke or drink alcohol.
Don’t sleep all day.
Don’t work all the time without any rest or relaxation.
Don’t isolate yourself from friends and loved ones.
Don’t neglect basic personal hygiene.
Don’t be violent.

Psychological first aid during Ebola virus disease outbreaks

35

3. Give information
People affected by the outbreak will want accurate information about:
»»

»»

»»

»»

»»

Ebola virus disease»» See facts about Ebola in the introduction.
»» Try to keep yourself informed of the latest updates on the outbreak.
Loved ones»» Try to share practical information with the relatives of patients in treatment
centres. This should be done in consultation with staff, to ensure theinformation shared is appropriate, does not breach confidentiality and does
not cause confusion by giving conflicting messages.
»» Try to find ways that family members can maintain contact with the patient.
For example, relatives could give health workers items or messages of love andencouragement to pass on to the patient.
Their safety»» Share information about how to stay safe.
»» Share information about measures the government is taking to support victims
during and after the outbreak.
Their rights and responsibilities»» This includes their rights to treatment and care, legal rights, being treated with
dignity, etc.
»» This also includes their responsibility to follow the guidance of local
authorities and health workers.
Services and supports»» This includes how to access services and other things they need.

Getting accurate information during the outbreak may be difficult. The situation may
change as information about the number of cases, areas affected, etc., becomes known
and relief measures are put in place.

36

Psychological first aid during Ebola virus disease outbreaks

Rumours may be common
The less information that is shared, the more likely it is that rumours will spread.
Sharing accurate information is the best way to stop rumours. Try to be aware of themore common rumours so that you are prepared to respond with reliable and accurate
information. Rumours may be very dangerous; for example, rumours that blame certain
people for the disease outbreak may lead to violence, or rumours about fake, harmful
treatments may lead to unnecessary deaths.
You may not have all the answers at any given moment, but wherever possible, try to get
as much information as you can before you offer people support and information. It may
be helpful to use official written information, such as posters and leaflets in the local
language, or in pictorial form for people with low literacy, to complement the information
you are giving. Try to ensure vulnerable people know about existing services and how to
obtain information (see Section 3.4).

When providing information:
»»
»»
»»
»»

Chapter 3»»

explain the source of the information and how reliable it is;say only what you know – do not make up information or give false
reassurances;
keep messages simple and accurate, and repeat the information to be surepeople hear and understand it;it may be useful to give information to groups of affected people, so thateveryone hears the same message;
let people know if you will keep them updated on new developments,
including where and when.

When giving information, be aware that the helper can become a target of the frustration
and anger people may feel, especially when their expectations of help have not been met
by you or others. In these situations, try to remain calm and be understanding.

Psychological first aid during Ebola virus disease outbreaks37

4. Connect with loved ones and social support
It has been shown that people who feel they had good social support after a crisis cope
better than those who feel they were not well supported. Because of this, linking people
with loved ones and social support is an important part of PFA.
This task may be very difficult, as many people may have lost most of their loved ones toEbola, and because of the stigma associated with the illness. Affected people can feelvery isolated. Therefore, it will be very important to help people identify who else within
their community could be of support. There may be existing groups and community
networks that can provide support.
Mental health and psychosocial workers can help those lacking social support by visitingor accompanying them. Social reintegration in the community for those who survived
Ebola or those confirmed negative for the disease is also important. This can help toreduce stigma, decrease other people’s fear of interacting with them, and to identify othersources of support if relatives are missing.

In connecting people with loved ones and social support:

38»»

Help keep families together, and keep children with their parents and loved
ones if possible, while also observing the safety measures to avoid Ebola diseasetransmission. If a child with Ebola is admitted to hospital, they should be able tohave safe and regular contact with one trusted family member.
»» Refer to the information on People who likely need special attention in
Section 3.4 regarding the specific needs of children and adolescents that havelost parents to Ebola or are being rejected in their communities.

»»

Help people to contact friends and relatives so they can get support; for example,
provide a way for them to call loved ones, including admitted patients.
»» Use phones to give psychosocial support: a phone could be madeavailable at the treatment centre for patients’ use only, so relatives can talk totheir loved ones.

Psychological first aid during Ebola virus disease outbreaks»»

If a person lets you know that prayer, religious practice or support from religious
leaders might be helpful for them, try to connect them with their spiritualcommunity, always observing safety measures.
»» Given the risk of spreading the disease in public gatherings or through directcontact, it is important to find new ways of praying together. For example,
relatives or religious leaders could pray with patients in treatment centres
through the telephone, or possibly from across the safety barrier of dedicateddisease centres, if they are permitted. Religious leaders can also help by finding
new ways to provide spiritual support and guidance that don’t involve touching
to prevent the spread of disease and to protect people by preventing the spreadof disease.

»»

Help bring affected people together to support each other. For example, ask
people to help care for the elderly or the children who have lost their carers, or linkindividuals without family to other community members.
»» See the section on Offering PFA to grieving people to help affected families
and communities who cannot engage in traditional burials (due to the riskof spreading the disease) to find new ways of mourning and honouring thedeceased.

Ending Your Help

Psychological first aid during Ebola virus disease outbreaks

39

Chapter 3

What happens next? When and how you stop providing help to someone will depend on
the situation of the Ebola disease outbreak, your role and circumstances, and the needsof the person you are helping. You may be working in the affected community for sometime, but if you are ending your assistance with someone, explain that you are leaving.
If someone else will be helping the person after you, try to introduce them. If you havelinked the person with other services, let them know what to expect and be sure they
have the details to follow up. No matter what your experience with the person, you cansay goodbye in a positive way by wishing them well.

3.4 	People who likely need special 		attention
People who may be vulnerable and need special help in a crisis include:
1. Children, including adolescents.
2. People with health conditions or disabilities.
3. People at risk of discrimination or violence.

Remember that all people have resources to cope, including those who arevulnerable. Help vulnerable people to use their own coping resources andstrategies.

1. Children, including adolescentsChildren with suspected Ebola should always be accompanied to a
hospital, local health post or designated Ebola Care Centre.
If a parent needs medical attention, consideration must be taken to
ensure any children in their care will be looked after and not left tofend for themselves.

Many children – including adolescents – are particularly vulnerable in an outbreak.
Ebola disease disrupts their familiar world, including the people, places and routines thatmake them feel secure. Many will have lost their parents and other relatives. There arereports of children being abandoned. Stigma and discrimination is isolating them fromprotection and support, and putting them at a great risk. Young children are particularly

40

Psychological first aid during Ebola virus disease outbreaks

vulnerable since they cannot meet their own basic needs or protect themselves. Girls
usually face the greatest risk of sexual violence and exploitation, and those who havebeen abused may be stigmatized and further isolated. Girls and young women can beat greater risk of exposure to Ebola disease, when they are caregivers or frontline healthstaff.
How children react to a crisis depends on their age and developmental stage. It also
depends on the ways their carers and other adults interact with them. For example, young
children may not fully understand what is happening around them, and are especially inneed of support.
Children generally cope better when they have a stable, calm adult around them.
Children and young people may experience similar distress reactions as adults (seeSection 3.3). They may also experience the following specific distress reactions:
»»

»»

»»

Young children may return to earlier behaviours (for example, bedwetting or
thumb-sucking), cling to carers, and reduce their play or use repetitive play related
to the distressing event.
School-age children may believe they caused bad things to happen, develop newfears, become less affectionate, feel alone and be preoccupied with protecting or
rescuing people in the crisis.
Adolescents may feel “nothing”, feel different or isolated from their friends, or
display risk-taking behaviour and negative attitudes.

An important first step is to reunite separated children – including adolescents – with
their families or carers. If this is not possible (e.g., family or carers are deceased), try tolink them immediately with a trustworthy child protection agency (governmental or nongovernmental) that can begin the process of registering the child and ensuring they arecared for. The agency may be able to reunite them with relatives in other areas, or withother trusted members of the community that they know, such as neighbours or distantrelatives.
It is very important not to do this on your own, but rather to work through childprotection agencies. If you make mistakes, it will make the child’s situation worse(see CONTACT LIST OF EBOLA DISEASE OUTBREAK SERVICES IN YOUR AREA,
back cover).

Psychological first aid during Ebola virus disease outbreaks

41

Chapter 3

Family and other caregivers are important sources of protection and emotional support
for children. Those separated from caregivers (e.g., orphans because of Ebola) may findthemselves in unfamiliar places and around unfamiliar people during an Ebola disease
outbreak. They may be very fearful and may not be able to properly judge the risks anddanger around them.

Children may witness horrific events, even if they or their carers are not directly affected.
For example, they might be curious about the health workers wearing protective clothing,follow them, and witness how they take a person in an advanced state of the disease
from their home. Or they may see people who have died of the disease. In the chaos of acrisis, adults are often busy and may not be watching closely what children are doing or
what they see or hear. Try to shield them from upsetting scenes or stories.
Remember that children have their own resources for coping.
Learn what children’s resources are for coping and support positive coping strategies,
while helping them to avoid negative strategies. Older children and adolescents can often
help in crisis situations, such as putting up posters with accurate information about Ebola.
Finding safe ways for them to contribute may help them to feel more in control. Children,
adolescents and youth may also have networks and associations that can provide social
support.

How carers can help children
Infants

»»
»»
»»
»»

Keep them warm and safe.
Keep them away from loud noises and chaos.
Keep a regular feeding and sleeping schedule, if possible.
Speak in a calm and soft voice.

Youngchildren»»»»»»Give them extra time and attention.
Remind them often that they are safe.
Explain to them that they are not to blame for bad things that have
happened.
Whenever possible, avoid separating young children from parents andcarers, siblings, and other loved ones.
Keep to regular routines and schedules as much as possible, or help
create new ones in a new environment.
Give simple answers about what has happened without scary details.
Allow them to stay close to you if they are fearful or clingy.
Be patient with children who start demonstrating behaviours they had
when they were younger, such as sucking their thumb or wetting thebed.
Provide a chance to play and relax, if possible.

»»
»»
»»
»»
»»

»»

42

Psychological first aid during Ebola virus disease outbreaks

How carers can help children (continued)
Older
children andadolescents

»»
»»
»»

»»

»»
»»
»»
»»
»»

Give them your time and attention.
Help them to keep regular routines, including school/
learning.
Provide facts about what has happened, explain what isgoing on now and give them clear information about how to
reduce their risk of being infected by the disease.
Encourage and allow opportunities for them to be helpful inconcrete, purposeful common interests (e.g., taking on safe
but relevant tasks in the community as part of the overall
outbreak response).
Allow them to be sad. Don’t expect them to be tough.
Listen to their thoughts and fears without being
judgemental.
Set clear rules and expectations.
Ask them about the dangers they face, support them anddiscuss how they can best avoid being harmed.
Link them with existing networks of adolescents, youth andother community and social support groups.

»»
»»
»»
»»
»»
»»
»»

Be calm, talk softly and be kind.
Listen to children’s views on their situation.
Try to talk with them at their eye level (e.g. sit or kneel on the floor), and use words
and explanations they can understand.
Introduce yourself by name, let them know you are healthy and that you are there
to help.
If talking with a child who has Ebola, explain that although you can’t touch them,
you can listen and care about how they are feeling.
Find out their name, where they are from, and any information you can in order tohelp find their caregivers and other family members.
If passing time with children, try to involve them in play activities or simple
conversation about their interests, according to their age and to the safety
regulations for Ebola.
Psychological first aid during Ebola virus disease outbreaks

43

Chapter 3

When providing PFA to children, remember to Listen, Talk and Play:2. People with health conditions or physical ormental disabilities
People with chronic (long-term) health conditions, with physical or mental disabilities(including severe mental disorder), and the elderly may need special help. This may
include help to get to a safe place, to connect with basic support and health care, or totake care of themselves. The experience of a crisis event, and the impact of Ebola diseaseon the availability of medical resources, can worsen different types of health conditions,such as high blood pressure, heart conditions, asthma, anxiety and other health andmental disorders. Pregnant and nursing women may experience severe stress from thecrisis that can affect their pregnancy, their own health and their infant’s health. People
who cannot move on their own, or who have problems seeing or hearing, may havedifficulty finding loved ones or accessing services.
Here are some things you can do to help people with other health conditions or
disabilities:
»»
»»
»»

»»

»»

44

Help them to get to a safe place.
Help them to meet their basic needs, such as being able to eat, drink, get cleanwater and care for themselves.
Ask people if they have any health conditions other than Ebola, or if they regularly
take medication for a health problem. Try to help people get their medication oraccess available medical services.
Stay with the person if they are very distressed, or try to ensure they have someone
to help them if you need to leave. Consider linking the person with a protection
agency or other relevant support, to help them in the longer term.
Help them if they are experiencing Ebola disease symptoms. Avoid physicalcontact, but help refer them for immediate medical care. Ensure other people do
not come into contact with them.

Psychological first aid during Ebola virus disease outbreaks

3. People at risk of discrimination or violence
People at risk of discrimination or violence may include women, people from certain
ethnic or religious groups, and people with mental and physical disabilities. In the caseof an Ebola disease outbreak, people at risk may include relatives of those affected by
Ebola, relatives wanting to bury the dead, and people working in Ebola operations (e.g.,
people doing contact tracing or dead body management). They are vulnerable because
they may be:
»»
»»
»»

left out when basic services are provided;left out of decisions about aid, services or where to go; andtargeted for violence, including sexual violence.

People at risk of discrimination or violence may need special protection to be safe ina crisis situation, and may need extra help to address their basic needs and accessavailable services. Be aware of these people and assist them by:
»»
»»
»»
»»

helping them to find safe places to stay;helping them to connect with their loved ones and other trusted people;
providing them with information on available services and helping them to link
directly with those services when necessary.
As above, help them if they are experiencing Ebola disease symptoms. Do nothave physical contact with them if you don’t have the necessary equipment foryour protection, but help refer them for immediate medical care.

Chapter 3

Psychological first aid during Ebola virus disease outbreaks

45

Chapter 4

Caring for yourself
and your colleagues
46

Psychological first aid during Ebola virus disease outbreaks

In this chapter, we will discuss:
4.1	Getting ready to help
4.2 Managing stress: Healthy work and life habits
4.3	Rest and reflection

You or your family may be directly affected by the Ebola outbreak. Even if you are notdirectly involved, you may be affected by what you see or hear while helping. As a helper,
it is important to pay extra attention to your own wellbeing. Take care of yourself, so
you can best take care of others!

4.1 	Getting ready to help
Consider how you can best get ready to be a helper in crisis settings. Whenever possible:
»»

»»
»»
»»

Learn about the Ebola disease outbreak situation, and the roles andresponsibilities of different kinds of helpers (e.g., health authorities and community
workers).
Consider your own health, and personal or family issues that may cause severe
stress as you take on a helping role for others.
Make an honest decision about whether you are ready to help in each particularsituation and at this particular time.
Be sure that you know and understand how to observe all the safety measures toavoid Ebola disease.

Chapter 4

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47

4.2 MANAGING STRESS: HEALTHY WORK
	AND LIFE HABITs
A main source of stress for helpers is day-to-day job stress, particularly during a disease
outbreak. Long working hours, overwhelming responsibilities, the lack of a clear job
description, poor communication or management, and working in areas that are notsecure are examples of common job-related stress that can affect helpers assisting in theoutbreak.
As a helper, you may feel responsible for people’s safety and care. You may witness oreven directly experience terrible things, such as death, severe illness and suffering, social
unrest or violence. You may also hear stories of other people’s pain and suffering. All ofthese experiences can affect you and your fellow helpers.
Consider how you can best manage your own stress, to support and be supported by yourfellow helpers. The following suggestions may be helpful in managing your stress:
»»
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»»

»»

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48

Think about what has helped you cope in the past and what you can do to staystrong.
Try to take time to eat, rest and relax, even for short periods.
Try to keep reasonable working hours so you do not become too exhausted.
Consider, for example, dividing the workload among helpers, working in shifts
during the acute phase of the crisis and taking regular rest periods.
You may feel inadequate or frustrated when you cannot help people with all of
their problems. Remember that you are not responsible for solving all of a person’s
problems, and it is not realistic or possible for you to do so. Do what you can tohelp people help themselves.
Minimize your intake of alcohol, caffeine or nicotine and avoid non-prescription
drugs.
Check in with fellow helpers to see how they are doing, and have them check inwith you. Find ways to support each other.
Talk with friends, loved ones or other people you trust for support.

Psychological first aid during Ebola virus disease outbreaks

4.3 	Rest and reflection
Taking time for rest and reflection is an important part of ending your helping role.
The Ebola crisis situation and the needs of people you have met may have been very
challenging, and it can be difficult to bear their pain and suffering. After helping in theoutbreak, take time to reflect on your experience and to rest. The following suggestions
may help your recovery:
»»
»»
»»
»»

Talk about your experience of helping in the crisis situation with a supervisor,colleague or someone else you trust.
Acknowledge what you were able to do to help others, even in small ways.
Learn to reflect on and accept what you did well, what did not go very well, andthe limits of what you could do in the circumstances.
Take some time, if possible, to rest and relax before beginning your work and life
duties again.

If you find yourself with upsetting thoughts or memories about the event, feel very
nervous or extremely sad, have trouble sleeping, or drink a lot of alcohol or take drugs, it
is important to get support from someone you trust. Speak to a mental health specialist if
these difficulties continue for more than one month (see CONTACT LIST OF MENTALHEALTH AND PSYCHOSOCIAL RESOURCES IN YOUR AREA, page 54).

Chapter 4

Psychological first aid during Ebola virus disease outbreaks

49Offering psychological first aid
to grieving people
In many crisis situations the normal rituals and processes that help people grieve and say
goodbye to their loved ones cannot occur. This is particularly true in the case of Ebola
disease. For example, local cultural or religious practices for burials may not be possible
because of the risk of spreading infection.
Losing a loved one can be like a wound that hurts. It can leave people feeling very angry
and frustrated that they do not have a way to honour and remember their loved ones.
People may feel overwhelmed with sadness because of their loss and the situation they
are in. They may be unable to accept that the person has died. These are all normal grief
reactions following the loss of a loved one.
It is important to recognise that people need the time and space to grieve. In many
cultures, traditional and religious rituals and burial ceremonies enable the person or
family to start coping with their loss of a loved one. Not being able to engage in these
ceremonies because of the risk of disease spread may create more anger, sadness andfear.
It is essential to inform grieving people about the risks and dangers of handling the bodyof a person who has died of Ebola, but also reassure them that there can be other ways ofgrieving, honouring and remembering the person.

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Psychological first aid during Ebola virus disease outbreaks

If you are offering PFA to bereaved people it is important to:
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Help them feel calm and safe.
Listen to them and allow them the time and space to feel sad and grieve.
If they wish, you can introduce them to others who have been bereaved andencourage them to support each other.
Allow them the time and space to talk about their loved ones.
If they are struggling to accept that they cannot bury their loved ones in a
traditional ceremony, encourage them to think of alternative ways that they canhonour, remember and grieve for them.
Consider engaging religious leaders in helping to develop alternative rituals thatare safe for the mourners (see Annex for space to record local alternative rituals forsafe mourning).

Ideas for safely mourning and honouring thedeceased:
People affected by Ebola disease have come up with new ways that help people
to grieve, without engaging in traditional ceremonies and rituals that involve
handling the dead body:»» In other cultures, individuals and families have planted trees inremembrance of their loved ones.
»» Others have been able to hold memorial services for their loved ones using
photographs of the person as a focal point.
It may be helpful to share these ideas with bereaved families and communities,
and help them consider ways of safely mourning their loved ones that will workfor them.

Psychological first aid during Ebola virus disease outbreaks

51

Relaxation and Breathing Exercises
Relaxation is a useful way of reducing stress, and deep breathing helps the body andmind to relax so that people can stay healthy and calm. Many traditional types of
meditation as well as modern psychology use some form of breathing exercise to teachpeople how to relax.
However, before you can teach others, you should try it yourself. Try following the steps
below to experience the sense of relaxation it can give. Then you can instruct others in
the exercise using the instructions below. Remember to speak slowly and in a calm toneof voice.

Relaxation Exercise Script
During stressful times, it is important to find ways to relax the mind and body so that
we can cope effectively with challenges, demands and emotions. Deep breathing helps
to trigger relaxation to help people stay healthy and calm during difficult times. By
practising this EVERY day for a few weeks, most people will start to feel more relaxed andbetter able to cope.
You can do the following exercise at any time of the day. Try to devote at least 5 minutes a
day to the exercise. It is best done in a quiet room where you will not be disturbed.

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Psychological first aid during Ebola virus disease outbreaks

Let us practise together:
»»
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»»

»»

Begin by lying down or sitting in a comfortable position. There is no special
position, just find a position that feels comfortable for you.
Close your eyes and relax your face. Feel yourself supported by your chair or by
the floor if you are lying down. Begin to relax any tension you feel in your body.
Begin to concentrate on the rhythm of your breath. Slowly feel your breath as you
inhale through your nose, and then as you exhale through your nose. Feel the air
filling your lungs and circulating through the body with each inhale and exhale.
Now, inhale slowly to the count of four (count slowly with the person to the paceof one-one-thousand, two-one-thousand....). Pause with the breath held in to thecount of three. Then, exhale slowly to the count of five.
»» Continue with this breathing process for a few minutes, instructing the person tobreathe regularly and slowly like this:Inhale... two, three, four...Pause...two, three....Exhale...two, three, four, five....
Inhale... two, three, four...Pause...two, three....Exhale...two, three, four, five....

»»»»

You can suggest that each time they breathe out they say in their mind the word
‘relax’ or an equivalent in their local language. People who are religious may wantto say a word that is important to their faith.
To end the exercise, feel the relaxation you have created in your body and mind.
Thank yourself for this important time of rest and care.

Psychological first aid during Ebola virus disease outbreaks

53

Contact List of Mental Health andPsychosocial Resources in Your Area

Name

Contact

Type of Service
Provided

1
2
3
4
5
6
7
8
9
10

54

Psychological first aid during Ebola virus disease outbreaks

Notes

Local Alternative Rituals for Safe
Mourning after the Death of a Personwith Ebola

1
2
3
4
5
6

Psychological first aid during Ebola virus disease outbreaks

55

Psychological first aid: Pocket guide
What is Psychological First Aid?
Psychological First Aid (PFA) describes a humane, supportive response to a person who issuffering and may need support.
Providing PFA responsibly means:
1. Respecting people’s safety, dignity and rights.
2. Adapting what you do to take into account the person’s culture.
3. Being aware of other emergency response measures.
4. Looking after yourself.
In providing PFA responsibly during an Ebola virus disease outbreak:»»»»Ensure people know their rights (such as right to treatment and care, being treated with
dignity, etc.) as well as their responsibilities in the Ebola disease outbreak, such as their
responsibility to follow the guidance of local health authorities and health workers.
Look after your own physical and mental wellbeing! As a helper, you may also beaffected by the Ebola outbreak or may have family, friends and colleagues who are
affected. Pay extra attention to your own wellbeing and be sure that you follow allsafety precautions.

Prepare»»»»»»Learn about Ebola virus disease.
Learn about available services and supports.
Learn about safety and security concerns.

PFA Action Principles:
Look

»»
»»
»»

Check for safety.
Check for people with obvious urgent basic needs.
Check for people with serious distress reactions.

Listen»»»»»»Approach people who may need support.
Ask about people’s needs and concerns.
Listen to people, and help them to feel calm.

Even if you must communicate from a distance because of safety precautions, you can still givethe person your full attention and show that you are listening with care.

Link

56

»»
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Help people address basic needs and access services.
Help people cope with problems.
Give information.
Connect people with loved ones and social support.

Psychological first aid during Ebola virus disease outbreaks

Ethics:

Be honest and trustworthy.

»»»»

Respect people’s right to maketheir own well- informed
decisions.

»»»»

Be aware of and set aside yourown biases and prejudices.

»»»»

Make it clear to people thateven if they refuse help now,
they can still access help in
the future.

»»
»»

»»

Respect privacy and keep
personal details of the person’s
story confidential, if this isappropriate.

»»

Behave appropriately byconsidering the person’s
culture, age and gender.

»»
»»
»»

Don’t exploit your relationshipas a helper.
Don’t ask the person for any
money or favour for helping them.
Don’t make false promises orgive false information.
Don’t exaggerate your skills.
Don’t force help onto people,
and don’t be intrusive or pushy.
Don’t pressure people to tell you
their story.
Don’t share personal details of
the person’s story with others.
Don’t judge the person for theiractions or feelings.

PFA POCKET GUIDE»»ANNEX 1

Ethical do’s and don’ts are offered as guidance to avoid causing further harm to the person
receiving PFA, to provide the best care possible, and to act only in their best interests. Offer
help in ways that are most appropriate and comfortable to the people you are supporting.
Consider what this ethical guidance means in terms of your cultural context.

PEOPLE WHO NEED MORE HELP THAN PFA ALONE:
Some people will need much more than PFA alone. Know your limits and ask for help
from others who can provide more advanced mental health support, medical care or otherassistance.

PEOPLE WHO NEED MORE ADVANCED MENTAL HEALTHSUPPORT IMMEDIATELY:
»»
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People who are so upset they cannot care for themselves or their children.
People who may hurt themselves.
People who may hurt others.
Psychological first aid during Ebola virus disease outbreaks

57

Contact List of Ebola Disease OutbreakServices in Your Area
Name

Contact
NumberType of Service
Provided

1 Local Ebola

Advice on Ebola

2 Child

Support forunaccompanied
children andadolescents

hotlinenumberProtection
Agency

3
4
5
6
7
8
9
10
11
12

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Psychological first aid during Ebola virus disease outbreaks

Notes