Japanese Bulletin of Traumatic Stress Studies Number 14:41-58, 2019

Literature paper
Title: Diffusing and Implementing Psychological First Aid for Schools in Japan
Author: Eizaburo Tanaka
Affiliation: Hyogo Institute for Traumatic Stress
Abstract: Psychological First Aid (PFA) is a set of techniques that tells you what mental
preparation you should have when talking to or taking care of disaster survivors and how you
should deal with them in the aftermath of a disaster. I translated the “Psychological First Aid for
Schools (PFA-S) Field Operations Guide,” developed in the US, into Japanese and conducted
workshops to diffuse the PFA-S approach in Japan. In this paper, I discuss the history of PFA andreview the experimental studies conducted on those techniques. I also summarize the points for
introducing and implementing PFA-S.
Keywords: Psychological First Aid for Schools, mental care, children, adolescentsText:
I. Introduction
Psychological First Aid (PFA) is a set of techniques that tell you what mental preparation
you should have when talking to or taking care of disaster survivors and how you should deal
with them in the aftermath of a disaster. The WHO defines its PFA to be a “humane, supportiveand practical assistance to fellow human beings who recently suffered a serious stressor.”1) I
herein present the history of PFA and review the findings of experimental studies conducted on
those techniques up through the present (in 2018). I created the Japanese version2) of the“Psychological First Aid for Schools (PFA-S) Field Operations Guide,” developed by the US
National Child Traumatic Stress Network and the US National Center for PTSD, and conducted
workshops to diffuse these techniques in Japan. I, therefore, also give an overview as to the
diffusion of PFA in the country and discuss the key points for implementing PFA-S.
II. History of PFA
The concept of PFA was already present in the 1950s.3) You can find the term “PFA andTriage” in “When Disaster Strikes,” a monumental textbook in the field of post-disaster psychiatry
published in 1986.4) As the elements of PFA, the author of the book lists the following: (1) basic
comfort; (2) physical care; (3) goal setting; (4) search and reunion; (5) practical assistance; (6)emotional adjustment; (7) sense of safety and sense of reality; (8) network of support; (9)protection from secondary harm; and (10) assessment. Those elements have been passed down intoday’s PFA concept. PFA is a very common-sense approach; it instructs you to “grasp the needsof disaster survivors, to try not to worsen the situation for them, and to create a setting that helps
their self-recovery from the disaster.” Because of its commonsensicality, however, the importanceof PFA was long ignored.
During the period from the 1970s to 1980s, a method for managing stress caused bydisasters called Critical Incident Stress Debriefing (CISD) was developed. CISD, which was
originally designed as an early-stage intervention to prevent firefighters from suffering from
PTSD, is a group method in which you share your traumatic experience with other people1Japanese Bulletin of Traumatic Stress Studies Number 14:41-58, 2019

immediately after the experience to cope with the trauma. In the 1990s, CISD came to be used as
an intervention to take care of not only support providers, but also disaster survivors, although bythis time it had come to be known as Psychological Debriefing (PD). Studies conducted later
found, however, that a single session of PD in a setting where disaster survivors cannot receive
sufficient specialist post-disaster care does not alleviate their PTSD or other disaster-related
mental disorders, but could rather have a negative psychological effect on them.5) And thus
emerged PFA as a standard approach for post-disaster mental care alternative to PD.
Since the 2000s, nearly 30 kinds of PFAs have been proposed. Elements shared by thecurrent PFAs are: (1) safety; (2) comfort; (3) connection with the surroundings; (4) self-efficacy;and (5) hope.6) The most widely implemented PFAs both inside and outside of Japan are the US
PFA7) developed in 2005 and the WHO’s PFA1) developed in 2011. The US PFA has a version forchildren called “PFA-S,” while the WHO has “PFA for Children,” which was generated by Save
the Children. The US PFA is comprised of the following eight actions: (1) contact andengagement; (2) safety and comfort; (3) stabilization; (4) information gathering on needs andconcerns; (5) practical assistance; (6) connection with social supports; (7) information on coping;and (8) linkage with collaborative services. Anybody can provide PFA, however, it contains
detailed information on mental health in times of disaster. Thus, it can be said that the US PFA isdesigned for supporters who have its basic knowledge. The WHO’s PFA, meanwhile, is based on
the four action principles of (1) prepare, (2) watch, (3) listen and (4) connect, and it has a simpler
structure than the US PFA. Designed for use in low- and middle-income countries with limited
human resources, the WHO’s PFA is said to be for the general public.
PFA is built on the essential elements of psychological support with confirmed efficacy.
The necessity of PFA is mentioned in the “IASC Guidelines on Mental Health and Psychological
Support in Emergency Settings,” which are international guidelines on humanitarian support, andalso in the “Sphere standards.” Although there is a criticism that few experimental studies havebeen performed on the efficacy of PFAs,8) some small-scale intervention studies in recent years
are reporting that PFA is effective with junior and high school students,9) college students,10) andcitizens in low-income countries.11)
III. Diffusion of PFA in Japan (as of 2018)
As the means to propagate PFA, the following three methods are used: self-study using
a manual guide; interactive workshops; and online learning.
The US PFA & PFA-S- Psychological First Aid Field Operations Guide, Second Edition- Psychological First Aid for Schools Field Operations Guide
Website of the National Child Traumatic Stress Networkhttps://www.nctsn.org/
Website of the National Center for PTSD
https://www.ptsd.va.gov/index.asp
The WHO’s PFA- PFA Guide for Field Workers
This guide is available on the WHO’s website
http://apps.who.int/iris/bitstream/handle/10665/44615/9789241548205_jpn.pdf;jsessionid=DF5957ACC7D9E54D8D7082752238EF30?sequence=18- Psychological First Aid for Children (PFA for Children)2Japanese Bulletin of Traumatic Stress Studies Number 14:41-58, 2019

The brochure is available on the Save the Children’s website
http://www.savechildren.or.jp/lp/pfa/
We can also use the following online-learning programs:
US PFA- PFA mobile (iPhone/Android)
Mobile applications for self-study on the US PFA are developed and made available on thewebsites of the National Child Traumatic Stress Network and the National Center for PTSD.
https://www.translatetheweb.com/?search=&resource_type=94&trauma_type=All&language=A
ll&audience=All&other=All&from=&to=ja&a=https%3A%2F%2Fwww.nctsn.org%2Ftreatmen
ts-and-practices%2Fpsychological-first-aid-and-skills-for-psychological-recovery%2Fnctsnresources&f=1
https://www.ptsd.va.gov/appvid/mobile/pfa_app_pro.asp- Psychological First Aid Online/Psychological First Aid for Schools webinar (English version)
A six-hour webinar on PFA has been developed and made available by the US National Child
Traumatic Stress Network. The program, which contains video lectures by experts in trauma andfirst-hand accounts by disaster survivors, is useful in studying PFA for the first time as well as torefresh one’s knowledge on PFA. A webinar on PFA-S is also available, although it is in English
only.
https://learn.nctsn.org/
Other PFAs
The PFA developed by John Hopkins University, called the RAPID model, is available throughthe university at Coursera, an online learning platform. The University of Minnesota also makes
available an online learning course called “Psychological First Aid tutorial.” Both in English only.
- Johns Hopkins University: https://www.coursera.org/learn/psychological-first-aid- University of Minnesota: http://www.sph.umn.edu/pfatutorial/
As you can see above, various means are employed to popularize PFA. Studies on theeffectiveness of those means were also conducted.12-16) I must point out, however, that theeffectiveness of interactive workshops is not strictly verified in those studies, considering the factthat they were conducted without a control group to compare the knowledge and understanding
levels between before and after workshops.
I created the Japanese version of the “PFA-S Field Operations Guide,” conducted oneday interactive workshops based on the Guide, and evaluated the effectiveness of those workshops.
As the name indicates, PFA-S is designed for schools; schools are not only the place where mostchildren spend much of their time, but can also be a hub for support activities in the aftermath ofa disaster. The PFA-S techniques are designed to provide psychological and social supports for
not only children, but their parents and teachers as well. It is possible for anybody to provide PFAS if he or she has the knowledge, but the most likely providers will be teachers and school
counselors. Therefore, in this study, I limited my workshop participants to school staff who havecontact with children for five or more days every week. I held eight one-day interactive workshops
in total, in which nearly 200 people participated. To evaluate the effectiveness of those workshops,
I randomly assigned the participants to an intervention group or waiting group to compare their
PFA-S competency. The outcome indicators were subjective confidence in providing mental careand the frequency of mental care actions deemed as desirable by PFA-S. The comparison between
the two groups found that the intervention group had significantly better results in both outcome
indicators than the waiting group. (The data are not published yet; “The Development of3

Japanese Bulletin of Traumatic Stress Studies Number 14:41-58, 2019

Psychological First Aid for Schools Japanese version,” a study conducted in 2015-2017 under the
Grants-in-Aid for Young Scientist (B) Program)
IV. Implementing PFA-S
From now on, I discuss the key points for implementing PFA-S at schools based on the
afore-mentioned study along with the PFA-S Field Operations Guide (hereafter, the “Guide”) andthe presentation slide I used in my training workshops (hereafter, the “Slide”).
IV-1. Introducing PFA-S
You need to clearly tell your school why the school should introduce PFA-S and when,
for whom and by whom PFA-S should be provided. The Guide says that PFA-S should be
provided immediately after the occurrence of a disaster event (during the period from one hour toweeks later) to maximize its efficacy. I believe that it is beneficial to use the PFA-S approach withyour students in ordinary times in order to heighten their resilience since the PFA-S actions arecommonsensical and not harmful. Moreover, it will be otherwise difficult for you to exercise it in
the event of a disaster; you need to get used to doing it in peacetime.
You should also pay attention to cultural diversity. Since PFA-S was developed in theUS, a country with multiple cultures, the Guide emphasizes the importance of respecting thediversity of cultures, ethnicities, religions, races and languages. In Japan, too, you should keep inmind the importance of respecting different cultures; respecting them is equal to putting yourself
in other people’s positions, an attitude that needs to be fostered in all PFA-S providers. You canfind PFA-S’ basic action policies in the Guide (pages 12-13), which will help you briefly describe
the whole picture of PFA-S for others who do not yet know it. As a tip outside the Guide, I suggestthat you prepare, before holding a training workshop on PFA-S, some icebreakers and determine
basic rules for your workshop (e.g., respect other people’s opinions, protect the confidentiality of
personal information, do not force others to speak what they do not want to); you will find them
useful to running your PFA-S training effectively.
IV-2. Action 1: Contact and Engagement
The most important thing in the support of disaster survivors is to build rapport withthem, and the goal of Action 1 is to get a foothold for such rapport-building. More specifically,
you should introduce yourself (by telling your name, affiliation and role) when you talk to disastersurvivors whom you have never met before, seek prior permission from them or their parent totalk with them, and focus on the needs of disaster survivors. You should also keep it in mind thatyou need to have empathy with disaster survivors whenever talking to or taking care of them.
Since it is particularly difficult to protect privacy in an emergency situation, make the best effort
to prepare a private setting before talking to a disaster survivor.
IV-3. Action 2: Safety and Comfort
Safety is the top priority. The goal of Action 2 is to ensure the safety of yourself, disastersurvivors and others at the site and thereby provide reassurance. The key factor of Action 2 is thecollection and handling of information. In an emergency situation, information does not come toyou; it needs to be collected through direct communication with other people, media, or on theinternet. It is often said that the better you use information, the earlier you recover from a disaster.
Meanwhile, various types of information abound in the acute stage of a disaster. Exposing
4Japanese Bulletin of Traumatic Stress Studies Number 14:41-58, 2019

children to excessive information about the disaster carries the risk of causing them to suffer asecondary trauma, and hence adults should censor some information for children. Adolescents,
however, can easily get information on the internet by themselves, and it is impossible for adults
to control it. Therefore, you should ask adolescents what information they have and how they fell
about it. If you find they are misinformed, correct it. When asked questions by children, parents,
or other school staff members, give them only accurate information in an easy-to-understandmanner; never give them any speculated, inaccurate information. When asked about something
you do not know, tell the person that you have no information about it, limiting yourself to tell
him/her what might work to get that information.
IV-4. Action 3: Stabilization
You should carry out Action 3, or stabilization, only when it is necessary. The goal is tohelp disaster survivors who are emotionally overwhelmed to stabilize their feelings. It is important
to know that many disaster survivors do not require your intervention to stabilize their feelings.
You should carry out stabilization only for those who are obviously very agitated or confused,although there are cases where people who appear to be calm outside are actually very agitatedor confused inside (and for them, too, you should carry out stabilization). You can find how to
perform “grounding,” a stabilization method, in the Guide (pages 39-40). I recommend that you
practice the method before holding a workshop on PFA-S.
IV-5. Action 4: Information Gathering on Needs and Concerns
Information is essential to properly assessing the situation. The goal of Action 4 is toclarify the needs and concerns of disaster survivors and figure out priorities. In order to collectsuch information, you may sometimes have no choice but to ask disaster survivors about thetraumatic event that they have gone through. Therefore, you should not start Action 4 if Actions
1-3 are still incomplete, in other words, do not start Action 4 if you have not yet established arapport with disaster survivors, if neither safety nor comfort is yet secured, or if disaster survivors
are not yet stabilized. At the acute stage of a disaster, you should also be careful so as not to ask
too many details about the traumatic event. When disaster survivors try to tell you every detailabout it, you should tell them, without nevertheless instructing them to stop the talk, that you do
not need any other information than that regarding their current needs, but tell them that you knowa school counselor or other expert to whom them they can talk about the traumatic experience.
IV-6. Action 5: Practical Assistance
Under extreme stress, people, whether children or adults, tend to become incapable ofseeing things in the big picture. When faced with a problem that is too serious to solve, people
tend to think “there is no solution” and lapse into apathy. The goal of Action 5 is to provide
disaster survivors with assistance that helps them regain the energy to solve their problem. The
first thing to do is to clarify what the problem is. Then, divide it into smaller pieces that are as
specific as possible. Do not try to solve a problem at once. The next step after clarifying the
problem is to think, together with disaster survivors, about how to solve it. You will probably findbrainstorming useful as a way to come up with a solution. Brainstorming is a group free discussion
to create new ideas. When organizing a brainstorming session, you should pre-determine rules,
such as not judging the feasibility of an idea on the spot, coming up with as many ideas as possible,
and integrating ideas to evolve them. Once you and disaster survivors have a solution, it’s time toplan how to implement it. Throughout all the processes, you should limit your role to playing
5

Japanese Bulletin of Traumatic Stress Studies Number 14:41-58, 2019support and let disaster survivors solve their problem on their own.
IV-7. Action 6: Connection with Social Supports
Social supports are the most important element to bring mental stability and recovery todisaster survivors. After experiencing a traumatic event, people tend to lose their sense ofconnection with other people in both materialistic and psychological terms. Your role is to givethem advice so that they can regain the sense of connection they used to have. Not to mention thehelp they are needing to regain the sense of connection with their family members and friends assoon as possible, various kinds of social supports such as those provided by public organizations
can also be important sources. In addition, you are, indeed, a meaningful supporter for disastersurvivors even though it is only recently that they meet you.
IV-8. Action 7: Information on Coping
The goal of Action 7 is to provide stress-related psychoeducation for disaster survivors
to enhance their adaptive skill. In that education, you tell them, in an easy-to-understand manner,
what stress reactions involve and what reactions can be triggered by traumatic experiences, all
the while emphasizing that such reactions are normal reactions to emergency situations. Everydisaster survivor has his/her own skill to cope with stress. Your role is to help disaster survivors
exercise their coping skill to a sufficient extent.
IV-9. Action 8: Linkage with Collaborative Services
Every support activity has an end. The goal of Action 8 is to link disaster survivors withthe resources that they will need in the future. This is a very important Action to provide consistent
support.
IV-10. Self-care of Support Providers
PFA-S providers need to be taken care of, too. You cannot provide good support fordisaster survivors unless you are physically and mentally healthy enough. To give self-care to
yourself, you should “notice” the reactions of your mind and body, try to “strike a balance”
between activity and rest, and “stay connected” with your family members, colleagues and othersupport providers. The approach and techniques that you will use for disaster survivors will also
work for you to maintain your own mental balance.

6Japanese Bulletin of Traumatic Stress Studies Number 14:41-58, 2019

References
1. World Health Organization, War Trauma Foundation, World Vision International.
Psychological first aid: Guide for field workers WHO: Geneva 2011.
2. Hyogo Institute for Traumatic Stress, National Mental Support Center for School Crisis,
Osaka Kyoiku University, Psychological First Aid for Schools Field Operations Guide,
Edition 2, 2017.
3. Drayer C. S., Cameron D. C., Woodward W. D., et al. Psychological first aid in community
disaster. J Am Med Assoc. Sep 4;156(1):36-41. 1954.
4. Raphael B. When disaster strikes. New York: Basic Books Inc; 1986.
5. van Emmerik A. A., Kamphuis J. H., Hulsbosch A. M., et al. Single session debriefing after
psychological trauma: a meta-analysis. Lancet. Sep 07;360(9335):766-71. 2002.
6. Hobfoll S. E., Watson P., Bell C. C., et al. Five essential elements of immediate and midterm mass trauma intervention: empirical evidence. Psychiatry. Winter;70(4):283-315;
discussion 6-69. 2007.
7. Hyogo Institute for Traumatic Stress, Psychological First Aid Field Operations Guide,
Edition 2, 2009.
8. Dieltjens T., Moonens I., Van Praet K., et al. A systematic literature search on psychologicalfirst aid: lack of evidence to develop guidelines. PLoS One;9(12):e114714. 2014.
9. Ramirez M., Harland K., Frederick M., et al. Listen protect connect for traumatizedschoolchildren: a pilot study of psychological first aid. BMC Psychol;1(1):26. 2013.
10. Everly G. S., Jr., Lating J. M., Sherman M. F., et al. The Potential Efficacy of PsychologicalFirst Aid on Self-Reported Anxiety and Mood: A Pilot Study. J Nerv Ment Dis.
Mar;204(3):233-5. 2016.
11. Wijesinghe C. A., Williams S. S., Kasturiratne A., et al. A Randomized Controlled Trial of a
Brief Intervention for Delayed Psychological Effects in Snakebite Victims. PLoS Negl Trop
Dis;9(8):e0003989. 2015.
12. Lee J. S., You S., Choi Y. K., et al. A preliminary evaluation of the training effects of a
didactic and simulation-based psychological first aid program in students and school
counselors in South Korea. PLoS One;12(7):e0181271. 2017.
13. El-Khani A., Cartwright K., Redmond A., et al. Daily bread: a novel vehicle fordissemination and evaluation of psychological first aid for families exposed to armed conflictin Syria. Glob Ment Health (Camb);3:e15. 2016.
14. Akoury-Dirani L., Sahakian T. S., Hassan F. Y., et al. Psychological first aid training for
Lebanese field workers in the emergency context of the Syrian refugees in Lebanon. Psychol
Trauma. Nov;7(6):533-8. 2015.
15. Everly G. S., Jr., Lee McCabe O., Semon N. L., et al. The development of a model ofpsychological first aid for non-mental health trained public health personnel: the Johns
Hopkins RAPID-PFA. J Public Health Manag Pract. Sep-Oct;20 Suppl 5:S24-9. 2014.
16. Chandra A., Kim J., Pieters H. C., et al. Implementing psychological first-aid training for
medical reserve corps volunteers. Disaster Med Public Health Prep. Feb;8(1):95-100. 2014.

7

Introduction

Psychological First Aidfor Schools
Hyogo Institute for Traumatic StressSenior Researcher/Psychiatrist Eizaburo Tanaka M.D., M.P.H.

• This training is based on the Psychological FirstAid for Schools (hereinafter referred to as PFAS) Field Operations Guide, and lectures on PFAS which are opened to the public on the web by
the National Child Traumatic Stress Network(http://www.nctsn.org/). Please note, however,that this is not official training in PFA-S.
• The materials used in this training were preparedusing Grants-in-Aid for Scientific Research of
JSPS (Japan Society for the Promotion of
Science) (JP15K17323).

Icebreaker activity

Objectives• Form groups of 4 or 5
• Each participant introduces him/herself• Give name, affiliation, and what you want tolearn through this training• The lecturer and participants discuss andclarify how to practice mental health care inschools in accordance with PFA-S• Understand the philosophy and specificintervention strategies of PFA-S• Utilize PFA-S to prepare for and respond to
emergency situations• Plan schoolwide support involving students,
teachers and staff, and families

Developers of PFA-S• Melissa Brymer (chair)• Pia Escudero• Anne Jacobs• Mindy Kronenberg• Robert Macy

• Lou Ann Mock
• Linda Payne• Robert Pynoos• Matt Taylor• Juliet Vogel

Goal: Change your behavior throughthe training
To achieve it,• Make yourself relevant.
• Actually do things yourself.
• Link to your immediate problems.
• Think about what you can actually do fromtomorrow.
• Do it from tomorrow.
• Keep trying.

What is PFA-S?

Why in schools?

• An evidence-informed approach to help
children, adolescents, adults and families indisaster-stricken schools and communities.
• Evidence-informed means "the elements ofvarious support methods whose effectivenesshas been verified are systematically compiled."• Schools play an important role in the event of adisaster or other emergencies (Examples: asevacuation centers, providers of child care, etc.).
• Schools need to be prepared for emergencies.
(Example: disaster resilience education)• Children are vulnerable to psychological stress(psychological trauma).
• Distress associated with psychological trauma canhave long-term effects if overlooked.
• Even brief interventions can produce positive
results.

Target persons

PFA-S providers• Those who have been exposed to a
stressful/traumatic event
I. Students
II. Teachers and other staff members
III. Families• Any teachers and staff can provide PFA-S• PFA-S is not psychotherapy. Therefore, abackground in psychology, psychiatry, etc. is notessential.
• Other potential providers of PFA-S• Mental health professionals• Religious practitioners• Disaster-relief volunteers• Healthcare professionals• In an emergency situation, teachers and staff playa major role in promoting students’ resilience, inrecognizing the signs of traumatic stress, and in
helping students to regain a sense of normalcy.

When should PFA-S beprovided?
• School emergencies• Disaster• Act of terrorism
PFA-S can be provided immediately after theoccurrence of these events

Prior to providing PFA-S• If you are going to provide PFA services in aschool as an outside supporter, you need to get
information about the school circumstances inadvance.
• You need to be aware of the nature of thestressful/ traumatic event.
• Identify who is particularly vulnerable tostress/trauma (Example: experience of losing
someone, some sort of disability,
physical/psychological proximity to an event).
• Give consideration to cultural and racial diversity.

Guidelines for providing PFA-S

Guidelines for providing PFA-S• Implement within the framework of a school's
emergency response system.
• Before you approach the person(s) ,first observe
him/her/them.
• Listen carefully and understand what the children
are trying to tell you.
• Speak slowly and calmly.
• Offer practical assistance (Example: food, water).
• Ask the children simple questions about how you
may help them.
• Focus on the strength of children and bring out
their coping abilities.

• Provide information to address the child's
current needs.
• Provide accurate information in an ageappropriate manner. Tell the truth in simple
terms.
• Tell children that adults are there to protectthem.
• Try to maintain the school routine.

Behaviors to avoid

Providers should also be caredfor.

• Adults should not make quick assumptions about
how children are feeling and thinking.
• Do not assume that everyone who was exposed toa disaster will be traumatized.
• Do not pathologize.
• Do not view children as weak.
• Do not assume that all children want or need totalk about what they have experienced.
• Do not debrief by asking for details.
• Do not speculate or give inaccurate information.

• Support for children is the main focus in PFAS, but various adults who support children alsoneed to receive care.

Eight actions of PFA-S

Action 1: To initiate contacts with survivors
and start engagement

1. Initiate contact with survivors and startengagement
2. Safety and comfort
3. Stabilization
4. Information gathering
5. Offer help in solving practical problems
6. Help promote contacts with people around them
7. Information on coping
8. Linkage with collaborative services• Goal: To initiate contacts or to respond tocontacts by students, teachers, and staff in a
non-intrusive, compassionate manner

Action 1: To initiate contacts with survivors
and start engagement

Action 1: To initiate contacts with survivors
and start engagement• Build relationships with survivors in a nonintrusive, compassionate manner.

• Be aware of the following points if you are notfamiliar with the survivor’s cultural background• Introduce yourself and describe your role.
• Ask for permission to talk to survivors.
• Explain the purpose.
• Find out what they need now.
• Speak slowly and calmly.
• If a child is in severe psychological distress, contact
the school counselor, parents, etc. immediately.

✓Do not stand too close.
✓Do not make too much eye contact.
✓Avoid physical contact.

Action 1: To initiate contacts with survivors
and start engagement

Approach to children• Avoid delivering PFA-S to large groups ofindividuals.
• For a child who is particularly unstable, provide
a place where privacy can be ensured.
• Organize small groups of children with thesame experience (Example: A friend deceased)
to have a place for discussions.
• Focus on providing information that might behelpful and coping methods, etc. in activities insmall groups with children who have hadvarious experiences.

• Think of one child you have concerns about.
• Let's think about how to approach the child.
• In pairs
A person who plays the role of the child: Play
while imagining how the child would react
A person who plays the role of the teacher: Dealwith the child in a way you actually do in real life
• Goal: To become able to have a specific andvisual image of the child's situation.

Approach to children

Rapport experiment

How: Questions & compassion• Questions
Types of questions: open, closed, Socratic
Good questions will be those that promoteawareness and evoke many things in mind.
Adverse effects: tension ￪, pressure ￪, shrink away +• Compassion
Do not jump to a conclusion!
• Create a relationship whose nature is not conflict"If you push, some people will push back, others will
run away."
Pushing ￫ "But...", Good relationship ￫ "I see."• Child: Mr./Ms. xxx (teacher), I can't do thisassignment. I think it's impossible. I've beenworking on it since last week, but I don't think I
can do it at all. I get irritated and I think it's no usetrying. Can I give up now?
• Teacher: Let's answer in the "pushing approach."• Teacher: Let's answer in the "no-pushingapproach."Action 2: Safety and comfort

Action 2: Safety and comfort• Goal: To enhance immediate and ongoingsafety, and provide physical and emotionalcomfort• Do things in the following manner.
➢Be active, rather than waiting passively.
➢In a practical manner by using available resources.
➢In a familiar manner by drawing on past experience.
➢Soothe, relax, and calm down.

• Provide accurate and up-to-date information.
• Tell what supporters are doing to ensure safety.
• Provide comfort and help connect with others.
• Protect individuals from exposure to additional
potentially traumatic events and reminders.

Action 2: Safety and comfort

Action 2: Safety and comfort• Discuss negative consequences of excessive
viewing of media coverage.
• Ask children what information they havelearned, and address any errors or distressing
information.
• Introduce parents, teachers, and staff to official
websites that provide up-to-date information
and resources.

Attend to grief• Listen attentively.
• Learn about cultural norms.
• Understand that grief reactions vary fromperson to person and inform children and staffof this.

Action 2: Safety and comfort

Summary of Safety and comfort

Support teachers and staff• Even if teachers and staff look calm, do not assume
that they are not worried about their safety. The
majority of them try to hide anxieties for the sake ofchildren.
• Discuss with teachers and staff in a private place thatis apart from the students.
• Enhance a sense of safety by providing psychologicaleducation about general emotional reactions.
• Acknowledge fears or concerns about personal safetyor health.
• Assist teachers and staff so that they can contact theirfamily members.

• Information• Provide accurate information in easy-to-understandterms.
• If you cannot answer a question, say so honestly.
• Confirm what information the person has obtained andcorrect it if it is wrong.

• Resume their normal daily routine activities.
• Protect children from news, SNS, etc. (Discuss withthe child)• Caution: During the acute phase, care should betaken to protect them from trauma reminders.

Responses to bereaved
individuals

Responses to bereaved
individuals• Group discussion (5 minutes)• Have you ever dealt with a bereaved child? If
you have, please share your experience withthe group.
• If not, please tell us your own experience,
within the range you can share, about the lossof your loved one (feelings, thoughts, actions,
physical conditions, etc. at that time). You don't
have to force yourself to talk.
• Share with all the participants (5 minutes)• Acute grief reactions

Things you should not say tobereaved individuals

Things you should not say tobereaved individuals• I know how you feel.
• He is better off now.
• At least he didn't suffer.
• Let's talk about something else.
• It’s good that you're alive.
• You'll feel better soon.
• You did everything you could.

• You need to relax.
• Something worse might have happened. You
still have a family.
• Someday you will find an answer.
• (To a child) You're the man/woman of thehouse now.
• You should work towards getting over this.

Action 3: Stabilization

Action 3: Stabilization• Goal: To calm and orient overwhelmed ordisoriented students, teachers, and staff• When is stabilization needed?

• Shock, disbelief in death, sorrow, anger, guilt, regret,miss the deceased, etc.
• Normal reactions to death• Change to bittersweet feelings over time through talking
about memories and thoughts about the deceased.

• Response• Grief reactions vary from person to person.
• Promote compassion, recognition, and connection withothers.

• Caution: Reactions to anniversaries of past events• Psychological reactions are so intense andpersistent that they are interfering with one’s dailylife.
• Very distraught or extremely restless immediately
after an event.

• Points to remember• Most individuals will not require stabilization
techniques.
• Temporary episodes of intense emotion, apathy,
and increased anxiety are common immediately
after an emergency.

Action 3: Stabilization

Action 3: Stabilization

Examples of persons who need stabilization• Staring blankly• Unresponsive• Exhibiting frantic behavior• Exhibiting intense emotional reactions• Having uncontrollable physical reactions• Exhibiting regressive behavior (Example:
sucking a thumb)Calming techniques for children• (Yourself) Remain gently and quietly in the present
situation.
• Speak in a calm tone, making eye contact with thechild.
• Provide age-appropriate information (Do not give
too much).
• Reconnect the child with his/her guardians,teachers, or staff who know him/her well as soon
as possible.
• Distract the child from the situation by asking
questions about his/her hobby, favorite sport orsong.

Action 3: Stabilization

Action 3: Stabilization

Grounding• Ask the individual to look at you (provider) and listen toyou.
• Ask him/her to look around.
• Ask him/her to talk about things under his/her control,
or something he/she feels hopeful or positive about.
• Breathe slowly.
• Ask him/her to name five things he/she can see, hear,or feel that don't make him/her feel distressed.
(You can have the child name five colors of objects
around him/her.)• When the situation settles down, suggest that he/she
see a doctor just in case.

Stabilization in group settings• Monitor how students respond to discussions.
• If you see any student getting distressed,
stabilize the group by conducting a neutral
activity (drawing, coloring, writing, breathing
exercise, making a collage, etc.) .
• If there is a student still showing restlessness,take care of him/her individually.

Additional note: Grounding

Additional note: Grounding• Purpose: Regain contact with reality• Method: Use five senses• Techniques:• "Please listen to me and look at me."• Find out if he/she knows who he/she is, where
he/she is, and what is going on.
• Ask him/her to describe the surroundings andtell where both of you are.

• Sit in a comfortable position and take three slow
deep breaths.
• Name five non-distressing objects that you cansee.
• Name five non-distressing sounds you can hear.
• Name five non-distressing things you can feel.
• You might have a child name colors of objects thathe/she sees around him/her.
• “Next, name five colors you can see from where
you're sitting. Can you see something blue?
Something yellow? Something green?”Grounding exercise (5 minutes)

Other stabilization techniques• Practice in pairs• One of you plays the role of a child who isemotionally confused and agitated (oroverwhelmed and stunned) .
• The other implements grounding for thepartner.
• When finished, switch the roles.
• Discuss your impressions.

• Breathing exercise

Action 4: Information gathering

Action 4: Information gathering• Goal: To gather information surrounding asurvivor and identify his/her immediate needs
and concerns Tailor PFA-S interventions tomeet those needs.

• Purpose: To reduce anxiety by breathing slowly, lowering
blood oxygen levels, and focusing on one thing.
• Method: With abdominal breathing, breathe out slowly andquietly for about 4 seconds while concentrating on theexhalation. Then inhale in a relaxed manner (Continue thisfor at least 10 minutes).

• Muscle relaxation techniques (Introduced in Action 7)• Externalization• Write your thoughts out in sentences.
• Express emotions in a drawing.

The purpose of gathering information is todetermine the following.
• Need for immediate referral to other agencies• Need for additional support• Which PFA elements are likely to be helpful

Action 4: Information gathering

Action 4: Information gathering• In an emergency, you will have limited time togather information. It is therefore necessary to
identify individuals’ needs and priorities.
• Points to remember• Gather the following information directly• Be flexible in adapting PFA-S interventions• Formal assessment, which takes some time, isinappropriate.
• Gather enough information to determine how tointervene to meet the needs.

• What is the the person’s most pressing concern?
"How are you doing now? Is there anything youneed or are concerned about?"• How did he/she experience the event?
"Where were you during the event? How did you
feel? Are you scared now?"• How is his/her everyday life affected?
"How has the event impacted you, your family, andyour friends? Can you sleep? Can you concentratein school?"Action 4: Information gathering• Gather the following information indirectly• Ask teachers and staff to contact you if there is any
change in student behaviors.
• Make a map showing what happened.
• Monitor daily attendance and infirmary records toidentify students at-risk.

Additional note:
Information gathering• What kind of painful experience have you had?
(Summary)• Caution!
• Avoid asking details of traumatic experiences.
• Ensure that a child can talk at the his/her own pace.

• How to ask questions• What is bothering you the most now?
• How do you think/feel about it?
• Is there anything you can’t do any more that you wereable to do before?

• Decide how to help based on information gathered• Caution!: Assess objectively, do not jump to aconclusion!

Action 5: Practical assistance

Action 5: Practical assistance• Goal: To offer practical assistance to students,
teachers, and staff to address current needs
and concerns

Providing students with needed resources
will:• Empower them
• Help them have hope
• Restore their dignity

Action 5: Practical assistance

Action 5: Practical assistanceOffer practical assistance to teachers and staff• Let them know the currently available resources.
• Discuss how to structure classes and homeworkassignments (especially for students who havedifficulty concentrating).
• Encourage students to participate in various
extracurricular activities for recovery.
• Help teachers set class goals and make theclass’s progress visible.
• Think together about ways to support each other.

• Offer practical assistance to students,
teachers, and staff.
• Identify the most immediate needs.
• Clarify needs (What are the priorities and what
to do next?).
• Discuss and develop an action plan
(brainstorm).
• Help them act to address the needs (Example:
set an appointment, help paperwork).

Children's problems are usually difficult!

Additional note:
Problem-solving
technique

Sweating...

"Break down a big problem into
smaller chunks"

I lifted it!

Step 1: Identify problems• Listing problems(As specifically as possible)• Create an image of a situation in which aproblem has been solved.
(Avoid using negative forms such as "not.")

How do you get to the top of a mountain?

Brainstorming

Source: Implementation manual for Problem-Solving Therapy for cancer patients

Step 2: Consider possible solutions

Step 3: Is it a SMART goal?

Brainstorming• Rule 1. "Number" rule
• Rule 2. "Postponing judgment" rule
• Rule 3. "Variety" rule

• Specific: Is it specific or a small goal?
• Measurable: Can you later evaluate if it was
successfully done?
• Achievable: Is it not too difficult?
• Relevant: Does the problem seem to get any
smaller?
• Timed: Do you think you can achieve it byaround next week?

Step 4: Select a solution• Rule 4: Eliminate solutions that are obviously
impossible or extremely difficult to implement.
• Rule 5: Eliminate solutions that will bother
others or burden yourself.
• Rule 6: Consider advantages, disadvantages,
feasibility, and expected effects of eachsolution.

Step 6: Evaluate the outcomes• Rule 8: Keep a record of the outcomes (What,when, and how you did).
• Rule 9: Write down what you think was
good/not good to do.
• Rule 10: Write down the problems anddifficulties you have experienced while trying.

Step 5: Implement the solution• Rule 7: Make it clear what, when, and how
much you want to do!

Development of problem-solving mindset• Problems arise as long as you live. Accept that there isa problem you need to face.
• Try to identify various factors, not assuming only asingle one, which cause the problem.
• Think of the problem as a "situation in which somesolution should be attempted," rather than a “worry.”• Break down a big problem into smaller pieces.
• Determine whether the problem is something "you will
be able to cope with" or "you can’t cope with," insteadof "something that can be solved."• Start by doing what you can. Challenge as an"experiment"

Using collective intelligence

Summary of problem-solving technique• Ox weight guessing contest (F Galton)• Quiz Millionaire
Coincidentally 65% < Experts 25% < General 91%(Only if diversity is ensured.)• Let as many people as possible express theiropinions freely• Organize the opinions that were presented
Grouping: Grouping of similar opinions
Flow: Making a flow chart of how to cope with the
problemTarget classification: When and for whom is it
effective?

• Help children take initiative in solving
problems.
• Help children acquire problem-solving skills.
• Identifying problems and setting goals areimportant.
• Take plenty of time to brainstorm• Emphasize that the goal is not to solve theproblem well, but to acquire attitude to try
problem-solving techniques and verify them(self-experiment).

Action 6: Connection with social supports

Action 6: Connection with social supports• Goal: To help establish brief or ongoing
contacts with primary support persons
including family, friends, teachers, and staff, as
well as with school and community helping
resources.

• Help to connect with people who provide
support (family, trusted friends).
• Support each other with people around you.
• Discuss support-seeking and giving.
• Identify a person who will be supportive.
• Think together about what to do and what todiscuss.
• Consider reasons for being reluctant to seek
support.

• Respond to extreme isolation and withdrawal.

Action 6: Connection with social supports

Action 6: Connection with social supports

Encourage connections with others in schools• Tell students, teachers and staff that everyone ison the way to recovery.
• Encourage students to watch out for each other.
Tell students that they should notify an adult if they
see a change in a friend's behavior.
• Create an environment to integrate new students
who have transferred to the school.
• Find ways for classmates to communicate witheach other if the school is closed.

Encourage connections with others in schools• Increase group activities and collaborative
assignments to facilitate mutual support.
• Pay attention to whether events such as a
graduation ceremony have been suspended,
and consider alternative events.

Create a network of support

Externalize a network of support• Look for someone you can greet or have a small
talk with.
"Who has something to do with you?"
It doesn't have to be a person.
• Look for someone or an organization that helps
you when you need support.
"Who (Where) can you talk to about yourproblems?"
Who (Where) ￫ How does it help?
• Look for someone who warms your heart by
merely imagining him/her.
"Who gives a good response to your heart?"
Imaginary persons or characters are OK.

Ms. C
Coffeeshop owner

Mr. A

Parents

Teac
her

DeceasedcatAdvice for people who are not good at seeking support• Make a note of what is bothering you and whatkind of help you want.
• In one consultation, focus on one topic.
• Separating Time (Example: Round up to 30
minutes).
• Praising yourself for asking for help, regardless ofoutcome or effect.
• Recognize the fact that "I had someone to consult
with," regardless of outcome or effect.
• Continue actions seeking help tenaciously. Don't
give up by only one trial.

Action 7: Information on coping• Goal: To provide information about stress
reactions and coping strategies to alleviate
distress and enhance adaptive functioning

Action 7: Information on coping

Action 7: Information on coping

Providing information about stress reactions
and coping• Convey what is currently known about theevent.
• Inform what support resources are available.
• Clarify psychological reactions after a disasterand how to manage them.
• Support and promote self-care and family care.

• While it can be helpful to tell survivors whatstress reactions are and that intense reactions
are common but often diminish over time, it is
not advisable to blindly assure that stress
reactions will disappear over time. It may givethem unrealistic expectations about recovery.

Action 7: Information on coping

Action 7: Information on coping

Provide brief information about stress
reactions and coping• Discuss mainly on the reactions experienced
by individuals• Include possible negative/positive reactions• Avoid pathologizing stress reactions• Discuss both adaptive/maladaptive coping
actions

Maladaptive coping actions￫ Result in unintended negative consequences• Isolation, withdrawal• Extreme avoidance of thinking or talking about theevent• Watching too much TV or playing computer games
too long• Anger, violent behavior• Alcohol, drugs• Overeating, refusal to eat• High-risk behavior

Action 7: Information on coping

Action 7: Information on coping

Adaptive coping actions￫ Bring about positive outcomes• Social supports• Positive distracting activities• Set a goal and try to achieve it• Shift expectations and priorities• Breathing exercise, relaxation techniques, and rest
• Exercising• Counseling• HumorHow long the stress reactions lasts depends
on the following factors• Intensity of exposure to a traumatic event andsignificance of losses• Adversities after a traumatic experience• Frequency of exposure to trauma reminders

What is stress?
• A stress-free state• A state under stressStressor

Additional note:
Stress and Coping

Stressreactions

Types of stressors

List as many stressors inyour life as possible
First, list them individually (2 minutes).
Next, share and discuss in each group (3 minutes).
Share with all the participants (around 2 minutes for each group)• Physical stressors: heat, cold, noise, congestion,etc.
• Chemical stressors: pollutants, drugs, oxygen
deficiency/excess, carbon monoxide, etc.
• Psychological and social stressors: humanrelations, work-related issues, family issues, etc.
⇒ Most of what we usually call "stress" refers tothis "psychological and social stressors"

Stress reactions

What stress reactions did you
have when you had a stressor?
First, list them individually (2 minutes).
Next, share and discuss in each group (3 minutes).
Share with all the participants (around 2 minutes for each group)• Psychological: Decreased vitality, irritation,
anxiety, depression (feeling depressed, losinginterest)• Physical: Pain in the joints of the body,headache, stiff shoulders, lower back pain, eyefatigue, rapid heart beating and shortness ofbreath, stomachache, loss of appetite,
constipation and diarrhea, insomnia• Behavioral: Increased alcohol intake andsmoking amount, increased errors andaccidents at work, and increased near misses

Stress coping• Behavioral coping: rest, sleep, nutrition,
exercise, and relaxation• Cognitive coping: rethinking• Social coping: social support

How did you cope with stress?
First, list them individually (2 minutes).
Next, share and discuss in each group (3 minutes).
Share with all the participants (around 2 minutes for each group)Stress reduction method 1)
Progressive muscle relaxation

Stress reduction method 2)
Mindfulness breathing exercise• Take a comfortable position and lightly make fists with your hands.

• Relaxation breathing exercise• 3-minute breathing exercise:Concentrate on breathing for only 3 minutes• Breath-holding exercise• Mindfulness breathing exercises• Your belly expands slowly when you breathe in,and it contracts when you breathe out.
• Float on the waves of your breath• If you notice that your mind has moved away fromyour breathing, check to see what the distraction isand then return to your breathing.

• Next, squeeze your fists slowly, then squeeze them tighter andtighter.
• With your fists clenched, focus your consciousness to them.
• Make sure you feel the tension and stiffness in your fist muscles (3-4
breaths).
• After you sufficiently feel the tension, release the force you used, allat once.
• Pay attention to the sense that your muscle tension is eased, andkeep the focus on the muscles.
• Feel the relaxed state of the muscles for a while. (3-4 breaths)• Fist ￫ upper arm ￫ shoulder ￫ neck ￫ face (eyes, mouth, and cheeks)￫ back ￫ stomach ￫ thigh ￫ calf ￫ instep

What are reactions to trauma
and trauma reminders?

Additional note: Reactions totrauma and reminders

Reactions to trauma• Intrusive reactions• Physical arousal reactions• Avoidance and withdrawal reactions
Reminders• Trauma reminders• Loss reminders• Change reminders

Intrusive reactions

Hyperarousal reaction

Traumatic memories come back as if the traumatic experience ishappening again, and you feel the same pain you felt at the event.

Constantly
being on-guard

Otherpeople

Sound

Light

Reinforcement of memory
through reexperiencing

Action 8: Linkage withcollaborative services

Avoidance reactions
Pushing traumatic memories into a black box in
the mind

Anger and agitation may cause
difficulties in interpersonal relationships

The mindavoids the recallof traumatic
memories

Behavior avoids
traumatic memories

Avoidance is a form of coping but is also
responsible for prolonging PTSD symptoms• Goal: To link students, teachers, and staff withavailable resources they need now or will needin the futureAction 8: Linkage withcollaborative services

Action 8: Linkage withcollaborative services• Determine whether or not further support isnecessary in light of a person’s needs and current
difficulties, and, if necessary, consult with theperson on how to connect with those additional
support resources.
• Examples of situations requiring a referral• Pay attention to a school policy and theexisting network of the school when referring toexternal agencies• Confirm compliance with the Act on theProtection of Personal Information and thepolicy of notifying parents• Do what is necessary to link to additional
resources effectively (Example: going to theoutside agency with family members)

Care for providers

Care for providers• Awareness
The first step is to seek awareness. To do this,you need to slow down and focus inwardly todetermine how you are feeling, what yourstress level is, what thoughts are going throughyour head, and whether your behavior isconsistent with what you really want to do.

• Balance
Next, seek balance in all areas of your life
(work, self, family, rest, hobbies). You will be
more productive when you have had
opportunities to rest and relax. When you
realize you are losing balance in your life, it is achance to change something.

Care for providers

Take Home Messages• Connection
The final step is connection. It is important tobuild supportive relationships with yourcolleagues, friends, family, and community. The
most powerful stress reducer is social
connection.

• You, who work in schools, are the key persons
who will restore schools.
• It is very important to provide PFA after an
emergency.
• Take a flexible and practical approach according toneeds, contexts, and phases of recovery.
• Please also refer to the PFA-S Field Operations
Guide.
• Take good care of yourself and your colleagues.

• An acute medical (psychiatric) problem• Worsening of a preexisting medical, emotional, or
behavioral problem• Harm to self or others• Alcohol, drug problems• Domestic violence, child abuse• Ongoing difficulties with coping