1. Introduction

Multiple studies have shown that psychological debriefing does not improve recovery from psychological trauma ^[1], and in some cases, may actually negatively impact mental health outcomes ^[2][3]. In contrast, PFA does not involve discussions about the recent traumatic event, but instead focuses on providing humane, supportive, and practical help to individuals who are suffering and in need of support ^[4]. As an overarching supportive approach responds to the urgent physical and psychological needs, PFA can be used immediately in the aftermath of a traumatic experience as well as in the days or weeks afterwards. PFA can also be used within programmes where humanitarian workers are exposed to prolonged and chronic stressors (i.e., during a protracted crisis), and aims to prevent acute distress reactions from developing into longer-term distress ^[5].

The main purpose of PFA is to instil feelings of safety, calmness, self- and community efficacy, connectedness and hope; elements deemed ‘essential’ to trauma interventions in the early aftermath of disasters and mass violence by Hobfoll and colleagues ^[6]. Provided that basic physical needs are also being met within a humanitarian response, PFA thus works to meet the psychological needs of individuals through providing comfort and support, psychoeducation, and facilitating service connections to continued mental health resources ^[7]. The three main principles of PFA are to look (for safety, for who needs help), listen (to the person in distress) and link (to further support) ^[4][8]. Despite a dearth of studies examining the effectiveness of PFA ^[9], PFA is widely used within the humanitarian sector, including during disease outbreaks and pandemics ^{[10][4][5][8][11][12][13][14]}. While ascertaining the effectiveness of PFA remains particularly challenging, PFA is recognised as being evidence-informed ^[15], and has been shown to improve our knowledge and understanding of psychological response and skills in providing support to those exposed to acute adversity ^[16].

Group PFA (GPFA), delivered in a group or a team setting, is a more recent adaptation of PFA that is supported by several major agencies, including the IFRC, as an effective way to care for staff and volunteers in crisis ^[5]. As exposure to trauma can be extremely isolating for individuals ^[17], the provision of psychoeducation and PFA in a group setting can help normalise reactions and responses to trauma and strengthen group cohesion ^[7]. According to Eriksson et al. ^[18], organisational support and positive relationships with co-workers may also increase resilience among staff. Like PFA, the provision of GPFA is not only limited to professional counsellors but can be provided by trained workers, volunteers and peers ^[4][8]. GPFA therefore offers humanitarian organisations the opportunity to provide an important resource to staff and volunteers, as a likely lower-cost, scalable, and potentially highly effective mental health and psychosocial support initiative, which can be delivered by managers to humanitarian workers before, during and after responding to crises. In addition, GPFA also has the potential to build peer support networks within a team ^[7][8]. The implementation of GPFA, including when it is initiated, by whom and how often, is often at the organisation’s discretion and dependent on the situation.

Given the increasing recognition of the importance of supporting staff and volunteers’ mental health within crisis settings ^[19], it is likely that GPFA will continue to attract increased attention in the coming years. Extant literature on the potential impact of GPFA to prevent or address anxiety and/or depression in the workplace, however, remains scarce. Therefore, the current study aimed to draw from the available evidence, including theoretical frameworks available from the existing PFA literature as well as similar group-style psychosocial based interventions, to understand “What works, for whom, in what context, and why for Group Psychological First Aid for humanitarian workers, including volunteers?”. In addition, and given that the humanitarian workforce are largely comprised of volunteers and staff who are at an early stage of their career, and that 75% of all lifetime mental health problems occur by the age of 24 ^[20], we further sought to understand how GPFA may be particularly relevant to young workers and volunteers (defined as those aged under 25).

2. Group Psychological First Aid for Humanitarian Workers and Volunteers

The group format of GPFA increases the capacity of psychosocial support provision through providing PFA to several individuals at the same time, while also fostering support and relationship building between group members ^[21]. Additionally, because it is not required for facilitators to be mental health specialists, GPFA offers a practical approach to provide psychosocial support to populations affected by a crisis, particularly in low-resource settings, once the sufficient training of facilitators occurs ^[22][23]. That said, GPFA remains an intensive approach that needs comprehensive consideration prior to implementation.

GPFA is a complex approach that should be embedded within wider support systems. As such, linkages and well-structured supports are required for the successful implementation of GPFA. GPFA should therefore only be implemented when organisations can either link to or provide additional resources to participants, specifically basic needs support and further services (i.e., more advanced mental health support). Appropriate staff make-up and competencies are also essential, including the availability of supervisors, trainers and facilitators. Resources for facilitators should also be available. Therefore, organisations should consider building appropriate support systems to ensure the successful implementation and impact of GPFA.

GPFA is applicable to a wide variety of contexts, including resource-constrained contexts. However, best practice still needs to be applied to ensure the ethical and appropriate support of participants. Our findings highlight many of the different contextual nuances necessary to consider in the implementation of GPFA. Of main importance among these findings is the recognition that GPFA is implemented in different contexts, and the specifics of GPFA are not one size fits all. The design or implementation of GPFA should therefore be preceded by a thorough contextual analysis which aims to identify: (1) the existing support services available for linkages and referral; (2) basic needs requirements and the ability of the organisation to support or provide these; (3) group history and experiences (e.g., are they a pre-existing group or to be newly formed); (4) socio-cultural conditions for the composition of the group, including any gender, age, or cultural considerations; and (5) the characteristics of facilitator(s) and how they will be trained, supervised and supported. Testing the finalised programme theories through real-world implementation would strengthen our understanding of how GPFA works, for whom, in different contexts. Additionally, the ways in which informal communication networks can be integrated and support GPFA members should be examined. Finally, exploring opportunities and challenges to provide GPFA remotely would be beneficial, especially in the context of epidemics such as Coronavirus Disease (COVID-19).

3. Conclusions

The humanitarian workforce faces many challenges, with staff and volunteers at an increased risk of anxiety, depression, and post-traumatic stress disorder. GPFA is widely recommended and implemented to provide humane, supportive and practical help in a group setting after an acute or during an ongoing event. However, there is a dearth of evidence on how, why and for whom GPFA works to address the needs of this cadre. What is more, the literature on GPFA for youth is extremely sparse. The current review puts forward a number of programme theories to advance our understanding of ‘how, why, for whom and in what contexts’ GPFA works. By applying these theories to existing evidence on youth, we have provided further key contextual and programmatic insights into GPFA for this specific demographic. Largely centring on the benefits of having appropriately implemented peer support, GPFA enables individuals to understand their natural reactions to stressful events and develop adaptive coping strategies, while also building social connections that promote a sense of belonging and security. The integrated design of GPFA ensures that individuals are linked to additional supports and have their basic needs addressed. While this approach is based on sparse evidence, its applicability to youth and its ability to provide support to humanitarian workers remains promising.