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1 Introduction

Israel has faced intense terrorism ever since it has been a state, within its territory, across the borders, and abroad. Residents of Gaza/West Bank and Israel are exposed to chronic tension and conflict , interspersed with periods of acute terror during outbreaks of violence and war. The residents in this region share a common experience of mistrust, stress and loss, and a need for community-based assistance to cope with that stress rather than allowing it to contribute to an increase in conflict. High rates of probable post-traumatic stress disorder (PTSD) and stress-induced health problems have been well documented among Palestinians (Hobfoll, 2011) and Israeli Jews and Arabs (Besser & Neria, 2012; Gelkopf, Berger, Bleich, & Silver, 2012). Traumatic reactions and post traumatic stress disorder (PTSD) frequently result in hyperarousal, hypervigilance, and increased aggression (Halpern & Tramontin, 2007). After a traumatic event (e.g., violence, war, disaster) or chronic frustrations such as poverty or deprivation, individuals are more likely to be aggressive (Renshaw & Kiddie, 2012). Populations in this region are distressed, depressed, and angry, and as a result many are prone to accepting violence and extreme ideologies as a means of coping. Additionally, children raised in these environments are likely to absorb and echo the violence and hostility that surrounds them, resulting in a multigenerational transmission of conflict and aggression between nations.

2 Psychological First Aid (PFA)

Following traumatic events, some individuals experience negative mental health impacts, such as PTSD, anxiety disorder, and/or major depression. However, others may experience posttraumatic growth and feel a positive reaction that brings strength (Pekevski, 2013). The field of disaster mental health focuses on methods to intervene and support both individuals and communities as they experience and cope with situations that can be extremely painful and disruptive to their lives (Halpern & Tramontin, 2007). The goal is to help the individuals and communities recover from disaster; recovery comes with an understanding of reactions to disaster as well as an understanding of when and how to intervene. Reactions to disaster include those that are categorized as normal, extreme, and prolonged or chronic.

Across these levels of response intensity, following a disaster, survivors may have physical, behavioral, material, social, emotional, and/or spiritual needs. Psychosocial support is key once the physical safety of survivors is ensured. Psychosocial support promotes resilience within individuals and communities to “heal the psychological wounds and rebuild social structures after an emergency or a critical event. It can help change people into active survivors rather than passive victims” (http://www.ifrc.org/en/what-we-do/health/psychosocial-support/). Putting that goal into practice, psychological first aid (PFA) uses these principles of immediate response to reduce the initial distress of the disaster event in order to promote longer-term coping. PFA is much like physical/medical first aid where first aid is provided by trained individuals from the general population whose immediate basic interventions might reduce or prevent the need for follow-up with medical providers (Jacobs & Meyer, 2006). PFA contains a set of helping actions that are aimed at reducing the initial posttraumatic distress and supporting short- and long-term adaptive functioning (Ruzek et al., 2007). PFA assumes that individuals will exhibit a wide range of reactions and emphasizes that most individuals will not develop severe mental health issues or prolonged recovery difficulties. In fact, it has been reported that only 11–15 % of survivors of a community-wide disaster would develop PTSD (Young, 2006).

3 Themes of Psychological First Aid

According to Sphere (2011) and the Inter-Agency Standing Committee (IASC) (IASC) (2007), PFA describes a humane , supportive response to a fellow human being who is suffering and who may need support. PFA involves the following themes:

  • Providing practical care and support, which does not intrude

  • Assessing needs and concerns

  • Helping people to address basic needs (e.g., 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

  • Protecting people from further harm (WHO, 2011)

PFA uses an evidence-informed approach built upon research on the individual components and by consensus in the field among disaster mental health experts; however, empirical research on the effectiveness of PFA is lacking (Pekevski, 2013). PFA seeks to use compassion and caring by those who intervene to reduce the stress of the response to disaster and promote coping among survivors (WHO, 2011). The techniques and actions are to be delivered in a culturally sensitive and respectful manner (Kantor & Beckert, 2011). As outlined in the Psychological First Aid: Guide for Field Workers (WHO, 2011) and depicted in Fig. 10.1, the core actions of PFA are as follows: Contact and Engagement; Safety and Comfort; Stabilization (provided only if needed); Information Gathering: Current Needs and Concerns; Practical Assistance; Connection with Social Supports; Information on Coping; and Linkage with Collaborative Services. Each of these components encompasses techniques such as listening, comforting, helping people to connect with others, and providing information and practical support to address basic needs (WHO, 2011). They also reflect the five essential elements Hobfoll et al. (2007) endorse as part of any intervention following immediate and midterm mass trauma, which include promoting safety, connectedness, self and collective efficacy, calm, and hope; when provided together these elements can assist individuals in their recovery.

Fig. 10.1
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Steps used in psychological first aid

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While PFA is not necessarily intended to be delivered in a particular order, each of the core actions of PFA often build upon the earlier action. For example, Contact and Engagement is the starting point of the interaction with the survivor. This action involves the basics of the worker introducing himself or herself and developing a working relationship with the survivors. This relationship is the foundation for the rest of the work to follow. This contact can be initiated by the survivor or by the worker. If it is initiated by the worker, then a compassionate and nonintrusive approach should be used. With this foundation, the worker is able to address the second core action of addressing Safety and Comfort with a goal to enhance immediate and ongoing safety, as well as to provide physical and emotional comfort for the survivor. Areas of focus in this step include decreasing any potential harm to the individual by removing them from debris or seeking a medical provider, if necessary. It is important to provide information on disaster and recovery at this point to empower individuals to help themselves as they best can (consistent with Hobfoll et al.’s (2007) emphasis on building self and collective efficacy). This information can assist in reorienting and comforting both children and families (National Center for Child Traumatic Stress Network and National Center for PTSD, 2006). During this phase workers may also be trying to locate missing family members and providing support with grief and spiritual issues, perhaps related to death and identification of bodies.

Stabilization is the next action item in PFA; however, it is only provided if necessary. This is important since PFA is built upon the notion that most individuals will recover without intervention if the individual is only provided with supportive contact (WHO, 2011). Stabilization involves extremely overwhelmed individuals, those who might be unresponsive or exhibiting extreme physical reactions such as shaking, hyperventilating, or crying uncontrollably for a long period of time or those who begin to engage in risky behavior. Addressing these extreme reactions to the disaster takes patience and compassion. Deep breathing, having the worker talk calmly to “ground” the survivor (WHO, 2011), or even medication or professional intervention are all components to be considered in this action item.

The next action items, Information Gathering: Current Needs and Concerns and Practical Assistance, focus on assessment of current needs in the context of the individual’s available resources and assistance with the provision of aid for immediate demands. This process of informal assessment seeks to identify the need for immediate referral and additional services. It has been well noted in the literature that it is important that the helper does not ask in-depth questions about the trauma experience as it may provoke additional stress and risk retraumatization of the survivor (Raphael & Meldrum, 1995). Survivors may want to talk about their experiences; however, they should not be pressed for details.

In the phase of information gathering, the assessment is not formal, nor is to provide a diagnosis. The goal is to clarify needs including physical, medical, and emotional needs, disconnection from family, and to identify prior emotional and physical/medical needs that may provide context for the current concerns. The worker should conduct this assessment in a sensitive way, particularly with children, the elderly, and others with vulnerabilities.

Once the needs and concerns are identified, then practical assistance can be offered. The survivor may require help to clarify the exact need before an action plan to address the need can be put into place (National Center for Child Traumatic Stress Network and National Center for PTSD, 2006). This may be especially true for children and families as they are trying to recover as a family with competing priorities for need and care (Gordon, Farberow, & Maida, 2013). Follow-through by the worker on the action steps identified with the survivor/family is key to ensure the action has been completed (National Center for Child Traumatic Stress Network and National Center for PTSD, 2006); reconnection with social networks has been shown to be an important task following a disaster to bolster overall recovery (Kaniasty, 2012). Helping survivors understand the value of social support, and, in turn, learning how to be supportive to others, is an important action. There is substantial evidence that perceived social support is a significant buffer to stress, even if the support comes exclusively from one reliable person (Norris et al., 2002). If possible, survivors should be physically reunited with loved ones who can provide information, practical support (e.g., help with chores), as well as emotional support and security. Helpers should ask directly “Who might you contact who could help you at this time?” As with the other action areas, special attention is needed for children, the elderly, or others, such as those with disabilities, who might need additional assistance to make or reconnect with social supports.

The final two action areas of PFA are Information on Coping and Linkage with Collaborative Services. These two actions are focused on emotional responses and less on the concrete services and needs that characterize the earlier phases of PFA. The information shared at this point involves both strategies to promote coping (e.g., stress management, suggestions to help with sleep, and ways to manage a healthy diet with limited resources) and education on maladaptive coping (e.g., anger management, or warnings about potential overuse of substances to cope) (National Center for Child Traumatic Stress Network and National Center for PTSD, 2006).

These collaborative services, such as mental health or medical health-care providers, can continue to help the individual to cope currently and over time.

The World Health Organization (2011) also points out that in this phase of PFA, it is important to focus on the developmental stages for children and adolescents to support coping by acknowledging that some regression to earlier stages is not uncommon (e.g., a child who was previously toilet-trained begins to bed-wet) and the child will regain forward developmental strides with reassurance and support. Figure 10.2 depicts some of the developmental milestones/events that children, adolescents, adults, and families may encounter that may be impacted at time of a disaster. The National Center for Child Traumatic Stress Network and National Center for PTSD (2006) asserts that the loss of developmental opportunities or achievements caused by a disaster can be perceived as a significant loss. This possible loss should be attended to using some of the basic principles of PFA communication techniques including listening, comforting, and helping, and through this the helper can link with collaborative services, as needed.

Fig. 10.2
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Developmental milestones

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4 The Project on Psychological First Aid

This USAID-funded project provided the foundation to assist the most vulnerable individuals (i.e. children, those with disabilities, the elderly) in the Middle East through a train-the-trainer program in PFA, with emphasis on conflict mitigation skills. The modified PFA model that was developed and delivered by the Institute for Disaster Mental Health emphasized that stress and trauma can lead to increased conflict because when stressed we cannot (1) be fully aware of our own feelings, (2) really know what we need, (3) communicate our own needs clearly, (4) accurately read another person’s nonverbal communication, and (5) hear what someone is really saying. This version of PFA also provided direct psychoeducation on how to mitigate stress and conflict by encouraging survivors to:

  • Manage their stress and stay calm.

  • Pay attention to the feeling of others. Try to recognize and respond to the things that matter to the other person.

  • Control their emotions and behavior.

  • Try not to hold onto resentments and anger.

  • Be aware of and respectful of differences.

The first stage of the project brought together mental health professionals from Gaza, the West Bank, East Jerusalem, and Israel for a 3-day workshop and training event at the Dead Sea in Israel. The location was selected as it was distant enough from other sites to avoid distraction and was experienced as a safe space by all attendees.

The goal of the meeting was multifold. First, together as an international group, in a train-the-trainer format, we sought to teach the principles and practices of PFA to encourage understanding of the impact of disaster and trauma on the different cultures, thereby increasing conflict mitigation. The meetings included cooperative exercises and role-plays that fostered understanding of one another. Second, we provided opportunities for pedagogical instruction in how to train others in PFA , as well as organizational guidance on how to reach appropriate trainees in each community. This train-the-trainer model multiplied the impact of the project, allowing each direct participant to extend their expertise to their wider community. Third, in separate groups, we translated and adapted the PFA materials from English into Hebrew and Arabic for culturally sensitive and relevant use in the communities-at-large. Finally, to carry out the final phase of the project, we instructed the participants on how to now take their training materials and skills to their home communities. Materials and data tracking forms were given to the participants in both paper and electronic formats to allow assessment of these community-based sessions.

4.1 Participants

The participants at the international train-the-trainer meeting included mental health professionals such as psychiatrists, social workers, psychologists, community health workers, and social service agency personnel. There were also several graduate students from health- and mental health-related professions. There were 16 participants from Arab communities including the West Bank, Gaza, and East Jerusalem, 15 from Israel (Some of the participants were from the Bedouin communities), and 5 participants from the United States. The principal investigators and lead collaborators, representing three different organizations based in Gaza, Israel, and the United States, coordinated the workshops.

4.2 Methods

The train-the-trainer sessions for the PFA materials were held in a large group format with all of the participants. The English version was taught to the group as a foundation that would then lead to the translation and adaptation of the materials in later meetings. The large group sessions allowed time for the materials to be presented and discussed, with time for questions. The room was set up in conference style with round tables; the Palestinian and Israeli participants were mixed at the tables to encourage cross-cultural conversation regarding the different components. Following the train-the-trainer component, opportunity to practice was provided. The participants each took turns at practicing teaching portions of the PFA materials. Facilitators provided feedback and encouragement to those practicing to enhance their skills.

The following day, the participants were divided into Hebrew speakers and Arabic speakers. The tasks for each group were to ensure that the translation of the PFA materials accurately reflected the intent of the PFA language and to adapt the materials to address any necessary cultural variations. Overall, the groups both made extensive, but not significant, changes to the language used; most changes were grammatical or semantic. The groups worked through the materials trying to envision how they would work “on the ground” to ensure the translations and cultural adaptations were realistic and meaningful.

Finally, the groups were instructed on how they were to take what they learned in the train-the-trainer sessions and go back into their home communities to apply their new knowledge of PFA, using the translated and culturally adapted materials.

As the final program component, using their training and the modified PFA materials, participants each conducted PFA trainings in their home settings, teaching groups of community members how to practice PFA in order to support themselves and others in times of stress and conflict. Before the trainings began, community learners/participants were given a pretest assessment, followed by a posttest assessment afterward to assess changes in their level of understanding of disaster, crisis, and the emotional response to crisis. The assessment items were developed by a committee to measure knowledge of training content and changes in perceptions. The full survey is included in Fig. 10.3.

Fig. 10.3
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Psychological first aid community training: pre- and posttest

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4.3 Translation and Adaptation of PFA Materials

The translation and adaption of the teaching materials through small group review and discussion found the cultural response to disaster and trauma to hold the most striking insight for participants and organizers. The Hebrew-speaking group overlaid a perspective on the training that shifted the English-language/American-cultural perspective of the original materials from a focus on empowerment and calming of the individual to one that allowed more open ventilation of feelings using language that was much more direct. This expression of emotion was not intended to be dysfunctional, rather it was felt that it would be more “normal” to be overtly emotionally reactive and that is what should be supported rather than the message to “relax” or “calm down” first. Once that phase of the more open emotional reaction ended, then the rest of the aid could be administered. At the end of the adaptation session, the Hebrew speakers were very satisfied with their changes to the training materials and felt that they were much more reflective of the Israeli culture and fit the speakers’ perspectives more appropriately.

The Arabic-speaking group took a different perspective in how they adapted the materials. There was consensus that terminologies used in the translation were accurate. However, one concern was on the maintaining of confidentiality for the individual while providing PFA due to cultural issues. For example, an impacted Palestinian person will likely be accompanied by close family members and close friends for the first few days following the event. The group put a lot of emphasis on the important role of family members and friends during crisis. Helping survivors connect with family, friends, and spiritual/religious leaders’ during crisis are considered to be of high importance. This group also discussed how using positive coping skills is becoming a challenge in this society due to the overuse of painkillers by traumatized persons. Painkillers are easily available at pharmacies without a doctor’s prescription. Tobacco smoking is also on the rise. Because of the prohibition of alcohol and drug use under Islamic law , most may deny their use and rarely talk about personal issues outside the family.

All of the final materials incorporating the groups’ adaptations are currently available on the website of the principal partner on the grant, the Institute of Disaster Mental Health (IDMH) at the State University of New York at New Paltz: http://www.newpaltz.edu/idmh/usaid.html.

4.4 Assessment of Training on Understanding and Response to Crisis

Using the modified PFA training materials, trainers went into the community to educate residents about how to implement PFA principles to assist their families and neighbors in times of conflict or disaster. In the West Bank, 371 (173 males and 198 females) were trained; the average age of the participant was 17.68 years with a range of 14–49 years. In Gaza, 116 (59 males and 57 females) were trained; the average age of the participant was 22.28 years with a range of 16–62 years. In Israel 183 (54 males and 128 females) were trained; the average age of the participants was 32.19 years with a range of 14–70 years. The majority of the trainings in the West Bank were delivered in schools (52 %), while 45 % of the trainings in Israel and 31 % of the trainings in Gaza happened in schools (the remainder in Gaza were predominately in social service agencies). Organizers were particularly pleased at this success in providing young people with productive coping skills as they may be more prone to reacting aggressively in response to acute conflict or chronic stressors.

The 670 individuals who participated in the community train-the-trainer sessions were surveyed using a pre- and posttest design to assess level of understanding of disaster, crisis, and the emotional response to crisis. The following are the results of that assessment by individual question. In each case, pre- and posttest responses for each nationality were compared using a paired samples t-test to check for statistically significant change resulting from the PFA training session.

1. How well do you understand how different kinds of crises or emergencies affect people?

Palestinian participants scored an average pretest score of 2.86 and an average posttest score of 3.90, a change which was statistically significant, t(486) = −16.243, p < 0.000. Israeli participants scored an average pretest score of 3.63 and an average posttest score of 4.15, also statistically significant, t(104) = −6.190, p < 0.000. As a result of this training, both Palestinian and Israeli participants reported a greater increase in understanding how disaster and emergency situations affect people.

2. How well do you understand which groups or individuals may need more help during or after a crisis or emergency situation?

Palestinian participants had an average pretest score of 3.00 and an average posttest score of 3.99, while Israeli participants had an average pretest score of 3.62 and an average posttest score of 4.17. Both changes were statistically significant (t(486) = −14.133, p < 0.000 for Palestinians and t(105) = −7.985, p < 0.000 for Israelis). Again, both groups reported a greater increase in understanding how to identify high-risk individuals groups that need more help during and after a disaster or emergency situation.

3. How well can you recognize if someone needs help after a stressful time?

Both groups also demonstrated significantly significant increases in this area. Palestinian participants average scores increased from 3.37 to 3.99 (t(486) = −9.177, p < 0.000) while Israeli averages rose from 3.60 to 4.01.

4. How well do you understand how to take care of yourself after assisting in an emergency?

Understanding in the area also improved significantly for both groups. Palestinians’ average scores rose from 3.40 to 3.98 (t(486) = −8.699, p < 0.000) and Israelis’ average scores grew from 3.05 to 3.80 (t(105) = −8.059, p < 0.000).

5. How well do you know how to assist your neighbor in or after a crisis situation?

Once again, the improvement in scores was statistically significant for both groups. Palestinian participants moved from an average pretest score of 3.23 to an average posttest score of 3.99 (t(486) = −11.579, p < 0.000). Israeli participants averaged 3.01 pretest score and 3.74 posttest, t(101) = −9.813, p < 0.000.

6. How well do you understand how ways of lowering stress can reduce conflict?

Change in this item was also statistically significant for both groups, with greater improvement among Palestinian participants who moved from an average pretest score of 3.09 to an average of 3.99 (t(486) = −12.815, p < 0.000), while Israeli participants began with a higher average of 3.32 and ended slightly lower than the Palestinians with a post-training average of 3.93 (t(101) = −7.157, p < 0.000).

7. How well do you understand ways to assist children, adolescents, and those with vulnerabilities?

Both groups also reported statistically significant improvement in understanding how to assist groups that often have more intense needs in times of disaster. Palestinians’ average scores increased from 3.15 to 3.97 (t(486) = −12.030, p < 0.000) and Israeli averages rose from 3.07 to 3.71 (t(101) = −8.524, p < 0.000).

8. When you are stressed and unhappy, how likely are you to blame/be angry with others?

Interestingly, this was one topic where neither group demonstrated any significant change as a result of the PFA training, with both remaining stable from pre- to posttest averages. Palestinian participants changed minimally from 2.88 to 2.87 (t(486) = −0.053, p < 0.958), while Israelis remained exactly level at 3.30 (t(100) = 0.000, p < 0.1.000).

9. When you are stressed or unhappy how likely are you to look for ways to make you feel less stressed?

Responses to this question returned to reflecting statistically significant improvement for both groups . Average Palestinian scores rose from 3.35 to 3.78 (t(486) = −6.176, p < 0.000) and Israeli averages went from 3.63 to 3.94 (t(102) = −5.031, p < 0.000).

10. During or after a crisis, how aware are you of and respectful of differences between you and other people?

Respect for differences also increased significantly and similarly for both groups, growing from 3.47 to 3.93 for Palestinian participants (t(486) = −7.010, p < 0.000) and from 3.48 to 3.89 for Israelis (t(102) = −5.477, p < 0.000).

11. How likely do you think training in psychological first aid (how to deal with stress) can help to reduce blame or conflict in your community?

Finally, results for the two groups diverged regarding change in beliefs about PFA’s utility in assisting their community, though reported post-training belief levels were very similar. Palestinian participants scored an average pretest score of 3.93 and an average posttest score of 4.33, a statistically significant increase in belief that PFA can help to reduce blame or conflict in their community (t(486) = −6.385, p < 0.000). Israeli participants’ scores did not increase significantly, going from 4.16 to 4.28 (t(102) = −1.560, p < 0.1.22). While the Israelis’ views did not change very much, they began at a higher baseline of belief in PFA. The Palestinians, in contrast, began with less faith in PFA’s power to help and concluded the community-based training with even stronger support for it than the Israelis.

4.5 Project Summary and Conclusion

This project, Mitigating Conflict Via Early Mental Health Interventions : Community-Based Psychological First Aid Training for Palestinians and Israelis , was intended to address three of the primary goals of USAID assistance for foreign countries: (1) furthering education, (2) assisting societies with preventing and recovering from conflicts , and (3) providing humanitarian assistance in the wake of natural and man-made disasters using PFA as the vehicle to promote communication and cooperation.

As there are significant logistical challenges in bringing Palestinians from Gaza, the West Bank, and East Jerusalem together with Arabic-, Russian-, and Hebrew-speaking Israelis, this cross-border project was ambitious but effective. Results from the train-the-trainer workshop assessment made it clear that the three goals listed above were accomplished. Palestinian and Israeli attitudes toward one another became more positive as a result of the workshop. Both groups furthered their education by learning the principles and practices of PFA, and they worked cooperatively to ensure that all training materials are both linguistically appropriate and culturally adapted to the intended audiences. They also learned pedagogical techniques to effectively teach PFA in their communities. As a result, there are now 30 highly qualified instructors available to not only provide this post-disaster evidence-informed practice themselves but with the skills and resources to train others to deliver PFA throughout their communities. Thus the 3-day workshop helped to reduce conflict, furthered education, and built capacity for effective response to disasters and complex emergencies in the region.

Most workshop attendees were able to deliver the PFA training in their community. The participants in Gaza and the West Bank far exceeded expectations as they trained boys and girls and men and women in a wide range of settings including schools and social service agencies. The Israeli colleagues successfully completed fewer training sessions but they also reached very diverse populations including graduate social work students, nursing students, high school personnel, Arab-speaking students working with the Bedouin population, and personnel providing substance abuse treatment.

Israeli and Palestinian trainers, who returned to their communities with more positive attitudes toward the other, delivered 26 separate PFA training sessions to 670 community members. As a result of these trainings, Israeli and Palestinian community members reported that they better understand how different kinds of crises or emergencies affect people; which groups or individuals may need more help during or after a crisis or emergency situation; how to recognize if someone needs help after a stressful time; how to take care of themselves after assisting in an emergency; how to assist their neighbor in or after a crisis situation; how to assist children, adolescents, and those with vulnerabilities; how to lower stress to avoid or reduce conflict; how to find effective ways to manage stress; and how to be more respectful of differences during or after a crisis. These results suggest the effectiveness of PFA to manage stress and reduce conflict.

Results from two of the items on the pre- and post-training surveys require more discussion. As a result of the PFA training, Israelis and Palestinians did not change their self-assessment on their tendency to blame others. However, their self-rating on this question was not very high at baselines. These participants may have already been predisposed not to scapegoat others when stressed. On the last item in the survey, there was a significant difference in the pre- and posttest scores for Palestinians, who were more likely to see PFA reducing blame or conflict in their community after the training. Israeli participant attitudes did not change significantly as the result of the training. However, it is clear that their view of the effectiveness of PFA to manage conflict was already high before the training and the training confirmed their already positive attitude toward the usefulness of PFA in promoting peace. After the training both groups of community members clearly saw PFA as an effective tool for conflict management and mitigation.

5 Future Directions

This is a region that has been severely traumatized with considerable stress, trauma, and loss. Multiple pathways to healing and conflict mitigation are necessary. The project goal was to mitigate suffering and conflict, working from the ground up. Results from both the workshop and community trainings suggest that the trainings may have made some contribution to healing and to peace, though it is difficult at this point to assess the total impact of the project as we do not know how many training sessions will be offered months or even years from now. The PowerPoint slides in English, Hebrew, Arabic, and Russian are available for use for future trainings and there is a well-developed and user-friendly training manual and survey instruments in multiple languages. Current trainers are in a position to deliver many more sessions to additional diverse audiences and we are hopeful that more will be offered. One weakness of this project to date was that workshop participants did not deliver joint trainings. That is, we were not successful in encouraging pairs of Palestinians and Israelis to overcome logistical barriers (such as travel restrictions and language differences) in order to deliver a training together. However, we do hope that this will occur in the future.

It is difficult to imagine working within the Middle East without encountering someone who has endured some type of physical or emotional reaction or trauma related to the ongoing conflicts in the region. While PFA is widely used and is considered an evidence-based intervention, it also requires additional research to understand its impact in the ever-changing environment of trauma and disaster. This program’s efforts to build community-level understanding of the principles of PFA and how to apply them is an initial way to build capacity to promote safety, efficacy, and resiliency throughout this troubled region in order to help stabilize residents and assist with coping and rebuilding.