Psychological first aid

1. Introduction

Version followed: Psychological First Aid: Field Operations Guide, 2nd edition (Brymer, Jacobs, Layne, Pynoos, Ruzek, Steinberg, Vernberg & Watson; National Child Traumatic Stress Network and National Center for PTSD, July 2006; "PFA-FOG") as the core protocol, with the WHO / War Trauma Foundation / World Vision International Psychological first aid: Guide for field workers (2011; "WHO-PFA", Look-Listen-Link) for ethics, preparation, ending contact and humanitarian settings. Where they differ, the version is named.

Psychological first aid (PFA) is not a psychotherapy and not a phased treatment. It is a modular, evidence-informed early-response framework for children, adolescents, adults, families and responders in the hours, days and (WHO) weeks after a disaster, terrorism, accident or other serious crisis. WHO-PFA defines it as "a humane, supportive response to a fellow human being who is suffering" (WHO 2011, citing Sphere and IASC), deliverable by non-specialists as well as clinicians. Both guides state plainly that PFA is not psychological debriefing: it does not ask for a detailed account of the event, does not ask people to analyse or sequence what happened, and does not press anyone to share feelings [source: PFA-FOG 2006, delivery guidelines; WHO 2011, ch. 1].

Core idea of change: PFA does not assume that everyone exposed will develop lasting problems. It aims to reduce initial distress and foster short- and long-term adaptive functioning by restoring the conditions linked to natural recovery: feeling safe, connected to others, calm and hopeful; having access to social, physical and emotional support; and feeling able to help oneself (WHO 2011, summarising the evidence base) [source: PFA-FOG 2006, Introduction; WHO 2011, ch. 1]. These five conditions correspond to Hobfoll et al.'s (2007) "five essential elements" of immediate and mid-term mass-trauma intervention [uncertain: the 2007 paper itself is not drawn on here; the link is stated from general knowledge of the literature, the five conditions themselves are from WHO 2011].

For a practising psychotherapist: PFA is what you do when you are deployed into, or receive clients from, an acute crisis. It is not a substitute for trauma-focused treatment; its job is to stabilise, meet needs, connect and link onward.

2. Framework

Structure. PFA-FOG is organised as eight Core Actions, used flexibly and not as fixed stages; time spent on each depends on the survivor's needs [source: PFA-FOG 2006, Core Actions overview]:

Contact and Engagement: respond to survivors who approach, or initiate contact non-intrusively and compassionately.
Safety and Comfort: enhance immediate and ongoing safety; give physical and emotional comfort.
Stabilization (if needed): calm and orient emotionally overwhelmed or disoriented survivors.
Information Gathering: Current Needs and Concerns: identify immediate needs and tailor the help (not a formal assessment).
Practical Assistance: help address immediate needs.
Connection with Social Supports: establish contact with primary supports and community resources.
Information on Coping: information about stress reactions and coping, to reduce distress and promote adaptive functioning.
Linkage with Collaborative Services: link to services needed now or later.

WHO-PFA compresses the same work into Prepare (before entering) and three action principles: Look (safety, urgent basic needs, serious distress reactions), Listen (approach, ask about needs and concerns, listen and help people calm), Link (basic needs and services, coping with problems, information, loved ones and social support), then Ending your help [source: WHO 2011, ch. 2 to 3].

Format and dose.

Single contact is typical; may be repeated briefly over days. No fixed session count exists in either source [source: PFA-FOG 2006; WHO 2011]. A contact can last minutes (a calm look, a blanket) to an hour or more (death notification support) [synthesis].
Settings: shelters, field hospitals and medical triage areas, emergency departments, staging areas, family assistance and reception centres, feeding sites, hotlines, homes, businesses, schools, camps, distribution sites, accident scenes (PFA-FOG; WHO). Individual, family or group (with families addressed via their spokesperson).
Timing: PFA-FOG: immediate aftermath of disaster or terrorism. WHO-PFA: during or immediately after the event, sometimes days or weeks later depending on duration and severity.
Delivery role: PFA-FOG requires delivery within an authorised, organised response (incident command, Red Cross, CERT, Medical Reserve Corps, school crisis teams, faith-based organisations etc.); do not self-deploy [source: PFA-FOG 2006, delivery guidelines].
Licensing: PFA is freely distributed and not a licensed programme; neither guide requires certification to deliver it. Training is offered by the developers (e.g. NCTSN's online PFA course) [uncertain: training offer; check your deploying agency's credentialing requirements, which usually do apply].

Sequencing and decision criteria [source: PFA-FOG 2006; WHO 2011; ordering logic partly synthesis as marked]:

Before anything: scene safety (WHO Look). If the site is unsafe, do not enter; communicate from a safe distance.
Override priority: life-threatening injury, need for rescue, risk of harm to self or others, or people too distressed to care for themselves or their children go first to medical, security or specialist help; stay with the person or arrange someone to stay [source: WHO 2011 "people who need more advanced support immediately"; PFA-FOG Core Action 2 urgent concerns].
Contact → Safety/Comfort: always.
Stabilization: only when the person shows signs of being overwhelmed or disoriented (PFA-FOG: extreme agitation, rushed speech, losing touch with surroundings, ongoing intense crying). If not needed, skip it.
Information gathering runs through the whole contact, and determines which of Core Actions 5 to 8 to emphasise.
Move to linkage / referral when: acute need cannot be met on site; thoughts of harming self or others; reactions so severe the person cannot function or care for dependants; medical or medication needs; substance withdrawal; or (PFA-FOG Core Action 7) reactions continuing to interfere with functioning for more than about a month.
Ending (WHO): based on the context, your role, the person's needs and your own limits; announce it, hand over by name where someone takes over, confirm onward links.
Next step after PFA (not PFA itself): the same developers published Skills for Psychological Recovery (SPR) for the weeks and months after; trauma-focused treatment where indicated [uncertain: SPR materials].

3. Guiding principles

From PFA-FOG basic objectives and delivery guidelines and WHO-PFA ethics and communication guidance [source: PFA-FOG 2006, Introduction and Preparing to Deliver PFA; WHO 2011, ch. 2 and 3]:

Non-intrusive human connection first. Observe before approaching; open with brief, respectful questions, often by offering something practical (water, blanket).
Do not assume trauma or pathology. Treat reactions as understandable and expected; avoid the words "symptoms", "disorder", "diagnosis", and labels such as "crazy".
No debriefing. Do not ask for a detailed account of the event; follow the person's lead if they choose to talk.
Present-focused, needs-led. Reduce distress and meet current needs; attend to what the person says matters most right now, not what you think matters.
Safety, dignity and rights (WHO). Avoid further harm; protect from physical and psychological harm (including media); treat fairly and according to culture, age and gender.
Self-determination and voluntariness. Offer, never force; respect a refusal, and tell people how to find help later.
Honesty. Give only information you know and its source; say "I don't know" and find out; no false promises about safety, goods, services or reunification.
Promote self-efficacy. Involve people actively in meeting their needs (walk with them to supplies instead of fetching); acknowledge protective actions and strengths; avoid solving everything for them.
Calm, visible, organised presence. Speak slowly, simply and concretely; no jargon or acronyms; model calm.
Silent presence is legitimate. Do not force conversation; being nearby is often enough.
Cultural and diversity humility. Defer to local norms on distance, eye contact, touch, who approaches whom (WHO: whether women should be approached by women), family spokesperson, mourning and religious practice; consult community leaders.
Attend to the at-risk. Children (especially separated), older adults, people with disabilities or health conditions, people at risk of discrimination or violence, the bereaved, those with prior trauma.
Stay in role and within competence. Work inside the authorised response; do not exaggerate skills; refer upward.
Confidentiality, with mandated limits. Protect privacy even in public settings; follow child-abuse and other mandated reporting; route information-release questions to a supervisor (PFA-FOG notes HIPAA disaster provisions in the US).
No exploitation (WHO). Never seek money, favours or any personal gain from the helping relationship.
Do no harm by over-promising follow-up [synthesis]: offer only follow-up you can actually deliver.
Look after yourself and colleagues. Your stress and limits shape your judgement; plan rest, rotation and supervision.

4. Intervention inventory

Organised by PFA-FOG Core Action, with WHO-PFA additions placed where they fit. All example language is the author's own illustrative wording unless shown in quotation marks with a citation. Section-level sources: PFA-FOG 2006 Core Actions 1 to 5 are drawn on in full; for Core Actions 6 to 8 the full text is drawn on only up to the start of Core Action 7 (pp. 71 to 78); the remaining sub-action headings were verified from the guide's Appendix A overview, and their detailed steps are marked [uncertain] or [synthesis].

4.0 Preparing to deliver PFA (before contact)

Purpose: enter the site able to act safely, accurately and within the response structure.
Steps: (1) Join through an authorised agency; know your role, supervisor and the incident command structure (PFA-FOG). (2) WHO "Prepare": learn what happened, when, where, how many and who are affected; which services exist (medical care, food, water, shelter, family tracing), where and how to access them, and whether communities are involved; whether danger is ongoing, which hazards exist and which areas are off-limits. (3) Learn cultural norms: dress, greetings, language, whether women should be approached by women, touch, who the leaders are, local explanations of the event (WHO). (4) Check your own readiness: health, personal and family stressors, recent losses; decide honestly whether you can help now (WHO). (5) On entering, observe the setting first and introduce yourself to site leadership; in group settings, be visible and calm (PFA-FOG Preparing headings: entering the setting, providing services, group settings, calm presence, cultural sensitivity, at-risk populations).
Example language (illustrative): to the shelter manager: "I'm here with the county mental health team; where would it help most for me to be, and who should I report concerns to?"
Watch for: self-deploying, arriving without service information (you will be unable to link), or your own unaddressed loss making the work unsafe for you.
[source: WHO 2011, ch. 2 Prepare and ch. 4; PFA-FOG 2006, delivery guidelines; Appendix A]

4.1 Contact and engagement (Core Action 1)

Purpose: establish non-intrusive, compassionate contact; this is the gateway to everything else.
When: with every survivor you encounter.
Steps: (1) Respond first to people who seek you out; if several approach at once, make brief contact with each (even a calm, interested look helps). (2) For people not seeking help, time your approach: do not interrupt conversations; offering practical help is often the easiest entry. (3) Introduce yourself with name, title and role; ask permission to talk; explain you are there to see if you can help. (4) Use surnames for adults unless invited otherwise. (5) Invite the person to sit, seek privacy, give full attention; speak softly; do not look around or appear distracted. (6) Ask about pressing problems; immediate medical needs come first. (7) With families, identify and address the spokesperson first. (8) Cultural cues: unless you know the culture, avoid close approach, prolonged eye contact and touch; watch for personal-space cues. (9) If the person declines, respect it and say how and where to find help later; expect that some people need time before trusting. (10) Children: first connect with the parent or accompanying adult, explain your role and get permission; if a distressed child is alone, find a caregiver as soon as possible and tell them about the conversation; get to eye level, use the child's name, speak softly; talk with adolescents as you would with adults.
Example language (illustrative): "Hello, I'm Dr Patel, I'm one of the mental health staff working with the Red Cross here. Would it be all right if I sat with you for a few minutes? Is there anything you need right now?" To a child, at eye level: "Hi Sam, I'm Maria. I'm here to help you and your family."
Watch for: relaxing posture, accepting water or a seat, the person naming a need. Avoidance or intense seeking out are both expected; neither means failure.
[source: PFA-FOG 2006, Core Action 1]

4.2 Managing confidentiality in the field

Purpose: protect privacy in crowded, public, media-exposed settings.
Steps: (1) Keep conversations as private as the setting allows. (2) If you are a mandated reporter, follow child abuse and neglect reporting duties. (3) Know the disaster provisions of your privacy law (PFA-FOG names HIPAA for the US). (4) Refer any request to release information to a supervisor or official in charge. (5) Keep confidentiality when debriefing stress with peers. WHO adds: never share a person's story with others.
Example language (illustrative): "What you tell me stays with me and the team helping you, unless I'm worried about someone's safety; then I'd tell you first."
[source: PFA-FOG 2006, Core Action 1; WHO 2011, ethics]

4.3 Ensuring immediate physical safety (Core Action 2)

Purpose: remove threats; restoring a sense of safety reduces distress.
Steps: (1) Check the physical environment and rearrange it if needed: broken glass, sharp objects, spills, tripping hazards, unstable furniture. (2) Report threats, weapons or similar concerns to officials who can act. (3) Make sure children have a supervised, safe play area. (4) Be alert to subgroups at risk of being targeted (ethnicity, religion, other affiliation). (5) Older adults and people with disabilities: improve lighting; reduce fall risk; ask specifically about glasses, hearing aids, wheelchairs, walkers, canes and keep them with the person; ask about help needed with dressing, toileting, grooming, meals; ask about medications and help the person obtain and keep a readable medication list; consider a list of people with special needs for more frequent checks; contact relatives; report unmet daily needs to authorities. (6) Urgent concerns: medical need or urgently needed medication → contact the unit leader or medical staff immediately and stay (or arrange someone to stay); risk of harm to self or others (intense anger, extreme agitation) → summon medical, EMT or security support. (7) Recognise signs of shock (pale or clammy skin, weak or rapid pulse, dizziness, irregular breathing, glassy eyes, unresponsiveness, loss of bladder or bowel control, restlessness or confusion) and get medical help immediately.
Example language (illustrative): "Before we talk, let me move these boxes so nobody trips. Do you have your glasses and your medicines with you?"
Watch for: people who cannot report their own needs (cognitive impairment, sensory loss, small children).
[source: PFA-FOG 2006, Core Action 2; WHO 2011, Look]

4.4 Providing information about response activities and services

Purpose: reduce uncertainty, rumour and helplessness.
Content: what to do next, what is being done, what is known about the event, available services, common stress reactions, self-care, family care and coping (PFA-FOG).
Steps: (1) Judge whether the person can take in information now. (2) Use clear, concise language without jargon. (3) Ask what questions they have and what they need authorities to know (e.g. special placement needs). (4) Address current danger and safety concerns with the facts you have. (5) If you do not know, do not guess: find out with them. (6) Do not promise safety or goods and services unless confirmed. (7) WHO adds: say where the information comes from and how reliable it is; keep messages simple and repeat them; give the same information to groups so everyone hears it; say when and where updates will come; expect frustration if expectations are unmet and stay calm.
Example language (illustrative): "Here's what I know for sure, and where it comes from. The next briefing is at 4 pm in the gym. I don't know yet about the road to your street; I'll ask the shelter lead and come back to you before then."
Watch for: information overload in distressed people (repeat later, write it down); your own urge to reassure beyond the facts.
[source: PFA-FOG 2006, Core Action 2; WHO 2011, Link "giving information"]

4.5 Attending to physical comfort

Purpose: physical comfort reduces arousal and gives a sense of being cared for; active participation reduces helplessness.
Steps: (1) Improve temperature, light, air quality, seating and furniture arrangement where possible. (2) Invite the person to get what they need and go with them to supply areas rather than fetching for them. (3) Help people soothe themselves and others. (4) Children: comfort items (e.g. soft toys) only if there are enough for every child who asks; teaching a child to look after the item can model self-care. (5) Older adults and people with disabilities: watch for blood pressure, fluid and electrolyte problems, oxygen dependence, frailty, sensory loss causing apparent confusion, cognitive difficulty, new mobility limitation, overstimulation, long queues, and worry about service animals.
Example language (illustrative): "The blankets are over by the stage; shall we walk over together and pick one out?"
[source: PFA-FOG 2006, Core Action 2]

4.6 Promoting social engagement

Purpose: calm others steady people; helping others reduces isolation and helplessness.
Steps: (1) Help survivors spend time with people who are coping adequately; keep very agitated people apart where possible. (2) Correct rumours and misinformation. (3) Place children near calm adults or peers, away from highly distressed people; briefly explain to children what they saw and encourage them to tell a trusted adult if upset. (4) Encourage people who are coping to support others with similar experiences (same neighbourhood, children of similar ages). (5) For children offer shared activities: reading aloud, art, card and board games, sport.
Example language (illustrative): "Mrs Okafor is from your block too, and she has a toddler; would you like me to introduce you?"
[source: PFA-FOG 2006, Core Action 2]

4.7 Children separated from caregivers; child-friendly space

Purpose: reunification is a top priority; unaccompanied children face added risks (WHO: abuse, exploitation, trafficking, recruitment).
Steps: (1) Collect identifying information (child's name, caregivers' and siblings' names, address, school) and notify the appropriate authority; WHO: work through a trustworthy child-protection agency, do not attempt reunification alone, and never leave the child unattended. (2) Explain simply who will look after them and what happens next. (3) Do not promise a quick reunion. (4) Support the child while caregivers are being found or while caregivers are overwhelmed. (5) Child-friendly space: a safe area away from traffic and rescue activity; staffed by people experienced with children of various ages; sign-in and sign-out control to prevent unauthorised pick-up; materials for all ages (toys, games, art supplies, books, safety scissors); calming activities (blocks, play dough, neutral colouring pages, team games); older children can mentor or read to younger ones; separate time and activities for adolescents (music, games, storytelling, scrapbooking).
Example language (illustrative): "I don't know yet where your mum is, but lots of people are looking. While they look, Jen and I will stay with you here."
[source: PFA-FOG 2006, Core Action 2; WHO 2011, children]

4.8 Protecting from additional traumatic experiences and reminders

Steps: (1) Shield survivors from reporters, onlookers and attorneys. (2) Tell adolescents they may decline media interviews and should have a trusted adult present if they agree. (3) Encourage limiting disaster media exposure; parents should monitor and limit children's viewing, talk about what children see, and watch what they say in front of them; adults too can take breaks from coverage. (4) WHO adds: protect children from gruesome scenes and upsetting accounts.
Example language (illustrative): "You don't have to talk to any reporters. If you'd like, I can ask them to give you space."
[source: PFA-FOG 2006, Core Action 2; WHO 2011]

4.9 Supporting survivors with a missing family member

Steps: (1) Expect fluctuating denial, worry, hope, anger, shock, guilt and vengeful thoughts. (2) Help families obtain updated information, find briefings and understand reunification procedures; point to official registries (PFA-FOG names the American Red Cross family-welfare and "Safe and Well" systems; use the current local equivalent). (3) Take extra time to listen to hopes and fears; answer honestly. (4) Review pre-disaster contact plans (school or work evacuation plans, out-of-area contacts, meeting points). (5) If someone wants to leave a safe area to search, explain dangers and precautions and when updates are expected; ask about medical needs and offer to inform authorities. (6) Limit young children's exposure to missing-person reports. (7) If a child must be interviewed, a trained mental health or forensic professional should do it or be present, with a trusted adult; tell the child it is fine not to remember. (8) If evidence suggests death, tell family that differing levels of hope among members are common and are not a measure of love; caregivers should not assume a child is better off continuing to hope, and should share concerns honestly and check understanding.
Example language (illustrative): "It makes sense to swing between hoping and fearing the worst. Let's make sure you're on every list that matters and know when the next update is."
[source: PFA-FOG 2006, Core Action 2]

4.10 Supporting the bereaved (acute grief)

Steps: (1) Learn local and family mourning norms; support the family's own rituals; do not assume group members share beliefs. (2) Normalise grief (sadness, anger, guilt, regret, longing, dreams of the person) with no single right way or timeline; children may grieve in short bursts, even while playing; family members may grieve differently. (3) Use the deceased person's name. (4) Say that waves of sadness, loneliness or anger are likely to continue. (5) Warn about increased risks (misuse of over-the-counter medication, smoking, alcohol) and share self-care and professional-help information. (6) Listen quietly; do not probe. (7) If grief or depression impairs daily functioning, suggest clergy or a grief counsellor, or referral via doctors, local mental health departments or hospitals. (8) Avoid cliches such as claiming to know how they feel, that it was for the best, that the person is better off, that they will feel better soon, that they did everything they could, that they are strong enough, or changing the subject; if the bereaved person says such things themselves, acknowledge the feeling, but do not initiate them. (9) Developmental knowledge: preschoolers may not grasp permanence and need the physical reality of death confirmed and reassurance the person is not in pain; school-age children may personify death or sense a ghost-like presence they keep secret; adolescents may react with rage or impulsive acts (dropping out, running away, substance use) needing prompt attention. (10) Coach caregivers: reassure children they are loved and will be cared for; watch for readiness to talk and never make a child feel guilty for talking or not; short, honest, age-appropriate answers, repeated as needed; say "I don't know" when true; reassure the child they did not cause the death and were not being punished, repeating as guilt recurs; be honest about funerals and rituals; give the guide's "When Terrible Things Happen" handout. (11) Loss of a parent: preschoolers need consistent care and routine; school-age children lose comfort as well as care and may direct anger at substitute caregivers; adolescents may resent extra responsibilities, so negotiate the balance over time.
Example language (illustrative): to a caregiver: "You could try: 'I miss Daddy too. I'm thinking about him right now. Are you?'" To the child: "Nothing you did or thought made this happen."
[source: PFA-FOG 2006, Core Action 2 "Help survivors when a family member or close friend has died"]

4.11 Attending to grief and spiritual issues

Steps: (1) Know which clergy are on the team and how to reach local faith communities. (2) Ask whether the person has any religious or spiritual needs right now; this is not an invitation to theological discussion or spiritual counselling. (3) You need not share their beliefs and are never required to act against your own. (4) Do not argue with or correct religious statements, even distressing ones; do not try to answer "why" questions, which usually express pain rather than request an answer. (5) Offer connection with clergy of their choice. (6) Help recover lost religious objects; find private space to pray and help with orientation if their practice requires a direction; help find a place where candles or incense are allowed. (7) If asked to join a prayer, you may decline or stand quietly. (8) Neither encourage nor discourage hope for a miracle. (9) Ask about religious requirements for care of the body, especially when remains are not recovered. (10) Where grief is loud by custom, offer a private space; ask a colleague to help if it is hard for you. (11) Listen non-judgementally to anger at God. (12) If outsiders press beliefs on survivors, do not intervene yourself: notify security or those in charge.
Example language (illustrative): "Is there anything you need for your faith right now, like a place to pray or someone from your community?"
[source: PFA-FOG 2006, Core Action 2]

4.12 Information about caskets, funerals and children at funerals

Steps: (1) Help families learn local laws on body preparation, burial and autopsy (often mandatory after traumatic death; a medical examiner may sometimes waive it, which matters where faith forbids autopsy). (2) Where tradition allows and the body is badly disfigured, a photograph on the casket can help mourners. (3) Children: attending can help accept the death and exclusion can hurt; give a real choice, encourage without pressure; explain beforehand what will happen (adults crying, family area, sequence); let the child choose a companion and always provide a way to leave with them; offer alternatives (staying with a trusted neighbour) and other ways to take part (reading something, a later personal memorial); for young children consider an early visit to the venue, describe the casket, approach together only if they wish, be cautious about viewing or touching the body; reassure that the person is not in distress. (4) Attend funerals only with the family's knowledge and permission.
[source: PFA-FOG 2006, Core Action 2]

4.13 Attending to traumatic grief

Purpose: after traumatic death some survivors fixate on preventability, the final moments or blame, which blocks mourning.
Signs: intrusive images that crowd out positive memories; withdrawal; avoidance of usual activities as reminders; children's repetitive trauma-themed play.
Steps: (1) Recognise that this puts the person on a different timeline from the family. (2) Speak privately with family members who witnessed the death; acknowledge the extra burden. (3) Suggest a mental health professional or clergy can help them decide what to share with family and cope with grief. (4) Link to follow-up (4.36).
Example language (illustrative): "Seeing what you saw is a heavy thing to carry. Someone trained in this could help you work out what, if anything, to share with the rest of the family."
[source: PFA-FOG 2006, Core Action 2]

4.14 Supporting survivors who receive a death notification

Context: you may accompany police, hospital staff or mortuary teams; early reports can be wrong, so urge families to await official confirmation.
Steps: (1) Do not rush; allow time to absorb and ask questions; expect strong reactions from agitation to numbness. (2) Use "died" for confirmed deaths, not euphemisms. (3) Show empathy as understanding of their feelings, not by voicing your own. (4) Get medical help if needed and authorities if anyone may harm themselves or others. (5) Make sure supporters (family, friends, neighbours, clergy) are present. (6) Work with individuals or family units at their own table, not in crowds. (7) Review passenger lists, morgue photos and similar only privately, in family groups, with appropriate authorities; keep children away from morgue photos. (8) If an unaccompanied child learns a caregiver died, stay (or arrange a colleague) until family or child protective services arrive. (9) Children may appear not to hear, cry, protest, go silent or be angry at the messenger; coach caregivers to say it is hard news, crying or not crying are both fine, and they will be there to talk any time. (10) Adolescents: caregivers should warn against risky responses (reckless driving, staying out, risky sex, substance use, storming off), expect some rage, and be firm on risk; take suicidal or revenge statements seriously and get help immediately. (11) Answer children's questions about who will look after them; avoid separating siblings if at all possible.
Example language (illustrative): "I'm so sorry. Your husband died in the collapse this morning. Take whatever time you need; I'll stay here with you."
[source: PFA-FOG 2006, Core Action 2]

4.15 Supporting body identification and confirming it to children

Steps: (1) Providers usually do not attend the identification but help before and after. (2) Some people need to see the body to accept the death; adolescents may ask to attend; discourage young children. (3) Families often want to know where and when the body was found and what the person went through; unanswered questions can distress more than answers. (4) After viewing expect shock, numbness, fainting, vomiting, trembling, screaming or lashing out; have medical support at hand [synthesis: arranging medical standby]. (5) Coach caregivers to tell the child directly that the person has been found and has died (young children may not grasp finality); explain forensic identification certainty in simple terms; reassure that the person was loved and the child will be cared for; reassure about suffering only when that is known to be true [synthesis: PFA-FOG advises reassurance that the person did not suffer; avoid stating it if it is false]; invite questions and promise to find out what you do not know; avoid disturbing physical details and steer toward positive memories.
Example language (illustrative): caregiver to child: "They found Uncle Jack. He died, and he is not coming back. I remember our fishing trips; which memory of him would you like to keep?"
[source: PFA-FOG 2006, Core Action 2]

4.16 Stabilizing and orienting an overwhelmed survivor (Core Action 3)

Purpose: calm and orient people whose distress prevents them from functioning, taking in information or deciding. Most people do not need this; strong emotion alone is not an indication.
When: PFA-FOG signs include extreme agitation, rushed speech, seeming to lose touch with surroundings, ongoing intense crying; WHO adds people who are unresponsive, unable to move, in shock or unable to care for themselves. The opening part of Core Action 3 (sub-actions "stabilize" and "orient" emotionally overwhelmed survivors) was confirmed only from Appendix A headings [uncertain for any further PFA-FOG detail].
Steps: (1) Ensure the person is safe and not alone (WHO: keep severely distressed people from being alone until the reaction eases or a handover is made). (2) Give a moment and privacy; stay calm, quiet and present rather than talking at them [source for this step: a 2022 training deck by Koyfman and Dominguez based on PFA-FOG; secondary]. (3) Ask the person to listen to you and look at you. (4) Check orientation: who they are, where they are, what is happening. (5) Ask them to describe their surroundings and say where you both are. (6) If they remain overwhelmed, move to grounding (4.17). (7) If none of this helps, or there is risk to self or others, psychosis, or extreme panic, get medical or mental health consultation (4.18).
Example language (illustrative): "Mr Diaz, can you look at me? Just listen to my voice. You're at the Lincoln High shelter; it's Tuesday afternoon; I'm Ana from the mental health team. Can you tell me what you can see around you?"
Watch for / working: slower breathing, eye contact, answering orientation questions accurately, able to state a need. Not working: no response, worsening agitation, confusion out of proportion (consider medical causes: head injury, hypoglycaemia, dehydration, intoxication or withdrawal, delirium in older adults [synthesis, consistent with PFA-FOG's guidance on older adults' confusion]).
[source: PFA-FOG 2006, Core Action 3 pp. 51 to 53; WHO 2011, Look and Listen]

4.17 Grounding

Purpose: shift attention from overwhelming internal experience back to the present environment.
Steps (PFA-FOG version): (1) Explain briefly that grounding helps people feel less overwhelmed by turning attention to the outside world. (2) Ask them to sit comfortably, arms and legs uncrossed. (3) Breathing slowly and deeply between each, ask them to name five non-distressing things they can see, then five non-distressing things they can hear, then five non-distressing things they can feel. (4) With children, ask them to name colours they can see.
WHO version: have the person feel their feet on the floor, tap fingers or hands on their lap, notice non-distressing things they can see, hear or feel, and focus on slow breathing; keep a calm, soft voice, eye contact where culturally fitting, and remind them you are there to help and that they are safe if that is true.
Example language (illustrative): "Let's try something that can help when everything feels like too much. Feet flat on the floor. Breathe in slowly... and out. Now tell me five things you can see in this room, anything at all that isn't upsetting."
Watch for: keep items non-distressing (redirect if the person names debris or injuries); do not insist on eye contact or touch; stop if it escalates distress.
[source: PFA-FOG 2006, Core Action 3; WHO 2011, "helping people to feel calm"]

4.18 Gathering information for a medication or medical referral

Purpose: medication is not a routine part of PFA; it is considered only when other approaches fail, with a specific, time-limited target (e.g. sleep, panic), for extreme agitation, extreme anxiety or panic, psychosis, or danger to self or others. Disasters can also interrupt existing treatment.
Steps: collect and pass to the prescriber: current medications; medications that need monitoring; access to prescriber and pharmacy; adherence; substance use or recovery history; ongoing medical or psychiatric conditions. Involve family if the person cannot report. Do not advise on doses [house rule].
[source: PFA-FOG 2006, Core Action 3]

4.19 Information gathering: current needs and concerns (Core Action 4)

Purpose: tailor help; this is not a formal assessment and continues across the contact.
Steps: (1) Ask brief questions within whatever time you have. (2) Cover, as relevant: nature and severity of what they experienced (follow their lead, do not press for details, arrange medical review if injured); death of a loved one; current post-disaster circumstances and ongoing threat; separation from or concern about loved ones; physical illness, mental health conditions and medication needs (high priority); losses (home, school, business, possessions, pets); extreme guilt or shame (listen for it and reflect it); thoughts of harming self or others (priority, see 4.20); availability, or lack, of social support; prior alcohol or drug use (ask about increases, past problems, withdrawal risk; refer medically if withdrawal is possible); prior trauma and loss (explain why you ask before asking); developmental impact (disrupted milestones and events such as exams, graduations, weddings). (3) Close with an open question to catch anything missed. (4) If several concerns emerge, summarise them and agree priorities together. (5) Document on the guide's Survivor Current Needs form (Appendix D) or your agency's equivalent.
Example language (illustrative): "Where were you when it happened? You don't need to go into detail." "Is anyone in your family hurt or unaccounted for?" "Is there a medicine you're going without?" "Who can you lean on right now?" "Is there anything else on your mind that we haven't touched?"
Watch for: drift into a trauma narrative (gently refocus on present needs); people who minimise needs out of guilt that others have it worse.
[source: PFA-FOG 2006, Core Action 4 pp. 57 to 62]

4.20 Responding to thoughts of harming self or others

Purpose: PFA-FOG marks this as a priority item within information gathering.
Steps: (1) Ask directly and calmly. (2) If risk is present, get immediate help (medical, mental health, security as appropriate) and stay with the person until appropriate staff arrive (PFA-FOG). (3) [synthesis, following current standard practice] If you are a licensed clinician on scene, do a brief structured risk assessment (current ideation, intent, plan, preparatory behaviour, past attempts, intoxication, access to lethal means, protective factors) and agree a safety plan; lethal-means counselling here means helping the person or family arrange safe storage or removal of means, especially in shelters where medications and weapons may be loosely held. (4) Take adolescents' suicidal and revenge statements seriously (PFA-FOG Core Action 2). (5) Document and hand over in person.
Example language (illustrative): "Sometimes after something like this, people have thoughts of not wanting to live, or of hurting themselves. Have you had thoughts like that?"
[source: PFA-FOG 2006, Core Actions 2 and 4; WHO 2011, people needing advanced support; risk-assessment detail is synthesis]

4.21 Practical assistance (Core Action 5)

Purpose: restoring a sense of control, hope and empowerment through solving concrete problems.
Steps (four-step PFA-FOG sequence): (1) Identify the most immediate needs; work on one at a time; some resolve at once (food, a call to a relative), others need several steps toward a longer goal. (2) Clarify the need: talk it through until the problem is specific enough to act on. (3) Discuss an action plan: let the person propose solutions or offer options; know local services beforehand, including realistic waits, eligibility and application steps; for children, share the plan with caregivers so they can help. (4) Act: help them take the step (book the appointment, complete the form together). WHO adds: help with basic needs people ask for, make sure vulnerable or marginalised people are not missed, give practical suggestions (e.g. how to register for aid), follow through on anything you promised, and avoid undermining self-efficacy by doing everything for them.
Example language (illustrative): "Of everything you've mentioned, what's the one thing that would help most if we sorted it today?" "The insurance line closes at five; shall we call now while I'm with you?"
Watch for / working: the person takes an active role and leaves with a concrete next step; unrealistic expectations of services (correct them early).
[source: PFA-FOG 2006, Core Action 5 pp. 65 to 67; WHO 2011, Link]

4.22 Enhancing access to primary and immediately available supports (Core Action 6)

Purpose: social support is linked to recovery; reconnecting people with family and trusted others is central.
Steps: (1) Help people contact family, friends and other primary supports (phones, registries, reunification services). (2) Where primary supports are absent, encourage use of supports immediately at hand: other survivors, staff, faith or community groups (WHO: bring affected people together to support each other, link isolated individuals with community members, connect with spiritual communities if wanted). (3) Keep families and children together (WHO). (4) Share information on social services, mental and medical health, addiction services, childcare and religious support. PFA-FOG sub-action headings confirmed ("enhance access to primary support persons", "encourage use of immediately available support persons") but their full text is [uncertain]; steps 1 and 4 are drawn from WHO 2011 and a secondary PFA-FOG-based training deck.
Example language (illustrative): "Who would you most like to reach right now? Let's try them from the volunteer phone."
[source: PFA-FOG 2006, Appendix A headings; WHO 2011, Link]

4.23 Discussing support-seeking and support-giving

Purpose: help people overcome barriers to asking for and offering support.
Steps: (1) Address reasons people hold back: not knowing what they need, embarrassment, guilt about taking help others need more, fear of being a burden or losing control, doubt that help will work, feeling no one understands, past disappointment, fear of others' anger or blame. (2) For withdrawn or isolated survivors, help them: decide what kind of support would help most; choose whom to ask; choose a good time and place; tell that person how they can help; thank them afterwards. (3) Normalise wanting company without talking about the event; the survivor decides when and what to share. (4) Support-giving: help them identify ways to help others (volunteering at the shelter, helping children or older adults), pick a person and a time; show interest and care, offer time repeatedly; keep the focus on practical help and current needs rather than event details. (5) Give the guide's handouts on seeking and giving social support to adults and older adolescents when suitable.
Example language (illustrative): "It sounds like you don't want to burden your sister. What kind of help from her would make the biggest difference? When might be a good time to ask?"
[source: PFA-FOG 2006, Core Action 6 pp. 71 to 74]

4.24 Social connection for children and adolescents

Steps: encourage children to talk with caregivers about feelings, do enjoyable things with peers, spend time with younger siblings, help with chores, share belongings; if a child will not talk, shared activities (walking, playing catch, sitting together) still give comfort.
[source: PFA-FOG 2006, Core Action 6]

4.25 Modeling support

Purpose: show survivors (and nearby family) what supportive responses look like so they can use them with each other.
Steps: use, and point out, four kinds of response: reflective comments (restating what you heard), clarifying comments (checking understanding), supportive comments (validating feelings), empowering questions (asking what has helped before).
Example language (illustrative): reflective: "So the hardest part was not knowing where your son was." Clarifying: "Do you mean you'd rather stay here tonight?" Supportive: "That sounds incredibly hard." Empowering: "What has helped you get through tough times before?"
[source: PFA-FOG 2006, Core Action 6 pp. 73 to 74]

4.26 Basic information about stress reactions (Core Action 7)

Purpose: feeling able to cope aids recovery; accurate, non-pathologising information reduces alarm about one's own reactions.
Steps: (1) Briefly describe common reactions as understandable and expected, without "symptom" or "disorder" language. (2) Mention that positive changes can also occur (greater appreciation of loved ones, stronger spiritual or social ties). (3) Say intense reactions often lessen over time, but avoid blanket reassurance that they will vanish, which sets unrealistic recovery expectations. (4) For people with significant trauma exposure or loss, review three groups of posttraumatic reactions: intrusive (distressing thoughts, images, dreams; upset at reminders; flashbacks), avoidance and withdrawal (avoiding thoughts, feelings, people, places; numbing; social withdrawal; loss of interest), physical arousal (hypervigilance, startle, irritability or anger outbursts, poor sleep and concentration). (5) Explain reminders: trauma reminders (sights, sounds, places, people, feelings) can bring back the event; loss reminders bring up the absence of the person or thing lost; change reminders relate to how life has changed; avoiding reminders can restrict daily life. (6) Further headings in the guide: hardships, grief reactions, traumatic grief reactions, depression, physical reactions [uncertain: content past p. 78; WHO's list of distress reactions (physical symptoms, crying, fear, being on guard, insomnia or nightmares, irritability, guilt or shame, numbness or unreality, withdrawal, disorientation) can be used]. (7) If reactions keep interfering with functioning for more than a month, recommend psychological services.
Example language (illustrative): "Lots of people find pictures of what happened pop into their head, or they jump at loud noises. That's the mind and body still on alert after a frightening event. For most people it eases over the coming weeks. If it's still getting in the way of daily life after a month or so, that's a good time to talk with someone."
[source: PFA-FOG 2006, Core Action 7 pp. 77 to 78 and Appendix A; WHO 2011, Look]

4.27 Talking with children about body and emotional reactions

PFA-FOG sub-action confirmed by heading only [uncertain].
Steps [synthesis drawing on PFA-FOG's general guidance for children and WHO's age-specific reactions]: at eye level, use simple words to name feelings and body sensations (tummy aches, tight chest); avoid extreme words ("terrifying", "horrible"); normalise regression (bedwetting, clinging) in young children, self-blame and new fears in school-age children, numbness, isolation or risk-taking in adolescents (WHO); invite drawing or play as alternatives to talking; tell caregivers what you said.
Example language (illustrative): "When something scary happens, our bodies can feel wobbly or our tummies hurt. That's your body trying to keep you safe. It usually gets better."

4.28 Basic information on ways of coping

Steps: (1) Ask how they have coped with past difficulties and affirm their ability to cope now (WHO). (2) Ask what helps them feel better. (3) Encourage helpful coping: enough rest, regular eating and drinking, talking and spending time with family and friends, discussing problems with trusted people, relaxing activities, physical exercise, safe ways of helping others (WHO). (4) Discourage harmful coping: drugs, smoking or heavy drinking; sleeping all day; working without rest; isolating; neglecting hygiene; violence (WHO). (5) PFA-FOG has its own adaptive and maladaptive coping lists [uncertain: WHO's lists used here].
Example language (illustrative): "Think back to another hard time in your life. What got you through it? Which of those things could you do here, even in a small way?"
[source: WHO 2011, Link "coping with problems"; PFA-FOG 2006, Appendix A heading]

4.29 Teaching simple relaxation techniques (breathing)

Purpose: reduce arousal; daily practice may help sleep, concentration and energy.
Steps, adults (PFA-FOG handout): (1) Inhale slowly through the nose for a count of three, filling the lungs down to the belly. (2) Silently say a short calming phrase. (3) Exhale slowly through the mouth for a count of three, emptying the lungs. (4) Silently say a releasing phrase. (5) Repeat about five times, slowly; use as often as needed through the day.
Children: demonstrate with a hand on the stomach; breathe in through the nose so the stomach expands, out through the mouth so it falls; count three in, three out; practise together and praise. Make it playful: blowing bubbles, blowing cotton balls or paper wads across a table, a story where the child copies a character taking big breaths.
Other options listed: muscle relaxation, meditation, swimming, stretching or yoga, prayer, exercise, quiet music, time in nature.
Example language (illustrative): "Let's breathe together. In through your nose, two, three... and slowly out through your mouth, two, three."
Watch for: dizziness from over-breathing (slow down); some trauma survivors feel worse focusing on the body; offer an external focus (counting objects) instead [synthesis].
[source: PFA-FOG handout "Tips for Relaxation" (Basic Relaxation Techniques); Appendix A]

4.30 Coping for families and developmental issues

PFA-FOG sub-actions "coping for families" and "assisting with developmental issues" confirmed by heading only [uncertain].
Steps (WHO caregiver guidance and PFA-FOG Core Action 4 developmental item): (1) Ask about disrupted developmental events and plan practical substitutes. (2) Coach caregivers by age: infants: keep warm and safe, cuddle, keep routines, speak in a soft voice; young children: extra time and attention, repeated reassurance that they are safe and not to blame, keep them with caregivers and siblings, simple honest answers, patience with regression; older children and adolescents: time and attention, keep routines, allow sadness, listen without judging, set clear rules and expectations, discuss dangers and how to stay safe, give opportunities to help. (3) If caregivers are incapacitated, arrange help for them and care for the children; keep families together; record details if separation is unavoidable (WHO). (4) Remind caregivers that their own calm and coping is the main buffer for children [synthesis].
[source: WHO 2011, ch. 4 children; PFA-FOG 2006, Core Action 4; Appendix A]

4.31 Assisting with anger management

PFA-FOG sub-action confirmed by heading only [uncertain: steps]. A secondary PFA-FOG-based deck says only to offer anger-management techniques.
Steps [synthesis]: (1) Validate the anger as understandable while separating feeling from action. (2) Help the person name what triggers it (delays, unfairness, loss of control). (3) Help them weigh the costs of acting on it (relationships, children, access to services). (4) Offer concrete options: time out, walking, slow breathing (4.29), writing it down, channelling it into constructive action (complaint routes, advocacy, helping others). (5) If there is a threat to others, involve security (4.3). (6) WHO: expect frustration when expectations are not met, stay calm and understanding.
Example language (illustrative): "Anyone would be furious waiting three days for answers. What usually happens when you get this angry? What could you do with it right now that won't cost you?"

4.32 Addressing highly negative emotions (guilt and shame)

PFA-FOG sub-action confirmed by heading; Core Action 4 directs providers to listen for extreme guilt or shame, reflect it and give comfort and coping information; a secondary deck describes the approach as basic cognitive-behavioural [uncertain: full PFA-FOG steps].
Steps [synthesis except where noted]: (1) Reflect the feeling without arguing (PFA-FOG). (2) Gently check the belief behind it (e.g. "I should have known"); help the person consider what they knew and could do at the time versus hindsight. (3) Acknowledge protective actions they took (PFA-FOG delivery guideline). (4) Do not offer blanket absolution (PFA-FOG's list of phrases to avoid includes telling people they did everything they could). (5) For children: repeat that they did not cause it (PFA-FOG). (6) Link for follow-up if guilt is intense or persistent.
Example language (illustrative): "You seem really hard on yourself about leaving the house first. At that moment, with the smoke and the noise, what did you actually know?"

4.33 Helping with sleep problems

PFA-FOG sub-action confirmed by heading only [uncertain]; the secondary deck points to sleep hygiene advice and CBT-I resources.
Steps [synthesis]: ask what is disturbing sleep (noise and light in shelters, worry, nightmares, pain, caffeine or alcohol); problem-solve the environment (quieter area, eye mask, earplugs, family space); keep regular sleep and wake times as far as possible; limit caffeine, alcohol and nicotine late in the day; use the breathing exercise at bedtime; limit late-night disaster media; if poor sleep persists or impairs functioning, link to medical or psychological care (no medication advice from PFA providers).

4.34 Addressing alcohol and substance use

PFA-FOG Core Action 4 asks about increased use, prior problems and withdrawal risk, with medical referral for withdrawal; Core Action 2 warns the bereaved about increased use of alcohol, over-the-counter medicines and smoking; WHO discourages drugs, smoking and heavy drinking as coping; the guide has a handout on alcohol, medication and drug use after disaster [uncertain: Core Action 7 sub-action and handout text].
Steps [synthesis built on the sourced elements]: ask non-judgementally whether use has changed; note risk of withdrawal where supply is disrupted (alcohol, benzodiazepines, opioids) and refer medically at once; for people in recovery, help them find meetings or their sponsor or counsellor, and treatment continuity (e.g. opioid treatment programmes); offer alternatives for sleep and distress; link to substance-use services.
Example language (illustrative): "Some people find they're drinking more since the flood, to sleep or to stop thinking. Has anything like that changed for you?"

4.35 Linkage with collaborative services (Core Action 8)

Purpose: connect people with services they need now or later and support continuity.
Steps: (1) Provide a direct link: know which services exist and how to reach them; choose collaboratively with the person; make the connection actively (call together, escort, written details) rather than just giving a number. (2) Typical triggers for referral: acute medical need; acute mental health need or risk; worsening of a pre-existing condition; threat of harm; substance problems or withdrawal; physical, sexual or domestic abuse concerns; medication needs; ongoing grief or traumatic reactions interfering with functioning; need for spiritual, legal, financial, housing or child-care help [synthesis list consistent with Core Actions 2 to 7 and the Rutgers adaptation of the PFA-FOG Needs form]. (3) Children and adolescents: referrals usually through or with caregivers and schools [synthesis; heading confirmed]. (4) Older adults: account for mobility, sensory and medical needs [synthesis; heading confirmed]. (5) Promote continuity: if you are leaving the site, tell the person and introduce the next provider by name where possible; give handouts. Record whether the referral was accepted.
Example language (illustrative): "I'm off shift at six. Before I go, I'd like you to meet Kerry, who'll be here tomorrow; I've told her about the paperwork we started."
[source: PFA-FOG 2006, Appendix A headings; WHO 2011, Link and Ending your help; secondary training deck; Rutgers PFA forms]

4.36 Ending your help (WHO-PFA)

Steps: (1) Decide when to end based on the context, your role, the person's needs and your own limits. (2) Tell the person you are leaving. (3) If someone will continue, introduce them. (4) Give details of services you linked them to and what to expect. (5) Say goodbye warmly and wish them well.
[source: WHO 2011, ch. 3]

4.37 People needing special attention (WHO-PFA)

Children and adolescents: see 4.7, 4.10, 4.27, 4.30; shield from gruesome scenes and unnecessary interviews; engage at eye level, gather information to locate family, let them contribute safely.
People with health conditions or disabilities, older people, pregnant and breastfeeding women: help them reach safety, meet basic needs, access medicines and medical care; stay with them or ensure someone is with them; link to protection and support services; give information on services.
People at risk of discrimination or violence (women, some ethnic or religious groups, people with mental disabilities): help them find safe places, reconnect with trusted people, give service information and direct links. Survivors of sexual violence need privacy for any conversation.
[source: WHO 2011, ch. 4; PFA-FOG 2006, delivery guidelines on older adults and people with disabilities: speak to the person directly, believe self-reported disabilities, ask what help they want, keep aids with them]

4.38 Caring for yourself and colleagues

Steps: before deployment check your readiness (4.0). During: eat, rest, take short breaks; keep reasonable hours; share workloads, rotate shifts; remember you cannot solve everyone's problems; limit alcohol, caffeine, nicotine and non-prescribed drugs; check in with colleagues; talk with trusted people. Afterwards: talk the experience through with a supervisor, colleague or trusted person; acknowledge what went well, including small things; accept limits and what went less well; rest before resuming usual duties. Seek professional support if upsetting memories, sleep problems, intense sadness or nervousness, or heavy substance use persist beyond about a month (WHO). PFA-FOG adds attending to your own physical and emotional reactions throughout, with confidentiality preserved in peer discussion.
[source: WHO 2011, ch. 5; PFA-FOG 2006, delivery guidelines]

5. Handling problems

PFA has no formal "resistance" construct; the sources address several problems directly (marked with source) and the rest is the author's synthesis (marked).

Person declines help or avoids you. Expected; respect it, say how and where to find help later, check back unobtrusively; WHO: make clear help remains available even if declined now [source: PFA-FOG Core Action 1; WHO ethics]. Offer something practical rather than talk on a second pass [synthesis].
Person wants to tell the whole story / you feel pulled to debrief. Listen if they choose to talk, but do not elicit details or ask them to order events; gently bring the focus back to present needs and coping [source: PFA-FOG delivery guidelines; WHO ch. 1]. If they keep re-telling with mounting distress, use stabilization (4.16 to 4.17) [synthesis].
Overwhelm, panic, dissociation. Stabilization and grounding (4.16 to 4.17); keep them from being alone; if no response, or psychosis, extreme agitation or danger, escalate to medical or mental health staff (medication consultation, 4.18) [source: PFA-FOG Core Action 3; WHO].
Anger at you or at the response. WHO: expect frustration when expectations go unmet; stay calm and understanding. Don't take it personally; acknowledge the legitimate grievance, give accurate information and timelines, avoid promises; if threatening, involve security [source: WHO Link; PFA-FOG Core Action 2] plus anger steps (4.31) [synthesis].
Rupture: you gave wrong information or a promise fell through. Prevent by saying only what you know, citing sources and promising nothing unconfirmed [source: PFA-FOG; WHO]. If it happens: go back, say plainly what changed, apologise for the error, and give the next concrete step and update time [synthesis].
Non-follow-through on practical plans or referrals. Use the four-step practical assistance sequence with smaller steps; act together in the moment (call, form, escort) rather than handing over a number; involve a support person; confirm the referral was accepted [source: PFA-FOG Core Actions 5 and 8; synthesis for in-the-moment action].
"Stuck" person: unable to prioritise, repeating the same worry. Summarise concerns and agree one priority together (PFA-FOG Core Action 4); clarify the need until it is actionable (Core Action 5) [source]. If stuckness reflects disorientation, assess for medical causes [synthesis].
Uncertainty about missing people. Honest, regularly updated information, attendance at official briefings, explain that differing hope within a family is normal; never promise reunion [source: PFA-FOG Core Action 2].
Spiritual distress, "why" questions, anger at God. Do not debate, correct or try to answer; listen; offer clergy of their choice [source: PFA-FOG Core Action 2].
Cultural mismatch. Defer to local norms on approach, gender, touch and mourning; consult community and religious leaders; address the family spokesperson; ask rather than assume [source: PFA-FOG Core Actions 1 and 2; WHO]. Use trained interpreters, not children, for sensitive matters [synthesis].
Children who will not talk. Shared activity, play, drawing, being nearby; work through caregivers [source: PFA-FOG Core Action 6; WHO].
Caregiver too distressed to parent. Arrange support for the caregiver and care for the children, keeping them together [source: WHO ch. 4]; coach brief caregiver scripts (4.10, 4.14) [source: PFA-FOG].
Risk to self or others; abuse disclosures. Immediate help, stay until handover; mandated reporting [source: PFA-FOG Core Actions 1, 2, 4; WHO]. Standard suicide risk assessment and safety planning by licensed clinicians; lethal-means counselling on safe storage or removal only [synthesis].
Substance withdrawal or interrupted opioid, psychiatric or other essential medication. Treat as medical priority and refer [source: PFA-FOG Core Actions 3 and 4].
Media, lawyers, onlookers, people proselytising. Shield survivors; adolescents may refuse interviews; report proselytising to security or leads rather than confronting it yourself [source: PFA-FOG Core Action 2].
Your own distress, over-involvement, rescuing. Self-care, rotation, supervision; remember you cannot solve everyone's problems; avoid undermining self-efficacy by doing everything [source: WHO ch. 3 and 5; PFA-FOG]. Watch for personal disaster exposure in your own team and a pull to keep working without rest [synthesis].
Modality-specific risk: drifting into therapy. Clinicians may start trauma processing, cognitive restructuring or diagnosis in the field. Keep PFA's scope (present needs, stabilisation, information, connection, linkage); offer trauma-focused treatment later through referral when indicated [synthesis based on the sources' no-debriefing and non-pathologising stance].
Ethical boundary risks. Never seek money or favours, exaggerate skills, or exploit the helper relationship [source: WHO ethics]. For clinicians: don't recruit disaster survivors into private practice from the field without agency agreement [synthesis].
Remote or hotline delivery. Both guides allow hotlines (PFA-FOG settings list); the same actions apply, with more reliance on verbal orientation, written follow-up and warm transfer to services [synthesis].

Sources

Sources:

Books and papers cited:

Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A., Vernberg, E., & Watson, P. (2006). Psychological First Aid: Field Operations Guide (2nd ed.). National Child Traumatic Stress Network and National Center for PTSD.
World Health Organization, War Trauma Foundation & World Vision International (2011). Psychological first aid: Guide for field workers. WHO.
Hobfoll, S. E., et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention. Psychiatry, 70(4). [not drawn on; cited for orientation only]

Not drawn on / gaps [uncertain]: PFA-FOG full text of Core Action 7 after p. 78 (hardships, grief, depression, physical reactions, children, coping lists, family coping, developmental issues, anger, negative emotions, sleep, substance use) and Core Action 8; PFA-FOG Appendix E handouts other than the relaxation handout; Skills for Psychological Recovery; NCTSN PFA training and any credentialing requirements; other PFA variants (e.g. Johns Hopkins RAPID model; PFA for Schools) are not covered.

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