With all this evidence at hand, PFA were designed by a collaborative effort of the National Center for PTSD and the National Child Traumatic Stress Network, of USA, intended for use by disaster mental health responders and others, including mental health counselors, who may be called upon to provide immediate support for trauma survivors (Ruzek et al., 2007). One of the qualities of the PFA is that they can be provided by people who are not necessarily mental health professionals, even though it requires a basic training for implementation. Another advantage is that they can be applied wherever there are survivors of trauma (Uhernik & Usson, 2009). In addition, the PFA are consistent with the concept of resilience in individuals and communities, which encourages self-efficacy and

The Pan American Health Organization [PAHO] (2006) notes that the PFA should be the first aid provided to those who are affected in an emergency, crisis or disaster, especially when there is a predominance of certain emotions such as fear, sadness, anger, tears and pain, after the event. Its objectives are: a) providing immediate relief of emotional suffering,

they had been led to virtually mandatory counseling.

relatives or the ability to recover from an injury.

networks is crucial to get a sense of security.

decreases the victimization and dependency.

**6.2 Psychological First Aid (PFA)**

many.

iatrogenic damage generated in the participants (Aulagnier et al., 2004; Rose et al., 2002; Sijbrandij et al., 2006; Woods, 2007). On the other hand, Chan and Huake (2004) conducted a study where they assess the effects of this technique in health care workers in Singapore who came to help their neighbors in Southeast Asia after the T-2004. The results of this intervention first revealed the high levels of acute stress experienced by rescue teams but also showed how beneficial it was for them, according to their own testimony. The same positive result reported a group of journalists from Singapore who participated in debriefing sessions after the T-2004 (Sin et al., 2005). Costa and De Gracia (2002) only presents evidence that supports the use of debriefing in disaster situations. Vera (2004) and Santacruz (2008) have reviewed studies for and against the effectiveness of this technique.

McNally et al. (2003) note that the main difference between studies developed by critics and defenders of the debriefing would arise due to the absence of a control group in studies that approved the debriefing, who defended themselves by pointing out that to leave people exposed to trauma without psychological support is hardly ethical. However, studies that follow an appropriate methodology conclude that, given a lack of satisfactory evidence for debriefing, it is best to seek other methods to prevent psychopathological consequences in people exposed to trauma.

There are several possible explanations to the iatrogenic effect that would cause the debriefing in some people. Aulagnier et al. (2004) propose that the debriefing involves a reexposure to the traumatic memory that can interfere with the natural course of recovery. The attempt to forget or distance themselves may be an adaptive response and intervention may interfere with this mechanism. Rose et al. (2002) suggest that it could even lead to "secondary trauma" due to the intense imaginary exposure to a traumatic incident within a short time from the event. It is possible that for some individuals this results in additional trauma and exacerbates their symptoms without helping the emotional processing. Although exposure therapy, practiced for the routine treatment of PTSD, may cause a slight initial exacerbation of symptoms as they remember the images of distress, it is reduced as the person reaches the habituation over time. However, in a single intervention, as in the debriefing, this habituation may not occur unless the recipient engages in additional exposure directed by himself or herself.

On the other hand, studies have shown that certain conditions are necessary to facilitate emotional processing of distressing material: "The material, especially in the early stages of treatment, should be made predictable, controllable, presented in small chunks, and tackled in a progressive but gradual way" (Rachman, 2001, p. 166, as cited in McNally et al., 2003). These conditions are not met in the debriefing, because it is more cathartic. Therefore, encouraging survivors to discuss their thoughts and feelings right away may increase the risk of feeling overwhelmed by the experience, which would be counterproductive.

Another explanation is that the "debriefing" can consider normal anxiety as a "medical condition" and therefore could increase the expectation of developing psychological symptoms otherwise it would not have been presented. While studies show that only a minority of people exposed to a traumatic event develop PTSD, the debriefing, since it raises awareness about the symptoms, may paradoxically induce this disorder which otherwise would not have been developed. Thus, the normal responses to stress produce expectations of developing subsequent pathologies (Raphael, 1995, as cited in Vera, 2004).

Finally, the treatment that promotes the debriefing, which includes all people exposed to a traumatic event, is excessive and ignores the positive effects of coping strategies that people naturally have and the potential of every human to learn and grow as a result of a traumatic experience (Vera, 2004). In addition, it focuses too much on the trauma, excluding other more relevant stressors, and may not be compatible with the natural coping strategies of many.

Summerfield (2006) indicates a darker aspect of the use of debriefing. This author argues, in relation to survivors of the T-2004 in Sri Lanka, that despite the alarmist voices which predicted up to 25% of children with PTSD and reported to have found up to 70% of these children with PTSD, demonstrated a rather remarkable resilience and joy in the survivors, and that the children seemed more inclined to return to school to talk about the events of 26 December. For this reason, they were described as "clearly in denial". There were a large influx of Western counseling teams specialized in trauma, most of them with little or no knowledge of the views and local culture. In Sri Lanka there are reports of survivors that say they had been led to virtually mandatory counseling.

Rose et al. (2002) concluded in an exhaustive way that the use of mandatory debriefing of trauma survivors must stop. Instead of that, the authors recommend early detection of those at risk of developing psychopathology to conduct early intervention only to this group.

#### **6.2 Psychological First Aid (PFA)**

220 Tsunami – A Growing Disaster

iatrogenic damage generated in the participants (Aulagnier et al., 2004; Rose et al., 2002; Sijbrandij et al., 2006; Woods, 2007). On the other hand, Chan and Huake (2004) conducted a study where they assess the effects of this technique in health care workers in Singapore who came to help their neighbors in Southeast Asia after the T-2004. The results of this intervention first revealed the high levels of acute stress experienced by rescue teams but also showed how beneficial it was for them, according to their own testimony. The same positive result reported a group of journalists from Singapore who participated in debriefing sessions after the T-2004 (Sin et al., 2005). Costa and De Gracia (2002) only presents evidence that supports the use of debriefing in disaster situations. Vera (2004) and Santacruz (2008) have reviewed studies for and against the effectiveness of this technique. McNally et al. (2003) note that the main difference between studies developed by critics and defenders of the debriefing would arise due to the absence of a control group in studies that approved the debriefing, who defended themselves by pointing out that to leave people exposed to trauma without psychological support is hardly ethical. However, studies that follow an appropriate methodology conclude that, given a lack of satisfactory evidence for debriefing, it is best to seek other methods to prevent psychopathological consequences in

There are several possible explanations to the iatrogenic effect that would cause the debriefing in some people. Aulagnier et al. (2004) propose that the debriefing involves a reexposure to the traumatic memory that can interfere with the natural course of recovery. The attempt to forget or distance themselves may be an adaptive response and intervention may interfere with this mechanism. Rose et al. (2002) suggest that it could even lead to "secondary trauma" due to the intense imaginary exposure to a traumatic incident within a short time from the event. It is possible that for some individuals this results in additional trauma and exacerbates their symptoms without helping the emotional processing. Although exposure therapy, practiced for the routine treatment of PTSD, may cause a slight initial exacerbation of symptoms as they remember the images of distress, it is reduced as the person reaches the habituation over time. However, in a single intervention, as in the debriefing, this habituation may not occur unless the recipient engages in additional

On the other hand, studies have shown that certain conditions are necessary to facilitate emotional processing of distressing material: "The material, especially in the early stages of treatment, should be made predictable, controllable, presented in small chunks, and tackled in a progressive but gradual way" (Rachman, 2001, p. 166, as cited in McNally et al., 2003). These conditions are not met in the debriefing, because it is more cathartic. Therefore, encouraging survivors to discuss their thoughts and feelings right away may increase the

Another explanation is that the "debriefing" can consider normal anxiety as a "medical condition" and therefore could increase the expectation of developing psychological symptoms otherwise it would not have been presented. While studies show that only a minority of people exposed to a traumatic event develop PTSD, the debriefing, since it raises awareness about the symptoms, may paradoxically induce this disorder which otherwise would not have been developed. Thus, the normal responses to stress produce expectations

Finally, the treatment that promotes the debriefing, which includes all people exposed to a traumatic event, is excessive and ignores the positive effects of coping strategies that people naturally have and the potential of every human to learn and grow as a result of a traumatic

risk of feeling overwhelmed by the experience, which would be counterproductive.

of developing subsequent pathologies (Raphael, 1995, as cited in Vera, 2004).

people exposed to trauma.

exposure directed by himself or herself.

MacNally et al. (2003) summarized studies that conclude that the provision of practical help can be seen as more useful and positive than specific psychological care. Trauma survivors have many immediate needs in their efforts to adapt to the event. For example, survivors may need a roof, help for overcoming exhaustion, for getting financial support, for finding relatives and friends, for protecting children, etc. There are also studies that emphasize the need for survivors to receive information from both the traumatic event, and the location of relatives or the ability to recover from an injury.

Although the provision of information by itself does not appear to promote recovery, it is generally recommended to provide information on common reactions to trauma, including natural recovery. Bryant (2006) recommends that after a trauma, victims should receive assistance in order of priority. The first priorities are basic requirements like food, water and shelter, followed by emotional support for physical suffering and psychological interventions. In the end only for those with acute stress disorder or PTSD. Black and Tufnell (2006) note that for survivors of traumatic events, access to support and information networks is crucial to get a sense of security.

With all this evidence at hand, PFA were designed by a collaborative effort of the National Center for PTSD and the National Child Traumatic Stress Network, of USA, intended for use by disaster mental health responders and others, including mental health counselors, who may be called upon to provide immediate support for trauma survivors (Ruzek et al., 2007). One of the qualities of the PFA is that they can be provided by people who are not necessarily mental health professionals, even though it requires a basic training for implementation. Another advantage is that they can be applied wherever there are survivors of trauma (Uhernik & Usson, 2009). In addition, the PFA are consistent with the concept of resilience in individuals and communities, which encourages self-efficacy and decreases the victimization and dependency.

The Pan American Health Organization [PAHO] (2006) notes that the PFA should be the first aid provided to those who are affected in an emergency, crisis or disaster, especially when there is a predominance of certain emotions such as fear, sadness, anger, tears and pain, after the event. Its objectives are: a) providing immediate relief of emotional suffering,

Prevention of Psychopathological Consequences in Survivors of Tsunamis 223

trauma and have difficulties in confronting the facts with others and consequently keep

McNally et al. (2003) note that studies of Pennebaker would confirm one of the main tenets of debriefing: that expressing thoughts and feelings about the trauma accelerates healing, and that "encapsulating" these feelings prevents it. However, Pennebaker (2001) noted that his research focused on the psychobiological benefits of writing about traumatic events that had remained hidden for months or years. Therefore, Pennebaker's work cannot be invoked in support of the psychological debriefing that occurs soon after the traumatic event. On the other hand, Vera (2004) uses the opinion of Pennebaker meaning that writing can be seen as a form of spontaneous social communication that is quite different from the forced expression used in a group debriefing, and that social pressure to speak and express emotions in front of a

Pennebaker's methodology has been tested with survivors of different types of trauma, including terrorist attacks (Fernández et al., 2004) or newly diagnosed women with breast

Given the importance of emotional expression and social support, the narrative intervention model, whose development was also influenced by the research of Pennebaker (Galarce, 2003, Tarragona, 2003), could be a useful model for preventing psychopathological symptoms in survivors of natural disasters. However, the relative newness of this approach has provided less evidence about its outcome. Among these, the revision of O'Kearney and Perrott (2006) who analyzed 19 studies stands out, which described the narratives of trauma in individuals diagnosed with PTSD symptomatology. Kaminer (2006), in turn, makes a review of other studies focusing on the influence of the narrative of trauma on recovery from PTSD, focusing on identifying the psychological processes involved in each of them, suggesting that the specific process involved in the narrative therapy is to identify the

The importance of attributing the meaning of traumatic experiences can be found in a study by Norman (2000) which concluded that while exposure to traumatic events can lead to PTSD, not all people develop the syndrome. The difference, according to Norman (2000), would be that "some people know how to find meaning for their horrific experiences, while others can't" (p. 305). The attempt to give meaning to negative experiences has been highlighted by recent positive psychology, a school that incorporates constructions such as resilience. This is a quality that some people have for overcoming adversity and traumatic events. The narrative model of White and Epston (Epston, 1994, White, 2002a, 2002b, White & Epston, 1993), consistent with this, states that the adverse experiences are stories of resilience and survival and that these aspects can be expanded and enriched through the

The narrative approach of White and Epston is based on the assumption that the narratives do not represent people's identity and problems, rather the narratives are the identity and problems. In this regard, Carr (1998) points out that human problems arise and are maintained by oppressive histories that dominate the lives of people. But these stories do not only determine the meaning attributed to his experiences, but also determine what

professional can awaken feelings of humiliation and shame for many people.

their difficulties secret.

cancer (Garcia & Rincon, 2009).

purpose and value of adversity.

therapeutic process (Kaminer, 2006).

aspects of the experience they select to assign them a meaning.

**6.4 Narrative therapy**

b) reduce the risk of normal reactions into something more serious and c) help meet the survival and basic needs that suffer most of the people who survive disasters (PAHO, 2006). Figueroa et al. (2010) recommend PFA for those most affected, even though they not present formal psychiatric disorders. Parallel to the PFA it should be done a psychological screening for detecting risk population that requires more specialized support.

According to Vernberg et al. (2008), the principles, objectives, and techniques of PFA are designed to meet four basic standards:

Figueroa et al. (2010) suggest not forcing the affected to talk about their feelings, since the psychotherapeutic interventions that do so, as does the debriefing, has not been shown to reduce the development of later psychiatric disorders and worse, it could increase them. However, the PFA also recommends making it possible for survivors to construct a "trauma story" narrative and to expose their feelings. But what differentiates it from a debriefing? The difference is that the PFA respects the desire of the person to talk or not, about the trauma. The goal of the PFA is not to maximize emotional processing of the traumatic event, but to respond to the urgent need that arises in many people who want to share their experience. At the same time the PFA respects those who do not want to talk about what happened (McNally et al., 2003). The conclusion is that in the immediate after-effects of trauma, practitioners should take their lead from the survivors and provide the help needed, instead of mentioning how the survivors will get better.

It still remains to be proved empirically if the PFA is effective in preventing or recovering from PTSD and other psychopathological consequences of natural disasters. However, its nature of general support and its proposal of non-directive intervention, as well as empirical support that sustain many of its components (satisfaction of basic needs, providing information, formation of social support networks and facilitation of emotional expression) suggest that it is unlikely to generate damage. Fortunately, the procedure of PFA is governed by standardized guidelines, making it susceptible to evaluation (Vernberg, 2008).

A complete guideline of PFA can be downloaded from

http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp

#### **6.3 Emotional disclosure**

Different research guided by Pennebaker or made following their postulates, has shown that the emotional disclosure of the meanings associated with the trauma prevents long-term health problems and generates an increase in immune function, among other consequences (Owen et al., 2006; Pennebaker, 1997; Pennebaker et al., 1988; Pennebaker & Seagal, 1999; Petrie et al., 1998). Pennebaker (2004) has developed an emotional writing exercise that has been applied in different contexts and that, according to a review of Cabrera (2006), has led to improvements in the physical and psychological health of participants.

On the other hand, Cabrera (2006) notes that certain ways of writing seem to show better effects on health than others. For example, it is important to identify and properly label the positive and negative emotions, to build a consistent and significant history of traumatic events and to be able to tell of the experience from different perspectives. Cabrera says that people who would be favored from the writing exercises are those that have experienced a trauma and have difficulties in confronting the facts with others and consequently keep their difficulties secret.

McNally et al. (2003) note that studies of Pennebaker would confirm one of the main tenets of debriefing: that expressing thoughts and feelings about the trauma accelerates healing, and that "encapsulating" these feelings prevents it. However, Pennebaker (2001) noted that his research focused on the psychobiological benefits of writing about traumatic events that had remained hidden for months or years. Therefore, Pennebaker's work cannot be invoked in support of the psychological debriefing that occurs soon after the traumatic event. On the other hand, Vera (2004) uses the opinion of Pennebaker meaning that writing can be seen as a form of spontaneous social communication that is quite different from the forced expression used in a group debriefing, and that social pressure to speak and express emotions in front of a professional can awaken feelings of humiliation and shame for many people.

Pennebaker's methodology has been tested with survivors of different types of trauma, including terrorist attacks (Fernández et al., 2004) or newly diagnosed women with breast cancer (Garcia & Rincon, 2009).

#### **6.4 Narrative therapy**

222 Tsunami – A Growing Disaster

b) reduce the risk of normal reactions into something more serious and c) help meet the survival and basic needs that suffer most of the people who survive disasters (PAHO, 2006). Figueroa et al. (2010) recommend PFA for those most affected, even though they not present formal psychiatric disorders. Parallel to the PFA it should be done a psychological screening

According to Vernberg et al. (2008), the principles, objectives, and techniques of PFA are

Figueroa et al. (2010) suggest not forcing the affected to talk about their feelings, since the psychotherapeutic interventions that do so, as does the debriefing, has not been shown to reduce the development of later psychiatric disorders and worse, it could increase them. However, the PFA also recommends making it possible for survivors to construct a "trauma story" narrative and to expose their feelings. But what differentiates it from a debriefing? The difference is that the PFA respects the desire of the person to talk or not, about the trauma. The goal of the PFA is not to maximize emotional processing of the traumatic event, but to respond to the urgent need that arises in many people who want to share their experience. At the same time the PFA respects those who do not want to talk about what happened (McNally et al., 2003). The conclusion is that in the immediate after-effects of trauma, practitioners should take their lead from the survivors and provide the help needed,

It still remains to be proved empirically if the PFA is effective in preventing or recovering from PTSD and other psychopathological consequences of natural disasters. However, its nature of general support and its proposal of non-directive intervention, as well as empirical support that sustain many of its components (satisfaction of basic needs, providing information, formation of social support networks and facilitation of emotional expression) suggest that it is unlikely to generate damage. Fortunately, the procedure of PFA is governed by standardized guidelines, making it susceptible to evaluation (Vernberg, 2008).

Different research guided by Pennebaker or made following their postulates, has shown that the emotional disclosure of the meanings associated with the trauma prevents long-term health problems and generates an increase in immune function, among other consequences (Owen et al., 2006; Pennebaker, 1997; Pennebaker et al., 1988; Pennebaker & Seagal, 1999; Petrie et al., 1998). Pennebaker (2004) has developed an emotional writing exercise that has been applied in different contexts and that, according to a review of Cabrera (2006), has led

On the other hand, Cabrera (2006) notes that certain ways of writing seem to show better effects on health than others. For example, it is important to identify and properly label the positive and negative emotions, to build a consistent and significant history of traumatic events and to be able to tell of the experience from different perspectives. Cabrera says that people who would be favored from the writing exercises are those that have experienced a

for detecting risk population that requires more specialized support.

3. Appropriate for developmental levels across the lifespan. 4. Culturally informed and deliverable in a flexible manner.

instead of mentioning how the survivors will get better.

A complete guideline of PFA can be downloaded from

**6.3 Emotional disclosure**

http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp

to improvements in the physical and psychological health of participants.

1. Consistent with research evidence on risk and resilience following trauma.

designed to meet four basic standards:

2. Applicable and practical in field settings.

Given the importance of emotional expression and social support, the narrative intervention model, whose development was also influenced by the research of Pennebaker (Galarce, 2003, Tarragona, 2003), could be a useful model for preventing psychopathological symptoms in survivors of natural disasters. However, the relative newness of this approach has provided less evidence about its outcome. Among these, the revision of O'Kearney and Perrott (2006) who analyzed 19 studies stands out, which described the narratives of trauma in individuals diagnosed with PTSD symptomatology. Kaminer (2006), in turn, makes a review of other studies focusing on the influence of the narrative of trauma on recovery from PTSD, focusing on identifying the psychological processes involved in each of them, suggesting that the specific process involved in the narrative therapy is to identify the purpose and value of adversity.

The importance of attributing the meaning of traumatic experiences can be found in a study by Norman (2000) which concluded that while exposure to traumatic events can lead to PTSD, not all people develop the syndrome. The difference, according to Norman (2000), would be that "some people know how to find meaning for their horrific experiences, while others can't" (p. 305). The attempt to give meaning to negative experiences has been highlighted by recent positive psychology, a school that incorporates constructions such as resilience. This is a quality that some people have for overcoming adversity and traumatic events. The narrative model of White and Epston (Epston, 1994, White, 2002a, 2002b, White & Epston, 1993), consistent with this, states that the adverse experiences are stories of resilience and survival and that these aspects can be expanded and enriched through the therapeutic process (Kaminer, 2006).

The narrative approach of White and Epston is based on the assumption that the narratives do not represent people's identity and problems, rather the narratives are the identity and problems. In this regard, Carr (1998) points out that human problems arise and are maintained by oppressive histories that dominate the lives of people. But these stories do not only determine the meaning attributed to his experiences, but also determine what aspects of the experience they select to assign them a meaning.

Prevention of Psychopathological Consequences in Survivors of Tsunamis 225

protection for the vulnerable, to bring families and communities together wherever it is possible, to create meaningful roles and livelihoods, and to restore institutions and services (religious, cultural, mental health) that promote community cohesion and a sense of order. Considering this background, it seems that the narrative approach, focused on the meaning of experience and reconnecting people with their social support networks, but at the same time respecting the rhythms of people and knowledge of local culture, could become a model for preventing or reducing symptoms of PTSD, so it is necessary to conduct studies to prove its effectiveness. One of those studies was developed by García and Rincón (2009) to prevent the occurrence of PTSD in patients that were just diagnosed with breast cancer and later used for individuals and group work for survivors of the T-2010 in Chile (García &

Mardones, 2010; Avalos & Balic, 2010).

Emotional Expression

Moment of application

Research outcomes

**7. Conclusion**

Model DEBRIEFING PSYCHOLOGICAL

Author Jeffrey Mitchell National Center for

Between 2 and 10 days after the

Inconclusive or even negative

Table 1. Comparative table of the four models

event

FIRST AID

PTSD and the National Child Traumatic Stress

Compulsory Facilitated Compulsory,

The day after the

Based on conclusive

The psychological reactions to a natural disaster like a tsunami are varied. Many of them are normal behaviors faced with an event of great emotional intensity, even if they are perceived as unpleasant. Focusing only on the psychopathological reactions prevents us from addressing more adaptive responses and also it has the risk of qualifying many of these normal reactions as symptoms of mental illness. In this regard, Cova and Rincon (2010) believe particularly valuable the responses aimed at strengthening the skills and resources of individuals and communities to be able to address their own problems and

Therefore, it is relevant to design and evaluate early intervention strategies that are able to prevent future maladaptive reactions in tsunami survivors, among others natural disasters.

Network

event

evidence

those that not only aim at specific "symptoms", but also at their quality of life.

EMOTIONAL DISCLOSURE TECHNIQUE

James Pennebaker

but written

Several days

Positive midterm and longterm effects

after

NARRATIVE THERAPY

Michael White & David Epston

Facilitated

Several days

investigation is

after

Further

needed

The goal of narrative therapy is to help clients to rewrite their life story, incorporating pieces of their history that have been marginalized from their experience, events that are exceptions to the current narrative: then the people will be able to give a new meaning to their past life and to plan a future less oppressive than the one manifested today. This approach also points out that new meanings assume greater value if they are transmitted and shared with the social network (family, friends) that surrounds and supports the patient, encouraging, therefore, several instances where it is possible to establish this connection, either symbolic (therapeutic letters) or directly (forums, workshops, family gatherings).

Narrative therapy is based on the principle that people categorize their experiences through language. However, in the process of putting the experience in the form of a story, certain parts are left out because they are not much considered than other parts. As people remember these neglected parts, they are able to formulate a more complete story of their experience. If patients are encouraged to attend to the neglected parts of their experiences, they can create full stories and give a new meaning to their experiences. In other words, narrative therapy invites the survivors to engage in a reassessment, to construct new meanings and integrate them into their experience (Petersen et al., 2005).

The narrative approach is also characterized by stimulating discussions to find personal resources to facilitate coping with difficulties in life, so it becomes a respectful approach to the experiences, beliefs and the times that a person takes to decide to address their difficulties. This shows a closer relation with some of the principles of the PFA than psychological debriefing. Within this respectful attitude there is an emphasis on finding and validating local narratives over the narratives of the dominant culture. In that sense, it is important to note the existence of studies that question the universality of the conceptualization and interventions on psychological trauma, suggesting adaptation to local situations (Miller, 2006). The same emphasis on ethno-cultural particularities before providing a standard psychological support to survivors of trauma was indicated by Rajkumar et al. (2008) regarding the T-2004 in India. The author argues that cultural practices should be included in any model of intervention. This is what Silove and Zwi (2005) say in their analyses of early psychosocial interventions in the disaster zone of T-2004, noting that the need for any intervention of this kind should be adopted in consultation with local professionals before implementation, otherwise it would be arrogant to decide so without their permission. According to Silove and Zwi (2005), those communities affected by the disaster should be the architects of their own psychosocial recovery. They warn that to come and go in with quick-solution approaches can cause more damage than good and may leave a bit of resentment and unfulfilled promises. Simons et al. (2004) suggest the same need to build on community resources rather than imported techniques. They worked with survivors of the T-2004 from a psychological community perspective. Summerfield (2006) also calls for the adaptation of the types of assistance to local cultures, in addition to questioning the concept of "disaster mental health" considering that initial aid should be primarily social and community. This emphasis on local culture can even have a repairing role before the deficit of the central organization to go in support of survivors. Therefore, when government agencies or the community are harmed as a result of the disaster, it is necessary to strengthen local networks; concluded Mendez et al. (2010).

Silove and Zwi (2005) propose that instead of using ineffective high-cost strategies, such as debriefing, appropriate culturally-social strategies should be emphasized to provide protection for the vulnerable, to bring families and communities together wherever it is possible, to create meaningful roles and livelihoods, and to restore institutions and services (religious, cultural, mental health) that promote community cohesion and a sense of order.

Considering this background, it seems that the narrative approach, focused on the meaning of experience and reconnecting people with their social support networks, but at the same time respecting the rhythms of people and knowledge of local culture, could become a model for preventing or reducing symptoms of PTSD, so it is necessary to conduct studies to prove its effectiveness. One of those studies was developed by García and Rincón (2009) to prevent the occurrence of PTSD in patients that were just diagnosed with breast cancer and later used for individuals and group work for survivors of the T-2010 in Chile (García & Mardones, 2010; Avalos & Balic, 2010).

Table 1. Comparative table of the four models

#### **7. Conclusion**

224 Tsunami – A Growing Disaster

The goal of narrative therapy is to help clients to rewrite their life story, incorporating pieces of their history that have been marginalized from their experience, events that are exceptions to the current narrative: then the people will be able to give a new meaning to their past life and to plan a future less oppressive than the one manifested today. This approach also points out that new meanings assume greater value if they are transmitted and shared with the social network (family, friends) that surrounds and supports the patient, encouraging, therefore, several instances where it is possible to establish this connection, either symbolic (therapeutic

Narrative therapy is based on the principle that people categorize their experiences through language. However, in the process of putting the experience in the form of a story, certain parts are left out because they are not much considered than other parts. As people remember these neglected parts, they are able to formulate a more complete story of their experience. If patients are encouraged to attend to the neglected parts of their experiences, they can create full stories and give a new meaning to their experiences. In other words, narrative therapy invites the survivors to engage in a reassessment, to construct new

The narrative approach is also characterized by stimulating discussions to find personal resources to facilitate coping with difficulties in life, so it becomes a respectful approach to the experiences, beliefs and the times that a person takes to decide to address their difficulties. This shows a closer relation with some of the principles of the PFA than psychological debriefing. Within this respectful attitude there is an emphasis on finding and validating local narratives over the narratives of the dominant culture. In that sense, it is important to note the existence of studies that question the universality of the conceptualization and interventions on psychological trauma, suggesting adaptation to local situations (Miller, 2006). The same emphasis on ethno-cultural particularities before providing a standard psychological support to survivors of trauma was indicated by Rajkumar et al. (2008) regarding the T-2004 in India. The author argues that cultural practices should be included in any model of intervention. This is what Silove and Zwi (2005) say in their analyses of early psychosocial interventions in the disaster zone of T-2004, noting that the need for any intervention of this kind should be adopted in consultation with local professionals before implementation, otherwise it would be arrogant to decide so without their permission. According to Silove and Zwi (2005), those communities affected by the disaster should be the architects of their own psychosocial recovery. They warn that to come and go in with quick-solution approaches can cause more damage than good and may leave a bit of resentment and unfulfilled promises. Simons et al. (2004) suggest the same need to build on community resources rather than imported techniques. They worked with survivors of the T-2004 from a psychological community perspective. Summerfield (2006) also calls for the adaptation of the types of assistance to local cultures, in addition to questioning the concept of "disaster mental health" considering that initial aid should be primarily social and community. This emphasis on local culture can even have a repairing role before the deficit of the central organization to go in support of survivors. Therefore, when government agencies or the community are harmed as a result of the disaster, it is

letters) or directly (forums, workshops, family gatherings).

meanings and integrate them into their experience (Petersen et al., 2005).

necessary to strengthen local networks; concluded Mendez et al. (2010).

Silove and Zwi (2005) propose that instead of using ineffective high-cost strategies, such as debriefing, appropriate culturally-social strategies should be emphasized to provide The psychological reactions to a natural disaster like a tsunami are varied. Many of them are normal behaviors faced with an event of great emotional intensity, even if they are perceived as unpleasant. Focusing only on the psychopathological reactions prevents us from addressing more adaptive responses and also it has the risk of qualifying many of these normal reactions as symptoms of mental illness. In this regard, Cova and Rincon (2010) believe particularly valuable the responses aimed at strengthening the skills and resources of individuals and communities to be able to address their own problems and those that not only aim at specific "symptoms", but also at their quality of life.

Therefore, it is relevant to design and evaluate early intervention strategies that are able to prevent future maladaptive reactions in tsunami survivors, among others natural disasters.

Prevention of Psychopathological Consequences in Survivors of Tsunamis 227

Brewin, C., Andrews, B., & Valentine, J. (2000). Meta-analysis of risk factors for

Bronisch, T., Maragkos, M., Freyer, C., Müller-Cyran, A., Butollo, W., Weimbs, R. & Platiel,

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### *Edited by Mohammad Mokhtari*

The objective of this multi-disciplinary book is to provide a collection of expert writing on different aspects of pre- and post- tsunami developments and management techniques. It is intended to be distributed within the scientific community and among the decision makers for tsunami risk reduction. The presented chapters have been thoroughly reviewed and accepted for publication. It presents advanced methods for tsunami measurement using Ocean-bottom pressure sensor, kinematic GPS buoy, satellite altimetry, Paleotsunami, Ionospheric sounding, early warning system, and scenario based numerical modeling. It continues to present case studies from the Northern Caribbean, Makran region and Tamil Nadu coast in India. Furthermore, classifying tsunamis into local, regional and global, their possible impact on the region and its immediate vicinity is highlighted. It also includes the effects of tsunami hazard on the coastal environment and infrastructure (structures, lifelines, water resources, bridges, dykes, etc.); and finally the need for emergency medical response preparedness and the prevention of psychological consequences of the affected survivors has been discussed.

Photo by BallBall14 / iStock

Tsunami - A Growing Disaster

Tsunami

A Growing Disaster

*Edited by Mohammad Mokhtari*


**8. Next Steps**

The large variation in both costs and outcomes coupled with limited evidence in health care to demonstrate the link between spending more money (higher health care costs) and better outcomes (higher quality) presents a dilemma when it comes to investing additional resources in a system that is already constrained. In order to reduce unnecessary health care spending, we must couple cost analyses with outcome studies and evaluate the relationship between the two. While quality improvement initiatives are often used as a tool to improve outcomes, there is also the necessary investment of resources (Figure 3). Therefore, trying to study the delicate balance between what costs are important and necessary and the quality of care delivered inherently comes with many confounders. It is possible to imagine that with greater investment of resources and thus increased costs, the quality of care delivered may be improved. Conversely, higher quality of care could also lead to decreased health care costs due to lower rates of complications, morbidities, and length of stay. Furthermore, utilizing mortality as a marker for quality of care can be problematic in and of itself, as mortality could also arguably decrease cost by reducing the length of stay and reducing resource utilization (in particular in the NICU population).

There is already a model that exists in collaborative quality improvement for centers to learn from best and worst performers in order to learn opportunities for improvement. The same approach should routinely incorporate costs into the conversation in order to allow tools such as *Choosing Wisely* and EHR to drive down unnecessary spending without a ffecting outcomes. There are both micro and macro-economic opportunities for cost reduction while allowing additional financial investments as new technologies, drugs and programs are introduced.

**Figure 3.** The relationship between quality improvement, outcomes, and costs.


*Editorial* **Special Issue "Production of Biofuels and Numerical Modelling of Chemical Combustion Systems"**

**Miguel Torres-García 1 , Paloma Álvarez-Mateos 2 and Juan Francisco García-Martín 2,\***

Biofuels have recently attracted a lot of attention, mainly as alternative fuels for applications in energy generation and transportation. The utilization of biofuels in such controlled combustion processes has the great advantage of not depleting the limited resources of fossil fuels, but leads to emissions of greenhouse gases and smoke particles similar to traditional combustion processes, i.e., those of fossil fuels. On the other hand, a vast amount of biofuels is subjected to combustion in small-scale processes, such as for heating and cooking in residential dwellings, as well as in agricultural operations, such as crop residue removal and land clearing. In addition, large amounts of biomass are consumed annually during forest and savanna fires in many parts of the world. These types of burning processes are typically uncontrolled and unregulated. Consequently, the emissions from these processes may be larger compared to industrial-type operations. Aside from direct effects on human health, especially due to a sizeable fraction of the smoke emissions remaining inside residential homes, the smoke particles and gases released from uncontrolled biofuel combustion imposes significant effects on the regional and global climate. Estimates have shown the majority of carbonaceous airborne particulate matter to be derived from the combustion of biofuels and biomass.

This Special Issue on "Production of Biofuels and Numerical Modelling of Chemical Combustion Systems" contains sixteen high-quality studies (fifteen research papers and one review paper) addressing techniques and methods for bioenergy and biofuel production as well as challenges in the broad area of process modeling and control in combustion processes.

First at all, García Martín et al. comprehensively review the latest advances focused on energy production from different olive biomasses, including the production of biofuels such as bioethanol and biodiesel and processes such as combustion, gasification and pyrolysis [1]; all of them can be applied to any type of biomass. For lignocellulose biomasses, mainly composed of cellulose, hemicellulose and lignin, the determination of their content in these fibers and moisture is of major importance to select the most suitable process for energy production. In this sense, Díez et al. provide a new efficient, low-cost and fast method for the determination of these contents in different types of biomasses from agricultural by-products to softwoods and hardwoods [2]. The proposed method is based on applying deconvolution techniques on the derivative thermogravimetric pyrolysis curves obtained by thermogravimetric analysis through a kinetic approach based on a pseudocomponent kinetic model.

Biofuels cannot replace our current dependence on coal, oil, and natural gas, but they can complement other renewable energies such as solar and wind energies. Thus, due to the merits of biofuel energy for environmental sustainability, biofuel and bioenergy technologies play a crucial role in the renewable energy development and replacement of chemicals from highly functional biomass. The following six research papers investigate the production of biofuels from biomass.

**Citation:** Torres-García, M.; Álvarez-Mateos, P.; García-Martín, J.F. Special Issue "Production of Biofuels and Numerical Modelling of Chemical Combustion Systems". *Processes* **2021**, *9*, 829. https:// doi.org/10.3390/pr9050829

Received: 5 May 2021 Accepted: 5 May 2021 Published: 9 May 2021

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Starting with liquid biofuels, Cuevas et al. obtain bioethanol from the acid hydrolysis at high temperature of olive stones followed by enzymatic hydrolysis and fermentation of the released sugars with the yeast *Pachysolen tannophilus* [3]. The pretreatment was optimized by means of response surface methodology with two independent variables (temperature and reaction time). With regard to the production of biodiesel by transesterification, García Martín et al. deal with the issue caused by waste cooking oils with high acidity, which cannot be directly transformed into fatty acid methyl esters by transesterification due to the soap formation [4]. The solution proposed, within the biodiesel production framework and the circular economy concept, is the esterification of these high acidity oils with the residual glycerol from transesterification. On the other hand, the existence of excess water content in the starting oil can retard the transesterification rate and make the resulting biodiesel not comply to legal specifications for its use as biofuel. Hence, Lin and Ma assess the optimum water content in the raw oil and its effects on burning characteristics of the resulting biodiesel [5].

Biomethane and syngas stand out among the gaseous biofuels. Alonso-Fariñas et al. obtain biomethane from the anaerobic digestion of olive pomaces within an olive oil mill framework [6]. These authors study the life cycle assessment of a scheme consisting of the production of biogas from the anaerobic digestion of the olive pomace, heat and electricity cogeneration by the combustion of the generated biogas, and composting of the anaerobic digestate. Syngas can be obtained from biomass as a renewable energy source though gasification. However, syngas from biomass contains some impurities, such as organic tars, which must be removed before its application. To perform this, Díez et al. synthesize a catalyst based on layered double hydroxides with a molar cation concentration Ni/Cu/Fe/Mg/Al of 30/5/5/40/20 for the steam reforming of toluene as a model compound of biomass tar [7], yielding high concentrations of H2.

Finally, the production of solid biofuels, such as pellets, is also highlighted. Notwithstanding, pellets from biomass cannot compete with those from fossil fuel sources because the biomass densifying process and the raw materials price make pellet production economically unfeasible. To overcome these issues, Clavijo et al. propose the use of eucalyptus kraft lignin as an additive for tree-leaf pellet production [8]. The resulting pellets fulfilled all requirements of European standards for certification except for ash content.

The following four research papers are focused on the production of biomass and biocrude from microalgae. Advanced biofuels obtained from microalgae have attracted great interest because they do not compete with food production since they can grow on non-arable land. The production of biomass is a key prerequisite in the production process of biocrude and other valuable compounds from microalgae. Thus, Fuentes et al. produce biomass at a large scale from the microalgae *Coccomyxa onubensis* in an 800-dm3 tubular photobioreactor [9]. These authors obtained a biomass productivity of 0.14 g dm−3 day−1 along with high contents of lutein, an interesting food colorant, when growing the microalga under outdoor conditions. Hydrothermal liquefaction has proven to be an attractive process for the production of biofuels from microalgae, rendering biocrude (the liquid organic phase), aqueous phase compounds, solid residue, and gas phases, as illustrated in three works published in this Special Issue by Dr. Vicente's research group. In the first, Megía-Hervás et al. assess the temperature, reactor loading and time of the hydrothermal liquefaction of the microalga *Nannochloropsis gaditana* at mild temperatures in order to reduce the N and O content in the biocrude and to maximize the yield of the pretreated biomass [10]. Subsequently, Sánchez-Bayo et al. improve the hydrothermal liquefaction of the same microalgae using heterogeneous catalysts [11]. To be specific, the catalysts were based on metal oxides (CaO, CeO2, La2O3, MnO2, and Al2O3), yielding remarkable amounts of biocrude, high values of C, H and heating value and low contents of N, O and S. In the third paper, Megía Hervás et al. perform the hydrothermal liquefaction of another microalgae (*Phaeodactylum tricornutum*) in a scale-up photoreactor [12]. The biocrude yields obtained in this scale-up photoreactor were lower than the ones obtained from the biomass cultivated at laboratory scale because of the lower lipid and high ash

contents in this biomass. However, the culture scaling-up did not have influence on the heteroatom concentrations in the biocrudes.

The last four research papers study the modelling and design of combustion processes of biofuels. Since biodiesel has higher viscosity than petroleum diesel, which leads to lower performances of compression ignition engine and higher emissions, Hamid et al. perform a numerical investigation of fluid flow and in-cylinder air flow characteristics [13]. As a result, the authors propose to install a guide vane design in the intake manifold, with shallow depth re-entrance combustion chamber pistons, in order to promote better diffusion, evaporation and combustion processes. Next, Orihuela et al. focus on the performance loss of the post-combustion system due to the variability that biofuels introduce in the exhaust particle distribution [14]. These authors use a well-validated particulate filter model available as commercial software to predict the filtration performance of a wall-flow particulate filter made of biomorphic silicon carbide (a bioceramic material made from vegetal waste) with a systematic procedure that allows one to eventually fit different fuel inputs. On the other hand, dual fuel engines (those that use diesel and fuels that are gaseous at normal conditions) are receiving increasing attention because they achieve the same (or better) power density and efficiency, steady state and transient performances than petroleum diesel. In his research paper, Boretti develops a numerical analysis of a novel, high-pressure (1.6 × 108 Pa) liquid phase injector for liquefied natural gas in a high compression ratio, high boost engine featuring two direct injectors per cylinder: one for diesel and one for liquefied natural gas [15]. Finally, Guo et al. assess the effects of the diameter and the angle of the pre-combustion chamber nozzle on the performance of a marine two-stroke dual fuel engine [16], finding that both parameters have influence on the flame propagation in the combustion chamber.

To sum up, this Special Issue on "Production of Biofuels and Numerical Modelling of Chemical Combustion Systems" comprehensively overviews and includes in-depth technical research papers addressing recent progress in biofuels production and combustion processes. All these manuscripts contributed—with their topics and their high quality—to the success of the present Special Issue.

**Funding:** This review paper received no external funding.

**Acknowledgments:** The Guest Editors are grateful to all the authors that have contributed to this Special Issue, all the reviewers for their excellent work in evaluating the submitted manuscripts and the editorial staff of Processes, especially Tami Hu and Milica Ma, for their assistance in the success of this Special Issue.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


**Saliva control difficulties.**

Difficulty in controlling saliva is a common problem for people with Cerebral Palsy (CP). Drooling is not normally a result of overproduction but inefficient control of salivary secretions due to: