Learning From Disaster

On a December morning in 1988, a massive earthquake tore through northern Armenia, devastating the small Caucasus country. Over 25,000 died – two-thirds of whom were children – while an estimated 100,000 people were injured and half a million were left without homes.

As part of the international relief efforts that followed, psychiatrists and other mental health professionals from all over the world traveled to Armenia. The response would kick off a remarkable and sustained mental health relief and research program that included UCLA doctors Armen Goenjian, Alan Steinberg and Robert Pynoos.

That long-running effort lasted over two decades and provided invaluable insights into designing and implementing mental health programs after major traumatic events. Those lessons have grown more important amid the COVID-19 pandemic, the ongoing plague of gun violence, and the increasing threat of climate-related disasters like hurricanes, wildfires and floods, say the UCLA researchers, who detailed their insights in a new book, “Lessons Learned in Disaster Mental Health: The Earthquake in Armenia and Beyond.”

Their book describes the clinical experiences of therapists who worked with survivors, the findings of cutting-edge studies, organizational challenges and successes, and memoirs from the most comprehensive post-earthquake mental health recovery program conducted after a catastrophic natural disaster. The project was sponsored by the Armenian Relief Society of Western United States.

“The enduring impact of treatment 25 years after the earthquake provided to children and adolescents at 1½ years after the earthquake showed the importance of implementing school-based trauma-grief focused interventions that can benefit a generation of adolescents as they transition to adulthood,” said Dr. Goenjian, the director of the project known as the Psychiatric Outreach Program.

According to Dr. Steinberg, almost all reported follow-up treatment outcome studies have been conducted two years or less after the disaster. Only a handful have followed up for five years.

“We found that, in the long run, strong social support also reduced the likelihood of people developing Post-Traumatic Stress Disorder and depression; while adversities such as lack of housing, heating, electricity and transportation increased the risk for chronicity,” according to Dr. Goenjian. Managing these various factors should be part of a comprehensive relief program, he said.

It’s also important to be mindful of cultural factors that could affect mental health treatment – and accordingly modify treatment. For instance, in Armenia, it was customary to drink at the graveside of loved ones. “Without understanding cultural practices, you’re not working most effectively with the patients that you’re dealing with,” said Dr. Steinberg.

“The multigenerational genetic studies of survivors showed that vulnerability to PTSD was partially heritable and carriers of three gene variants involved in regulating neurohormones were at higher risk of developing PTSD,” said Dr. Goenjian. “This gives us hope that advances in psychiatric genetics will one day be translated into therapeutic and preventive approaches,” he said.

Another important finding, according to Dr. Steinberg, was that traumatized adolescents had a better understanding of moral valuation, and counterintuitively, they evidenced pathological interference with conscience functioning. For example, in contrast to controls, traumatized adolescents endorsed items such as “I had a good side that got ruined growing up” or “After a certain event, I stopped caring about right and wrong.”

“Despite the many hardships of working in the earthquake zone, many of the mental health workers who were volunteers admitted that providing help to the survivors was one of their most gratifying life experiences,” said Dr. Goenjian.

In addition to Armenia, the UCLA researchers’ work providing mental health response in disaster areas has brought them to places as disparate as Honduras, Nicaragua, Greece, Turkey, Japan, and Taiwan. No matter the location, the challenges were similar.

After the Armenian earthquake, setting up a mental health treatment program in the then-Soviet nation was hardly easy, according to Dr. Goenjian. “It took time to gain the trust of government officials, school administrators, and teachers. We had to remember that we were guests in the communities stricken by tragedy,” said Goenjian, a full research psychiatrist at the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA. “We refrained from involvement in political and religious matters,” he added.

“Our goal was to screen as many children as possible and then focus on the moderate and severe cases,” said Dr. Goenjian. The researchers found that schools were the ideal location for providing treatment to children and adolescents and that some principals in Armenia were hesitant to allow in mental health workers out of concern that it would be too upsetting for the children to talk about the earthquake. 

“We had to use psychoeducation, explaining to the principals that the children are upset and shouldn’t be left to fester without being evaluated and being provided assistance and support,” said Dr. Steinberg, associate director of the UCLA/Duke University National Center for Child Traumatic Stress, which aims to improve the standard of care and access to services for children and families affected by trauma.

And while treatment is important, it isn’t enough on its own – the recovery environment also matters, the researchers found. Programs that restore communal spaces, like playgrounds or houses of worship that were destroyed during a disaster can help promote social activities and remove painful reminders of the traumatic event – or the “disaster after the disaster,” as Dr. Steinberg described it.

The book is recommended reading for psychologists, psychiatrists, social workers, public mental health professionals, and those working for relief organizations following disasters.