This book provides a comprehensive overview of the most sustained comprehensive mental health research and recovery program implemented after a natural disaster.
On December 7, 1988, a powerful earthquake measuring 6.9 on the Richter scale shook northwestern Armenia, causing widespread destruction and death. In Gyumri, Armenia’s second largest city, more than half of the structures were badly damaged or destroyed and 7% of the population died. The town of Spitak near the epicenter was almost completely razed and 16% of the population perished. In the aftermath of the earthquake, Armen Goenjian, MD, LDFAPA, FACGS, initiated and led the Psychiatric Outreach Program and, along with a group of dedicated volunteer mental health professionals, provided services to survivors for over 2 decades .
Dr. Goenjian and his UCLA colleagues – Alan Steinberg, PhD, and Robert Pynoos, MD – studied the psychological aftermath of the earthquake in Armenia and other major disasters in the United States, Greece, Nicaragua, in Taiwan, Honduras, Thailand and Japan. . They recently published the book Lessons Learned in Disaster Mental Health: The Armenia Earthquake and Beyond. The book provides a comprehensive overview of the most sustained comprehensive mental health research and recovery program implemented after a natural disaster.
The book covers the evolution of the program from the initial acute phase of clinical work in the field to its expansion as a 3-year program teaching and training local therapists to the construction of 2 mental health clinics in the devastated cities. It provides a wealth of longitudinal data on the course of post-traumatic stress disorder (PTSD), depression, grief, and separation anxiety in treated and untreated subjects.
“One of the reasons these treatment studies are unique is that the preteens were followed for up to 25 years after the earthquake,” says Dr. Goenjian, a research psychiatrist at the Semel Institute for Neuroscience and human behavior at UCLA.
“Nearly all follow-up studies of treatment outcomes have been conducted 2 years or less after a disaster. Only a handful have followed subjects for up to 5 years,” said Dr. Steinberg, associate director of the UCLA/Duke University National Center for Traumatic Stress in Children.
In controlled studies, adolescents who received trauma- and grief-focused therapy 1.5 years after the earthquake had significantly fewer PTSD and depressive symptoms than in the control group at 5 years, and benefits were maintained at 25-year follow-up. The new analyzes showed that symptoms in the treatment and control groups peaked between 4 and 5 years after the earthquake. “The findings indicate the importance of providing clinical intervention in the early years and subsequent monitoring of chronic psychiatric and medical issues in severely affected survivors,” Dr. Goenjian said. “Those who initially suffered from severe PTSD and/or depression had significantly more chronic conditions.”
Another finding was the significant impact that post-disaster adversities (often called “the disaster after the disaster”) played in the perpetuation of PTSD and depressive symptoms. The findings underscore the important role that governmental and non-governmental agencies could play in survivors’ recovery by providing timely housing, heat, electricity, transportation and medical services. “These types of support measures complement the benefits of psychotherapy and apply to other types of natural and man-made disasters, wars and violence, including domestic,” Dr. Goenjian said.
Another valuable chapter concerns the moral development and functioning of the conscience. “Spitak adolescents exposed to severe earthquake-related trauma exhibited pathological interference with the functioning of consciousness,” Dr. Steinberg said. For example, “these young people felt that they had lost their conscience after the earthquake – that their conscience no longer worked – and thought that it was justifiable to act without consideration of morality in order to survive”.
“Multigenerational genetic studies have shown heritability of vulnerability to PTSD, depression and anxiety. They have also shown pleiotropy, i.e. gene sharing between PTSD, depression and anxiety,” said Dr. Goenjian. They also identified 2 serotonergic genes (TPH1 and TPH2) and 1 dopaminergic gene (COMT) associated with PTSD. Whole-exon sequencing results showed an association between OR4C3 ( the olfactory receptor gene) and PTSD. Carriers of these genes had a higher risk of PTSD. “Results like these give us hope that advances in psychiatric genetics will one day translate into therapeutic and preventive approaches,” said Dr. Goenjian.
The book also discusses significant organizational successes and pitfalls of implementing the disaster recovery program. With respect to factors related to therapist performance and reduction of burnout, helpful steps included vetting applicants prior to enrollment; hold regular pre-departure group meetings with new members to disseminate information accumulated from previous groups and foster esprit de corps; provide guidelines for decorum, such as refraining from political and religious activism; and be respectful of local traditions, customs and religious practices.
The therapists worked in pairs to support each other. They had regular debriefings with peers or group leaders to discuss difficult cases and their own stress reactions to painful realities. They also took weekly rest days. These measures have minimized burnout.
“Despite the many emotional and physical challenges of working in the aftermath of the earthquake, nearly all therapists recognized helping survivors as one of their most rewarding life experiences,” Dr. Goenjian said. .
He concluded by saying, “My favorite chapter that represents the soul of the book is the chapter comprising the heartbreaking compassionate memoirs of the 2 therapists.”
Mr Millman is a Senior Media Relations Officer at UCLA Health. Dr Steinberg is the associate director of the National Center for Child Traumatic Stress in the Department of Psychiatry at UCLA. Dr Goenjian is certified in psychiatry. He is a professor-researcher in psychiatry at the UCLA Geffen School of Medicine and chief physician of the CenExel-CNS network.