Papers published in other journals
Practice report

Psychoeducation for Caregivers and Children in Camps after theGreat East Japan Earthquake and Tsunami
Naru Fukuchi*1,2 Shusaku Chiba*2,3 Moe Seto*4
Takahiro Hoshino*5 Asako Murai*6

Key words: Great East Japan Earthquake, psychoeducation, camp, mental health care

Abstract: A total of 10 camps were built from 2011 to 2019 for caregivers and children
living in areas affected by the Great East Japan Earthquake. Programs were offered tocaregivers and children, including psychoeducation and relaxation. Psychoeducation forchildren was titled “studying the heart”; it included instruction and drawing with picturestory shows, and breathing techniques using toys, such as blow-up pipes. The
psychoeducation content needs to be adjusted according to the recovery period of the region.
The condition of the children in the region must be monitored on a daily basis. Some of theparticipants were children who had experienced various traumatic experiences caused by theearthquake and children with mental illness. Managing the camp by talking to specialists who
were involved on a daily basis would have the secondary effect of building ties within thecommunity.

Introduction

the schoolyard, as a parking lot for evacuees; and a
nearby park, as a food kitchen. The children’s entire

The Great East Japan Earthquake that occurred in2011 caused extensive damage to the coastal areas of the
Tohoku region and had a major impact on the physicalcommunity was in a tense state, with the family
members who lived with the children unable to havepeace of mind. The children sensed this atmosphere andand mental health of all residents. As a member of amental health care team, the author has been visiting the

suppressed the expression of their emotions. Children
learn to regulate their emotions and behavior throughhomes of children immediately after the earthquake
disaster. A major concern is the loss of play spaces. The

play, so when the lack of play spaces continued for along period of time, involved parties became concernedschool gymnasium was used as an evacuation shelter;

about the impact on the children’s general development.

Naru FUKUCHI et al.: Psychoeducation for Caregivers and Children in Camps after the Great East Japan Earthquake
and Tsunami*1

Department of Psychiatry, School of Medicine, Tohoku Medical and Pharmaceutical University [1-15-1 Fukumuro, Miyagino Ward,
Sendai, Miyagi 983-8536, Japan]*2 Miyagi Disaster Mental Health Care Center, Miyagi Prefecture Mental Health and Welfare Association*3 Graduate School of Education, Tohoku University*4 Department of Psychiatry, Tohoku University Hospital*5 Saitama Children’s Mental Health Clinic*6 Miyagi Psychiatric Center, Miyagi Prefectural Hospital Organization

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Table 1-1. Overview of each camp
First
July 2011

Hosting period
Children
psychoeducation

SecondOctober 2011

Third
October 2012

FourthOctober 2013

Picture-story show Picture-story show Picture-story show Breathing methodand drawing
and drawing
and drawing
and muscle
relaxation
AbsentPresent
Present
Present
AbsentAbsentAbsentAbsentCaregiver program
Alumni program
Number of children
Boys
Girls
Average age (years)
House completely
destroyed
Had a near-deathexperience
InjuredSaw an injured person
Death of a loved one
Loss of something
precious
Witnessed Tsunami
PTSSC-15 before
camp was above thecutoff value

Fifth
October 2014
Breathing method
and muscle
relaxation
Present
Absent

21
11
10
8.1

22
12
10
8.3

18
10
8
8.3

21
5
16
8.3

19
12
7
8.8

2

6

6

7

6

2

6

6

5

5

0
0
5

1
4
9

0
4
8

0
1
8

0
2
6

2

12

7

10

9

2

6

7

7

6

13

16

9

9

7

I. Background of this project
We aimed to restore the children’s peace of mind by
taking them to a campsite in an inland area away fromthe coast and providing a series of programs. With the
Sendai Children’s Mental Study Group, which has been
continuing for many years in Sendai City, as the parent
organization, we decided to work with the cooperationof specialists in medical institutions and multiple
volunteer groups. The project started in July 2011 andcontinued approximately once a year since then, with a
total of 10 sessions by FY 2019 (Fukuchi et al., 2012;
Fukuchi, 2017; Fukuchi et al., 2019). This article
presents an overview of this project in the form of apractice report.
II. Program structure
The heart of this project was the program that wasprovided within the camp; and its subjects were children,
caregivers, and alumni (children who were former camp
participants and had graduated from elementary school)(Table 1). At the start, we offered a series of programs,
including psychoeducation only for children. There wasa subsequently increasing need for an exchange of
opinions with caregivers, and in the second to eighth
sessions, we also provided a caregiver program that

included psychoeducation and relaxation. Furthermore,
starting with the eighth event in 2017, we provided a
training program for junior high school students (former
participants who graduated from elementary school) andasked them to help out as staff on the day of the event.
This article is positioned as a practice report, but it
was compiled with the approval of the ethics committeeof the MDMHCC. This article was prepared with
sufficient consideration for the protection of personal
information so that the individuals who participatedwould not be identified.
1. Children’s program (First to tenth sessions)Purpose: This program was conducted with the purposeof providing a safe space for children to play, to help
them understand how their mind works, and to learn todeal with their anxiety.
Targets: Application guidelines were distributed toelementary school children through the boards ofeducation of the municipalities from which consent
was obtained. We sought to understand the living
conditions at the time of the earthquake and thechildren who needed special consideration by
conducting a pre- and post-questionnaire survey of thechildren and their caregivers. We conducted the PostTraumatic Stress Symptoms for Children 15 items(PTSSC-15) (Tominaga et al., 2002; Usami et al.,2014) to understand the children’s state of mind.

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Table 1-2. Overview of each camp

Sixth
October 2015
Breathingmethod andmusclerelaxation
Present
Absent
14
7
7
8.9
6
3
0
3
5
7
7
5

SeventhOctober 2016
Breathingmethod andyoga

EighthOctober 2017
Breathingmethod andyoga

Present
Absent
18
10
8
9.0
4
3
0
1
5
7
5
4

Present
Present
12
3
9
9.0
4
2
0
3
3
7
4
5

Implementation content: We provided a unified
package program for all 10 events (Table 2). In the oneday camp, the groups were organized evenly by age,with upperclassmen appointed as leaders and subleaders and organized to work in groups. Group work
was done at the beginning and end of the program,“today’s goals” were set, and the groups investigatedwhether they were able to achieve them. They used thecampsite facilities to practice cooking with the supportof the staff. Recreation was conducted after lunch, after
which psychoeducation was conducted under the title of“studying the heart.” The psychoeducation contents
were repeatedly examined among the staff, andactivities such as teaching and drawing by picture-story
show (Fukuchi, 2016), breathing methods and muscle
relaxation methods using toys (Document 1), and yoga
were conducted.
2. Caregiver program (second to eighth sessions)Purpose: This program aimed to help caregivers
understand their own mental state and that of theirchildren and provide appropriate support to theirchildren. The program also aimed to provide time forparents to relax themselves.

Ninth
October 2018
Picture-story
show andbreathingmethodAbsentPresent
10
7
3
8.7
0
0
0
0
0
0
0
5

Tenth
October 2019
Picture-story
show andbreathingmethodAbsentPresent
19
9
10
8.2
1
0
1
1
2
2
1
8

Total

174
86
88
8.51
42 (27.1%)
32 (18.4%)
2 (1.15%)19 (10.9%)51 (29.3%)
63 (36.2%)
45 (25.9%)
81 (45.6%)

Targets: They were the caregivers of the children who
participated in the camp.
Implementation content: After seeing the children
leave for the campsite, the caregivers were guided toanother venue and were provided with a series ofprograms. A specialist gave a mini-lecture on“children’s mental reactions after a disaster.” Relaxation
sessions, such as yoga and hand massages, were
provided by specialist instructors, with places forindividual consultation provided to those who wished
for it. We explained the psychoeducation and relaxation
content that were provided to the children in the camp,
and we devised ways for the caregivers to practice with
their children at home after the camp.
3. Alumni program (eighth to tenth sessions)Purpose: This program was conducted with the purposeof allowing the camp graduates who had experienced
being supported after the earthquake to experience being
on the side of providing support. One of the major goals
was to train supporters in the community and circulate
human resources.

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Table 2. Overview of children’s program
1. Bus transfer
2. Icebreaker
3. Group work
Participants were divided into groups of five to six, “today’s goals” were set, and they were presented to
one another.
4. Cooking practice
Cooking practice was conducted with the support of the staff. Dishes included curry rice, boiled potatoes, and hot
dogs. There was also a session for making emergency food.
5. Meals
6. Break
7. Outdoor recreation
We asked school teachers and boy scouts to oversee the activities, and we set activities where the participants
played physically demanding games.
8. Psychoeducation and relaxation
We conducted psychoeducation using picture-story shows, and we explained how the mind and body work, as wellas coping methods. We then conducted drawing, breathing methods, and yoga.
9. Group work
In groups, they reviewed “today’s goals” that were set at the beginning of the session.
10. Bus transfer
Participants: Among the children who previously
participated in the camp project and were already juniorhigh school or high school students, those in families who
responded that they would like to receive information
about similar events in the future were contacted.
Implementation content: The participants were gathered
on a different day than the day the camp was held, and a
training program was provided. We discussed and decided
on the contents of the cooking practice on the day of thecamp, and set some time to cook with everyone.
Additionally, assuming a situation where older students
would support the younger children, the international
human support guideline “Psychological First Aid forChildren (PFA)” was reconstructed into a junior highschool and high school version, and training was provided
by professional trainers (Save the Children Japan).
III. Results and discussion
Across all 10 sessions, a total of 174 children (86 boys
and 88 girls) participated. The average number ofparticipants per session was 17.4 people, and the averageage of the participants was 8.5 years (SD = 1.90). Amongthe participants, 42 (27.1%) had a “house completely
destroyed,” 32 (18.4%) “had a near-death experience,”
51 (29.3%) reported the “death of a loved one,” and45 (25.9%) “witnessed the tsunami.” Many children had a
traumatic experience from the earthquake disaster. Indeed,
81 children who exceeded the PTSSC-15 cutoff score of
23 points and 21 children with psychiatric symptoms that
required some kind of treatment were referred to a

specialized medical institution at the appropriate time.
Illnesses included PTSD and depression caused by theearthquake disaster itself. Moreover, many children had
developmental disorders, such as attention-deficit
hyperactivity disorder and autism spectrum disorder.
The psychoeducation of children was re-examined andrevised every two to three sessions. At the beginning of
the program, we sought to ensure that the children would
be able to come into contact with the earthquake disaster
experience in a way that would be familiar to them andwithout excessive exposure, ensuring that they would beallowed to express various emotions. However, weobserved that some children had difficulty listening to
explanations and working according to instructions due tohyperarousal. From the fourth session onwards, wereduced the learning elements and restructured the format
to mainly relaxation. We prepared yoga mats for thenumber of people involved, paired the staff with children,and introduced breathing methods and muscle relaxation
methods using toys such as blow-up pipes and paper
balloons (Document 1). These relaxation sessions becamea regular routine and a familiar program for children who
repeatedly participated. In each session, the contents
needed to be reset according to the children’s current
situation. We constantly monitored the recovery status of
the community. It was important to reflect on the support
side. If there was a strong desire to control the children(i.e., desire to have them do things properly), then the
program tended to become over-structured, and thechildren would be forced to spend time in a rigid manner.

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Document 1. Breathing method and muscle relaxation method using toys
(Moving indoors after moving the body by playing outside. Conducted after wiping sweat and rehydrating)Instructor: So, from now, we will try to calm down a bit and be quiet. From now, we will study the heart. What wewill study today is to breathe in and out, and strain and relax. Please form a pair of a child and an adult. Take one
yoga mat each and sit on the floor.
Instructor: We had a lot of fun today. How are you all feeling now?
⇒ Children: “fun,” “tired,” “I want to go home”
Instructor: Okay, how does everybody’s body feel?
⇒ Children: “sweaty,” “my heart is pounding,” “out of breath,” “it hurts if I get hit”
Instructor: Your body reacts when you do something fun, exciting, angry, orremember something bad.
Instructor: I will hand a toy to everybody. First, please play with this.
(blow-up pipes distributed to each person)⇒ Children: “what is this,” “I’ve seen this before,” “it’s in candy stores”
Breathing method instruction
Instructor: To blow the ball well, you need to take a deep breath and blow
little by little. Let’s practice this. As you inhale, expand your belly and breatheout slowly. This is called abdominal breathing. (practice abdominal breathingin pairs with a staff member)
Instructor: Now, imagine a ball floating in the air in your mind. This time,
without using a pipe, close your eyes and let the ball float in your head. Lieon your back on the yoga mat. The room will be darkened, and you should dothis quietly.
Muscle relaxation method instruction
Instructor: Next, we’ll use our bodies a bit. The key is to strain and then relax.
While lying down, make fists with both your hands. Then put more and moreforce into your fists. Put some force into your shoulders… this time, relax all
at once, and just let go. Okay, now we’ll repeat this.
Combining breathing and muscle relaxation
Instructor: Try to breathe in and out three times, and try to strain and relax three times.
Instructor: How is everybody’s body feeling?
⇒ Children: “I’m already sleepy,” “I’m hungry,” “I want to go to the bathroom”
Instructor: Everybody’s mind and body are connected. Let’s try to do this when we get excited, remember bad
things, get frustrated, or nervous.

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We did not set a caregiver program in the first session.

students—we conducted lectures and set roles andHowever, when the children were handed over to theirdialogues, and repeated roleplays. Although the number

caregivers after the end of the session, many questionsof junior high school and high school students who

were asked about the behavior of the children in theparticipated was low at eight students, the fact thathousehold, and we learned that some families had trouble

children who were once on the receiving end of support

dealing with the children. The caregiver questionnaires

had grown up and now experienced the position ofafter the end of the session also indicated the desire for aproviding support was meaningful from the perspective of

program aimed at the caregivers. Therefore, we set up afostering human resources in the community.

separate venue near the place where the children gathered,

Conclusionand from the second session onwards, we provided a
caregiver program. This was a package of lectures,This was a project that was continued with a certain

relaxation, and individual consultations. Professionals

degree of momentum; we could not sufficiently structuresuch as the authors regularly visited most of theit, in part owing to the hyperarousal in the children afterelementary schools that the children attended, and many

the disaster. Thus, we could not verify the effectiveness ofof the caregivers had already met before the camp. The

the program. In the beginning, we wanted to provide

caregivers were aware that their children had psychiatricchildren with a place to play and learn to overcome crises.

symptoms, and many families participated in the camps

However, those of us who provide support were able toseeking evaluations. Specialists visiting places close tolearn the importance of being in contact with children in

the residents and interacting with them in ways other thanplaces other than a clinical setting, create connections

medicalwithin the community, and experience the circulation of

care,

such

as

camps,

may

reducecaregivers’ anxieties.

people who provide support in that community.

We obtained the cooperation of the staff who operated

There are many natural disasters in Japan, and there is athe sessions by reaching out to not only the staff of theneed to prepare for disasters that are equivalent to the

MDMHCC but also a wide range of specialists with whom

Great East Japan Earthquake in the future. We hope that

we have daily clinical connections. We were also able tothis attempt will provide pointers for overcoming a crisis

obtain the cooperation of not only specialists, but also

in a community.

local university students, NPO groups, boy scouts, andAcknowledgments: We would like to thank everybody

other local residents. We also set up opportunities tofor their support and cooperation in the management ofprovide training in advance for staff who lacked

this project. Naotoshi Kinoshita of the Hyogo Mental

specialized knowledge. This process helped us provide

Health Center provided much advice from the perspective

psychological support to parents and children living in theof a child psychiatrist. The Miyagi Prefectural Highdisaster-affected area and had the secondary effect of

School of Nursing as well as university students in Miyagi

building community ties. For the eighth to tenth sessions,

Prefecture played with the excited children while being

we recruited volunteers among junior high school andthrashed about by them. The Boy Scouts Miyagi

high school students who had participated in past camps,

Prefectural Federation provided us with ideas and support

and they participated as staff members after we provided

for children’s recreation, including the fire-making

themprovided

experience. Most of all, we would like to express our deep

“Psychological First Aid for Children (PFA)” by

gratitude to all the staff members of the MDMHCC who

restructuring it for junior high school and high school

managed this project through trial and error.

withpreliminary

training.

We

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Psychoeducational Program for Children after

Summary
Psychoeducation for Caregivers and Children in Camps
after the Great East Japan Earthquake and Tsunami
Naru FUKUCHI et al.
The Great East Japan Earthquake (GEJE) with a magnitude of 9.0 on the Richter scale
hit the Pacific coast of northeast Japan on March 11, 2011. The disaster caused
tremendous damage and traumatized a large number of people, including thousands ofchildren. While most of these children showed psychological symptoms of trauma,
many could not receive appropriate care because of a lack of mental health professionals
in rural areas. To cope with this situation, we held single-day camps, followed bycontinuous, culturally appropriate psychoeducation, facilitated for children who
experienced the disaster. We explained how emotions are formed by picture story anddid abdominal breathing using a blowing pipe in the psychoedu,cational session. The
program of the camps should be set according to the recovery phase of their communities.
Some of the participants, who had psychological symptoms due to the disasters, could
receive appropriate treatment through the camps. It is possible that community bonding
plays a vital role in community-wide mental health recovery, regardless of whether
formal mental health resources exist or not.
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