Current status of recovery and challenges in Miyagi Prefecture*Reference: The Japanese Journal of Hospital and Community Psychiatry“The Japanese Journal of Hospital and Community Psychiatry” 57(3): 241-244, 2015

Miyagi Disaster Mental Health Care Center
Naru Fukuchi
I． Introduction
It has been approximately four years since the Great East Japan Earthquake on March 11th, 2011, and with every
passing moment, we can see changes in local lifestyles and support activities in the disaster area. Almost all of the debris
generated from the earthquake and tsunami was removed from the heavily damaged region, and construction projects
that raise the ground with dirt are present everywhere. The scenery of once lively towns is gradually disappearing, and
it is difficult to even imagine what the future appearance will be. Disaster public housing was newly built on safe andsolid foundations, and many individuals are being relocated from temporary housing. Meanwhile, many individuals are
moving out of container type temporary housing and vacant rooms are emerging everywhere. Various volunteer
organizations that have begun activities in the disaster area after the earthquake has begun to withdraw from the region
due to insufficient funding and the once-lively nature of activities in the region has begun to die down.
The objectives of this paper are to report on the current status of Miyagi Prefecture today (Fukuchi, 2013), to reflect
on the support provided during the emergency period, and to investigate long-term challenges left in the wake of thedisaster. Additionally, the paper will discuss observations made while the author was involved in mental health care in
the region and provide suggestions from the perspective of a care worker on the rebuilding of future mental health carein the region.
II． Post-disaster mental health characteristics
Characteristics of mental health following a disaster will first be discussed (Figure 1).
Existing mental health structures were significantly damaged due to the disaster and broken into many fragments. The“remaining resources” shown in the figure reflect resources whose magnitude was decreased due to the disaster but
can be sufficiently rebuilt with future ingenuity. Additionally, “resources that can be developed” refer to resourcesthat did not play a major role in existing mental health structures but can be developed and grown for future recovery
in the region. Specifically, this refers to resident volunteers in the region, such as welfare commissioners or dietitians;
and collective functions, such as the junior chamber of commerce and industry and women’s associations. Finally,“unrecoverable resources” refer to facilities or human resources that were lost due to the disaster that can no longer
be factored into future mental health development in the region. For example, clinics or hospitals that were severely
damaged and forced to close due to the tsunami cannot be included in this futuristic design.
Meanwhile, there are many “resources flowing into” the disaster area as a result of the earthquake, and many
health care/welfare organizations and volunteer organizations such as NPOs and NGOs from outside of the prefecture
have started to conduct activities in the disaster area. Additionally, willing human resources have sought work in
specialized institutions within the disaster area and began to work in the region.
A “future vision of mental health” is to be created by gathering these fragments and aligning them with regional
conditions. Human movement in disaster areas is fast, so it is important to constantly understand the present overallsituation and intervene promptly.
II． Activities of the Miyagi Disaster Mental Health Care Center
Here, the FY 2013 (April 2013 – March 2014) activities of the Miyagi Disaster Mental Health Care Center(henceforth, “Center”) are shown and the type of support that each region requires immediately following the disasteris discussed in a simplified manner.
－149－When breaking down the 6391 total support activities conducted by the center, home-visits to residents ortemporary housing comprised approximately 60% of all cases, with 3807 (59.6%). This strongly indicated the needfor outreach skills from care workers who worked in mental health disciplines after the disaster.
The age group with the highest number of consultation cases was among the senior citizen group, with 60-70
years for men and 70+ years for women, and knowledge on senior citizen-specific problems, such as nursing care or
isolation prevention, was thought to be necessary.
The ICD-10 based disease classification with the highest frequency among counselees was F2 (schizophrenia,schizotypal, and delusional disorders) and F3 (Mood- and emotion-based disorders). Many individuals had developed
these illnesses before the disaster, and it was thought that many of these were cases where symptoms were exacerbatedas a result of the existing protective factors weakening as a result of the earthquake. For this reason, it was thoughtthat there was a need for identifying residents who were already vulnerable beforehand as quickly as possible andconnecting them with the appropriate medical institutions. Although few, there were some cases of consultation
recommendations or referrals to specialized medical institutions or accompanied visits to a doctor.
From the above, it was thought that, at least for the four years immediately following the earthquake, there wasa need for① outreach skills, ② knowledge relating to senior citizen-specific problems, and ③ the identification ofindividuals with previous mental disorders and connecting them to health care.
However, it is not always the case that the same needs will be in demand in the future and there is a high possibility
that support activities will change with time.
IV． Changes in the community
Remarks of the author will be shared here regarding changes in regional conditions following the disaster. The
following changes in the overall community can be observed: (1) Strengthened unity, (2) Opening and closing of thecommunity, (3)excessive suspicion, and (4) overdependence.
（１） Strengthened unity
Various meetings were planned in the disaster area to overcome the dangerous conditions at the time, andstrengthened unity was observed. There was an increase in the number of various salons for affected residents,meetings for strengthening organizations or networks, and training programs for responding to future changes.
The living situation of regional residents changed with time, and the content demanded at meetings such as
salons changed as well. In other words: in the beginning, there was a natural occurrence of gatherings that focusedon container type temporary housing with the primary objective of maintaining communities. However, it waslater realized that it was the residents in privately-rented temporary housing rather than those in container type
temporary housing whose communities were at risk of falling apart, and there were numerous gatherings forresidents in privately-rented temporary housing planned throughout the region. Additionally, it was slowly realizedthat not all evacuated residents could return to their original regions, and there was an increasing need for hosting
gatherings regardless of disaster presence that focused on neighborhood associations, to build new communities
with evacuated residents.
Most of the participants in these activities related to regional community building were healthy senior-aged
women, regardless of the meeting type, and the question of how to increase the number of male participants wasraised.
（２） Opening and closing of the community
As time passed since the disaster, there were changes in the regional attitudes of accepting support(Figure 2). Immediately after the disaster, the region was wide open for all support and tended to accept
all care workers without limit. The disaster was truly short-staffed, and many care workers wereinspired to work in the region. The disaster area required heavy physical work such as individuals to
scrape away mud, and there was no significant issue with the fact that support cycled through every
few days.
However, as a few months passed, regions began to notice the harmful effects of accepting support
without limit, and they began to firmly close their doors to accepting support. It was at this time thatthe support that was demanded shifted to communication skills, such as conversation partners in salons.
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Establishing trust relationships and providing stable relationships became important, and regions
needed care workers who could remain for several months at a time. As time further passed, thisvigilance gradually wore away, with its doors opening and care workers with longer-term plans starting
to become accepted in the region.
In this way, the community variably opened or closed its doors to support over time, and it wasthought that care workers needed to provide support in a timed manner.

（３） Excessive suspicion
It is often the case when a crisis that threatens a community emerges that countermeasures are put inplace to ensure that the same incident does not occur again, and there is often a temporary period ofexcessive suspicion. For example, when solitary deaths or suicides began to occur in container type
temporary housing, there was a movement to more promptly identify these changes to prevent such
incidents from occurring again. Some movements checked both electric meters or mailboxes ofindividuals and installed security systems in all households to externally communicate emergencies.
Families with disabled individuals experienced how difficult it was to be understood in evacuation
shelters, and there were behaviors where they actively disclosed disabilities to regional residents during
normal periods so that their needs could be understood (Furusho et al., 2013).
Meanwhile, as can be seen in the construction of extremely large levees, some regions felt discomfort
with the excessive suspicion harbored by regional residents and who felt that such levees wereunnecessary, resulting in counterdemonstrations.
It is thought that over time, residents will hold these discomforts and their vigilance will gradually
return to normal.

（４） Overdependence
Overdependence can easily form between victims and care workers under specialized environments
such as those following a disaster (Table).
In some communities, both victims and care workers felt heightened emotions due to their overlapping
experiences of trauma and loss due to the large-scale disaster. These feelings can overlap, anddependencies can easily form as a result. Things that objectively would seem strange were considered
normal, and a certain implicit understanding began to develop within these groups.
For example, victims who had no particular physical handicaps would request care workers to do asimple grocery run for them, and care workers would help these victims without any question.
These dependencies are often first recognized by the care worker, who then hastily tries to eliminate
these relationships to break this status quo, which can easily result in “abandonment anxieties” in thevictim. This is identical to the transference and counter-transference phenomena observed in clinicalsettings within the general public.
V． Phenomena occurring in care workers

Specialists in mental health should be well aware of the concepts of transference and counter-transference.
However, these specialists easily began to empathize with victims when conducting support in disaster areas, and they
became swept away in these behaviors.
One reason for this is the proximity between victims and care workers. Many care workers previously wereemployed in clinical practice within hospitals, with support primarily based on counselee-focused mental healthconsultation activities, and consultations were conducted in a counseling room, where several rules and procedures
were in place. However, post-earthquake support involved numerous home-visits to victims, where care workers
repeatedly listened to emotional stories. The stories discussed here were qualitatively completely different from thoseof interviews, where the time and place were strictly defined. Even if the care worker did not develop empathy for theindividual victim, they began to empathize with the community or groups they are supporting and this phenomenonof being swept up in this emotional environment was frequently observed.
If this is the case, then how should care workers provide support? It is precisely because it is difficult to control
as an individual that it is important to provide support as a team.
－151－① Individual care workers should not take up cases, and instead should be shared amongst a team (i.e., multipleindividuals).
② Regularly receive supervision from external care workers and create a mechanism for course-correction
based on input.
③ Create a system that allows for regular departure from the disaster area and provide opportunities forviewing what is happening in their region from an outside perspective.
It is thought that these above measures will protect support staff and contribute to the recovery of the affectedregion.
References
1)

Fukuchi, N. （ 2013 ） . Current status and challenges of disaster areas. Japanese Journal of Hospital andCommunity Psychiatry 55:15-17.
2)

Furusho, J., et al.（2013）. Advances in the Medicine of Developmental Disabilities 25. Shindan ToChiryoshaNote) Original text

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