Current Status and Issues of Reconstruction in Miyagi Prefecture

Community Support Department Director
Doctor - Naru Fukuchi
1.

Introduction
Four years have passed since the Great East Japan Earthquake, and three years have passed since the

Miyagi Disaster Mental Health Care Center (hereinafter referred to as the center) began full-scale
operations. We can see changes in local life and support activities in the stricken areas with each passing
moment. In this paper, by reviewing past activities and analyzing the contents of the activities over time,
we will examine how mental health activities should take place after a large-scale disaster through thecenter, and we will consider future support for reconstruction after a disaster. For details of various statistics,
please refer to the activity status in Chapter 1.3.
This report is based on the report of the FY2012-2014 Ministry of Health, Labor and Welfare Science
Research Grant, “Research Contributing to the Understanding of Information on Mental Health Disorders,
Verification of Intervention Effects, and Improvement of Intervention Techniques” (Principal Investigator:
Yoshiharu Kim)1).
2.

Special features of disaster mental healthFirst, disaster mental health is often different from community mental health during peaceful times,

and I would like to first mention its distinctiveness 2) (Figure 1). A disaster severely damages the existing
mental health system and gets divided into several pieces. “Remaining functions” refer to resources thathave been reduced in scale due to the disaster but can be reproduced sufficiently with ingenuity in the future.
“Fosterable resources” are resources that were not the main part of existing mental health but could be
fostered and expanded for the recovery of the region in the future. “Unrecoverable functions” are facilities
and human resources that have been lost due to a disaster and can no longer be considered in designing
future mental health. On the other hand, there are many “flowing resources” into the area triggered by thedisaster, and the activities of external medical and welfare corporations, NPOs and NGOs, and othervolunteer groups are becoming active. The difficulty of disaster mental health lies in gathering these pieces
together and reshaping the vision of future mental health in light of local conditions.
Let's apply each fragment to the Great East Japan Earthquake. "Fosterable resources" are thought to be
the gathering functions of resident volunteers, such as members of the welfare commissioners and eating
habit improvement committees, the Young Entrepreneurs Group, and the Women's Association. Clinics
and hospitals that were severely damaged by the tsunami and were forced to close are considered“irreparable resources.” Motivated human resources may be employed by specialized organizations in theaffected areas and live in the community, and be considered as "inflow resources." In post-disaster mental
health, changes in the local situation over time are rapid and large, so it is necessary to always have a big
picture and timely intervention.

Remaining Features

Fosterable Resources

Existing
MentalHealth(welfare commissioners, Young
Entrepreneurs Group. Etc.)

FutureVisionInflowing Resources

Irreparable Resources(lost facilities, people, etc.)

Figure 1
3.

Special Features of Disaster Mental Health

Difficulties of emergency support team post-disaster
In Japan, after the occurrence of the major earthquake, one “mental health care center” wasestablished in each prefecture. After the Great Hanshin-Awaji Earthquake in 1995 and the Niigata
Chuetsu Earthquake in 2004, the “Hyogo Prefecture Mental Health Care Center,” and the “Niigata
Prefecture Mental Health Care Center” were established respectively. After the Great East Japan
Earthquake of 2011, "Mental Health Care Centers" were established in each of the three affected
prefectures in the Tohoku region. Various reports have been made on the difficulties of creating an
emergency support team based on past experiences 3) 4).
Our center established a preparation room in December 2011, and the Ishinomaki and Kesennuma
Regional Centers were established in April 2012 and started full-scale operations approximately one year
after the earthquake. Only a few of the volunteers who gathered for the opening of the center had previously
met each other. The time from the preparation stage to the start of activities was short, and it was difficult
to figure out the competence of each and organize and allocate roles. While a clear direction was notestablished as an organization, local centers far from the stem center were often lost in their activities, andit was necessary to devise a careful communication system. It is sometimes discussed whether these centers
are expansions of existing or new organizations, but if the latter is adopted, I think that the key to building
an organization is to start compact with a minimum number of branches.
With a variety of occupations, we decided not to divide the roles clearly according to the occupation,
but to improve our skills so that everyone could provide equal and wide support. In other words, at the timeof the establishment, even occupations specializing in individual treatment, such as doctors and clinicalpsychologists, were equally devoted to one-on-one visits and established a policy to connect to thenecessary local support organizations. At first, it was difficult to establish a clearer action policy than theabove, because the current situation in the area could not be understood accurately. For this reason, building
relationships with municipalities, which are the contact points for assistance, was the top priority. Several
disaster surveillance surveys were conducted, including a health survey for residents of temporary housing
conducted in Miyagi Prefecture, from which many high-risk individuals were identified. Under thesecircumstances, we believe that the center has been building trusting relationships with municipalities byactively conducting one-on-one visits. In this way, instead of "thinking and running," we had to become"thinking while running." There are many things we’ve realized as we ran, and it is important to check witheach other and determine the direction as an organization over time. On the other hand, activities that were
initially allowed a high degree of freedom were later added with rules and restrictions, which seemed tomake the activities feel more and more cramped. Of course, as a characteristic of the human resources whojoin these emergency support organizations, many people have performed activities with a high degree of
freedom in each region, which has made them feel as though they have lost that freedom.

4.

What can be seen from residents’ support
Next, I would like to analyze the Center's three-year support activities for residents and add someconsiderations. From the beginning, since the program mainly focused on one-on-one visits, the system forreceiving consultations (reservation system, interview room, etc.) was not sufficient, and there were no
telephones or hotlines. As a result, the number of visitors and telephone calls was low, and the number of
one-on-one visits accounted for about 60% of all activities. Regarding the gender of the recipients, womentended to be dominant at the beginning, and the number of men gradually increased over time. Since ouractivities were concentrated during the weekday, it was thought that one-on-one visits would inevitably
lead to interactions with unemployed women. It is also noteworthy that support for middle-aged
unemployed men has been increasing in the third year of activity. Regarding the age distribution of thesubjects, it is considered necessary to know issues specific to the elderly, such as prevention of nursing careand prevention of isolation, because there are many the elderly in need of support for both men and women.
F2 (schizophrenia / schizophrenia-type disorder and delusional disorder) occupied the majority of the
support recipients' disease classifications since the start of activities. Over time, F1 (mental and behavioral
disorders due to the use of psychoactive substances) and F3 (mood / emotional disorders) increased, and in
2014, the order was F2> F3> F1. It is thought that many of these diseases started occurring before thedisaster and that the existing protective factors were weakened by the earthquake and their condition
worsened in many cases. In the acute phase, among vulnerable residents suffering from illnesses such as
schizophrenia, the symptoms may have worsened due to difficulties in sending medical resources causedby disruptions in lifestyles. There is a need to find such residents as early as possible and connect them toappropriate medical institutions, representing a triage function. In the medium to long term, the number of
diseases caused by stress associated with life changes, such as alcohol-related diseases and depression, will
increase. Therefore, it is thought that there is a need to identify residents at risk by screening and taking
other actions to prevent them. This is what is referred to as a high-risk approach. In disaster mental health,support strategies and target audiences may change over time with changing local conditions.

5.

Change in Community
Here, I would like to comment on changes in the local situation. Groups have a defense reaction, andinstinctively try to protect themselves against strong stimuli by altering themselves. Communities are being
stimulated by disasters and are constantly changing to adapt to those changes. Changes throughout theregion include (1) increased unity, (2) open and closed communities, and (3) excessive vigilance.
( 1 ) Increased Unity

To overcome the crisis, various gatherings were planned in the affected areas, and a stronger unity
was observed. More cafés for disaster victims, meetings to strengthen organizations and networks, andworkshops to respond to future changes have increased. At cafés and other gatherings, the habits ofresidents have changed over time, and the content required for the gatherings have adapted to those changes.
Initially, gatherings spontaneously occurred primarily in container type temporary housing, mainly tomaintain the community. However, after that, we realized that those who were in danger of collapsing
communities were apartment type temporary housing residents rather than container type temporary
housing residents. Furthermore, after that, all the evacuated residents began to realize that they could not
return to their original areas and gathered to create a new community with the evacuated residents, whether
or not they were affected, mainly by neighborhood associations. Regardless of the type of activity involvedin community formation, the participants were relatively healthy elderly women, and how to increase theparticipation of men in the community was mentioned as an issue.
( 2 ) Open and Closed Communities

Overtime after the disaster, the local acceptance towards support has changed (Figure 2). Immediately
after the disaster, the communities’ doors were wide open and tended to accept supporters endlessly. The
affected areas were in a state of “wanting to borrow a cat's hand (I’ll take all the help I can get),” while thesupporters were uplifting. The assistance demanded by the stricken areas was heavy work such as mud
removal, and there were no issues with supporters changing every few days. However, after a few months,
we began to see the costs of accepting supporters endlessly and began to close our doors. The support thatwas sought during this period was changed to a role that required communication skills such as anindividual that residents can talk to at café activities. Over time, vigilance gradually melted down and thedoors opened again, accepting supporters in line with long-term plans. In this way, the doors of thecommunity were opened and closed over time, and the support needed was also changed, and it wasconsidered necessary for the supporters to provide the support that required determining to time.

Close Tightly

Open Widely

Slightly Open

“I’ll take all thehelp I can get”

“It can’t stay thisway”

“What should we
do from now…”

Supporters’
excitement

Weakening of
supporters

Stabilizing of
supporters

Focus on heavylabor, few workdays acceptable

Communication
skills required,positions from acouple of weeks tomonthsDemand for
management andspecial abilities, role
on a yearly basis

Table 2
(3) Excessive Vigilance

Opening and Closing Communities

In the event of a crisis that threatens the community, people often take excessive temporary precautions
to defend themselves from another similar event. When solitary deaths or suicides occurred in a container
type of temporary housing, there was a growing movement to notice each other's changes earlier on so thatthe same situation would not occur. It has also been observed that all the units are equipped with alarmsystems to check each other's electric meters and post boxes and to notify outsiders of emergencies.
Families of persons with disabilities experienced the difficulties of seeking understanding at evacuation
centers, and during the peaceful times, they actively shared information to help residents understand thedisability5). As will be described later, even on one-on-one visits based on health surveys, it is undeniable
that excessive vigilance is required to prevent the worst-case scenario from happening, as well as
continuous visits to residents until formally meeting them. On the other hand, in some areas, such as super
embankments, local people began to feel uncomfortable with excessive vigilance and felt that there was noneed for high embankments in their areas, and opposition movements occurred. It is conceivable that theresidents will feel uncomfortable with time, and that excessive vigilance will gradually return to normal.
6.

Big directions for mental health
Four years after the Great East Japan Earthquake, we are just past the acute phase. For the past four

years, none of the support teams have been able to set a clear policy and have been working hard to rebuild
the region using so-called human wave tactics. Supporters have been endlessly visiting and listening toindividuals and have all come together to overcome these difficulties. Isn't it necessary to rebuild the system
now? We need to look back at our activities, tabulate and analyze, and prepare for possible changes in the
future. In other words, it is time to shift from human wave tactics to traffic control.
In all regions, high-risk approaches based on health surveys are mainstream, and one-on-one visits arerepeated based on individual responses. Certainly, this method is the most standard and should not be
neglected. On the other hand, excessive vigilance is also at work here, and only numbers are emphasized,
but it seems as though the number of visits has become a quota for the one-on-one visit unit. The inhabitants
extracted from the health surveys are, so to speak, “visible high risk” individuals, but we are missing the“invisible high risk” group, who consist of temporary housing residents who did not respond or individuals
who do not live in temporary housing. In the future, the number of residents in temporary housing is
expected to decrease year by year, and the response rate to health surveys is also expected to decrease.
There is a need to make a significant shift to a population approach that focuses on specific groups andregions, rather than focusing only on “visible high risk” health.
For this, what is necessary to devise a population approach strategy that matches the local situation?
It requires an idea of noticing the characteristics of the area and taking advantage of it. If you are a memberof the area, it is very difficult to notice such characteristics, and you need to be proactive. For example, you
may be able to notice by connecting with other supporters from another area that have suffered the samedamages and compare your efforts. Besides, a new perspective may be gained by actively inviting outside
experts. Many supporters have already networked in their area and have good connections. What is neededin the future is a device that connects us to the outside more than now. The roles required are considered tobe the role of connecting regions to one another (Connector) and the role of projecting and guiding the big
picture (Projector).
7.

What is needed from now onHere, we will review reports from around the world, such as the 2004 Sumatra Earthquake and the2008 Sichuan Earthquake, and consider the process of rebuilding mental health after a disaster6)7)8). Past
disasters may trigger insights from outside the region following the disaster, which may lead to significant
improvements in social systems, including mental health9). However, it is sometimes unacceptable foroutside experts to propose legitimate remedial measures based on scientific evidence if they do not conformto the local culture10). In particular, schizophrenia and other mental illnesses often have large stigmas, and
it is very difficult to revise values based on these regional characteristics. It is reported that a large numberof supporters helped with the Sumatra Earthquake and that a psychiatric patient who had been left in thearea without appropriate treatment was found by an external supporter who had flown in after the disaster11).
A disaster has the potential to significantly change existing mental health, and in the Great East Japan
Earthquake, one-on-one visits have been conducted more actively and have the potential to break awayfrom mental health centered on visitors.
Generally, it is difficult to introduce an orderly support method immediately after disasters. If you
have some degree of basic mental health infrastructure before the disaster, simple screening techniques(e.g., rating scales) will be used, and you will gradually adopt a public health perspective. High-risk
individuals are chosen and followed based on a list, but after the acute phase, supporters will look back on
their activities, the data, and analyze it. Experts in epidemiology and public health will be involved. They
will understand the trends from previous activities and predict what will happen in the future. Research
results with statistical techniques tend to increase several years after the disaster12). We are now in the fifth
year, and it is time to do an activity analysis from human wave tactics.
In areas with scarce resources, it is necessary to develop human resources for mental health, but
it is difficult to rapidly increase the number of professions such as doctors because the emphasis is placedon raising awareness toward residents, causing residents’ activities and various gatherings to increase13).
Australia's post-fire assistance has reported some success with the introduction of intensive education
programs for the general population14). Eventually, the number of professions will not increase significantlyin the region but will increase the number of residents with general mental health knowledge. If theeducational base is stable, educational institutions will be able to raise awareness for younger generations15).
Disaster prevention education is provided at educational institutions, and measures for emergencies(evacuation drills, communication networks, etc.) are performed in the region. To be able to adapt to any
crisis, they will try to spread Psychological First Aid (PFA) as an adhesive plaster for human support16). In
fact, in some parts of the Tohoku region, disaster prevention education is being advanced, and PFA is
gradually being introduced.
8.

Conclusion
We have experienced a once-in-a-lifetime disaster and are dedicated to the unique task of rebuilding

mental health in the region. What I feel is that there is a need for a technique that considers the region as aunit and overall health promotion, rather than one that assesses individual mental symptoms and provides
appropriate support and treatment. I feel that this is not based on a psychological, psychotherapy, or
pharmacotherapy technique, but a public health mindset and power to facilitate groups. More important
than that, I think, is a technique that connects well with the local people and other organizations that provide
the same support. This is a patient attitude that draws on the other person's feelings, respects them, andcooperates without criticism. Once again, we need to confirm what is necessary for community
development and hope that we can turn this major disaster into a turning point in mental health.
References
1)

Yoshiharu Kim (Research Representative). Research contributing to the understanding of information on
mental disorders in the affected areas, verifying the effects of intervention, and improving intervention
techniques. FY2012-2014 comprehensive research report, 2015 [in Japanese]

2)

Naru Fukuchi. Current status and issues of mental health in affected areas. Hospitals and community
psychiatry, 55 (4), 2013,15 -17 [in Japanese]

3） Hyogo Prefecture Mental Health Welfare Association Mental Health Care Center (Edit) Mental HealthCare Center Activity Report

1999 -After five years of activities, Kobe, 2001 [in Japanese]4） Niigata Prefecture Mental Health Welfare Association Mental Health Care Center (Edit) Summary of
project implementation report for 7 years (FY2005-2011), Niigata, 2011 [in Japanese]5)

Junichi Furusho, et al. Advances in Developmental Disorder Medicine 25. Diagnosis and treatmentcompany, 2013, Tokyo [in Japanese]

6)

Greg Miller. Who needs Psychiatrists?. Science, 335, 2012, 1294-1298

7)

Natural Disasters, coping with the health impact. Disease Control Priorities project, 2007. Available at
http://www.dcp2.org/file/121/

8)

Shoaf K, Rottman S. Public health impact of disasters. Australian Journal Emergency Management, 15,
2000, 58-63

9)

Harry Minas. Leadership for change in complex systems. Australas Psychiatry, 13, 2005, 33-39

10)

Yasuhide Nakamura, Hiroyuki Yamamoto. Seeking support for an open society - Aceh Earthquake Tsunami
Support Interdisciplinary Survey. MEXT. Needs-responsive area research promotion project for the world,
2009 [in Japanese]

11)

Greg Miller. The Tsunami’ s Psychological Aftermath. Science, 309, 2005,1030

12)

Frits van Griensven, M. L. Somchai Chakkraband, Warunee Thienkrua, et al. Mental Health Problems
Among Adults in Tsunami-Affected Areas in Southern Thailand. JAMA, 296, 2006, 537-548

13)

Vikram Patel, Helen A Weiss, Neerja Chowdhary, et al. Effectiveness of an intervention led by lay healthcounselors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster
randomized controlled trial. Lancet, 376, 2010, 2086-2095

14)David Forbes, Susan Fletcher, Bronwyn Wolfgang, et al. Practitioner perceptions of Skills for
Psychological Recovery* a training programme for health practitioners in the aftermath of the Victorianbushfires. Australian and New Zealand Journal of Psychiatry, 44, 2010,1105-1111

15)

Betty P, Jon A, American Academy of Child and Adolescent Psychiatry Committee on Quality Issues.
Practice parameter on disaster preparedness. J American Academy of child & adolescent psychiatry, 52,
2013,1224-1238

16)

0. Lee McCabe, Natalie L. Semon, Carol B. Thompson. Building a National Model of Public Mental HealthPreparedness and Community Resilience: Validation of a Dual-Intervention, Systems-Based Approach.
Disaster Medicine and Public Health Preparedness, 8, 2014, 511-526