Practical report on psychological education in Miyagi
prefecture※Source: Japanese Society of Pediatric Psychiatry and Neurology. Pediatric Psychiatry and

Neurology, Vol. 56, No. 1, 19–23 (2016)
Miyagi Disaster Mental Health Care Center (MDMHCC)
Naru Fukuchi
Key words: psychological education, Great East Japan earthquake, relaxation

Introduction
I do not conduct general medical examinations in child psychiatry in his present role but focuses
exclusively on developing support for parents and children in disaster areas. Therefore, those who receive
support are those who consult a specialized organization due to a particular medical condition, but rather
parents and children living with stressors in the community. In this paper I would like to report on parentchild camp projects1, 2 that target these residents, and also consider future psychological training/education
after a disaster.
I. Camp overview
In principle, a total of five meetings for elementary school students were held from July 2011 to thepresent, January 2015. I created a leaflet introducing the program, visited an elementary school that suffered
great damage, and distributed it at the school with the approval of the respective local board of education.
We took the children by themselves to a campsite away from the afflicted area and offered a series ofprograms that included psychological education. By incorporating psychological education into the program,we aimed to provide accurate knowledge about disasters, help participants understand the workings of theirown minds, and offer an approach that will allow them not to be overwhelmed by anxiety. For parents, we
set up a separate venue close to the meeting place where we provided programs including professional
lectures, relaxation activities, and individual consultations.
II. Contents of psychological education
As for the content of this pediatric psychological education program, in the first and third sessions children
drew pictures using a picture story show (kamishibai), and in the fourth and fifth sessions they used a toy topractice breathing and muscle relaxation techniques. The details of this program are described below.
1. Drawing using a picture-story show (reference 1)
We presented a picture-story show that made it easy for the children to express their feelings
through shapes and colors, and then asked them to make drawings with colored pencils and crayons
reflecting their feelings. After drawing, we had them show each other their pictures, discuss thequestion of whether they could add anything to make the pictures more fun, and then go back andadd to their pictures.
2. Breathing using toys and muscle relaxation techniques (reference 2)
I attempted to convey abdominal breathing using a blow pipe and muscle relaxation techniques.
They breathed in deeply through the pipe and exhaled little by little so that the ball continued tohover over the pipe, and by practicing this repeatedly they naturally engaged in abdominal
breathing.
III. Evaluation and results
We conducted a preliminary survey by mail prior to families’ participation in the program in order tograsp each family’s situation in the aftermath of the disaster and the children’s mental and physicalconditions. After the program was concluded, a questionnaire was once again given to both parents andchildren. Only children completed the Post-Traumatic Stress Symptoms for Children-15 (PTSSC-15) before
and after the camp.3 Changes in participants’ psychological state before and after camp participation are
shown in Fig. 1. In general, PTSSC-15 scores were 23 or higher for PTSD, indicating a high risk for－149－

depression, but 54 children (53.5%) were judged to be high risk before the camp. Since a control group was
not established, it is not possible to compare the effects overall, but except for the fourth session, PTSSC-15
scores tended to decrease post-intervention.
Project backgroundIn this program for children, one static program, two dynamic programs, and three ceremonial programs
were devised in an alternating progression to provide a smooth sequence in a short period of time. Because
psychological education was conducted after play involving intense physical exercise, it was observed thatsome children were not able to readily switch over to psychological education because of their elevatedmoods. These children were paired with staff members in a slightly darkened room, where they were able togradually regain their concentration. Because the target age group for this camp was broad, it is possible thatin some cases the content was not well suited to their ages. For example, some younger children who were
not able to understand the intention of the picture story show activity tended to mimic the drawings thatwere depicted in the teaching session. Also, in the exercise with blow pipes, because lung capacity varies
with age, younger children had to blow as hard as they could just to get the ball to float. In the future we will
also need to adjust the content of the picture story show according to age and to change the type of toy used
for the breathing technique (pinwheel, bubble ball, paper balloon, etc.).
The greatest outcome obtained through this camp was thought to be local solidarity and the sense of
security that accompanied it. Groups associated with the project ranged from volunteer groups, various
sports clubs in the area, boy scouts, and student volunteers, among others. Children were connected withvarious people in the area, and they sometimes consulted staff who had taken care of them when they werein trouble. Among these children, there were cases in which the medical treatment facility for which theauthor was responsible sent children who required specialized care for temporary treatment at a hospital. In
addition, a number of children participated in the program several times, which became an opportunity forthem to get together once a year, and, because of their knowledge of the program, they were also able to act
as leaders. Staff who returned to participate more than once were able to experience the reward of
supporting the growth of children in the community and witnessing their growth and development during
each camp session. In this way the camp functioned as a place that connected children in the community,
their parents, and various professionals.
Conclusion
As time goes on, children with an awareness of the disaster are less likely to participate, and thepsychological education included in the program needs to be changed so that it can be applied to everyday
life. There is a similar tendency among parents to avoid programs concerning stress after the disaster, andinstead to seek consultation on topics such as developmental disorders. The difficulty of mental health after
disasters is that the needs of the community change over time, and supporters must accurately grasp thesechanges and provide assistance according to what is needed at the time. It seemed necessary to disseminate
more general stress coping strategies for local children who lived with stress but may never have visited a
medical care setting.
References
1) Fukuchi Naru, Murai Asako. The practice of support for children in disaster areas. The Japanese
Journal of Hospital and Community Psychiatry, Vol. 55, No. 1, 56–58 (2012).
2) Igarashi Takashi (Research Representative). A Study on Post-Disaster Mental Support for Children.
2013 Summary and Research Assignment Report (2014).
3) Tominaga Yoshiki, Takahashi Satoshi, Yoshida Ryuzo, et al. The creation and validity of the PostTraumatic Symptom Scale for Children (PTSSC15) child in children admitted to children’s facilities
and students suffering from bullying. Journal of Human Development and Clinical Psychology, Vol. 8,
29–36 (2002).

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Source 1: A teaching method of drawing with use of a picture story show
(Original concept: Fukuchi; image: Akiko Miyake)1

Characters of various shapes and colors lined up beside a boy.

2

A character that is as plain as possible, colorless, just a circle withhands and feet. Leader: “My name is “Koro.” My shape and color
changes with different feelings.”

3

A scene in which “Koro” is inside a boy’s body. Leader: “I am insideof Taro.”4

A scene in which “Koro’s” head is gently stroked. Leader: “Whenyou treat me gently . . .”5

He appears with a vivid aqua blue color and a gentle peacefulexpression.” Leader: “This is how I look, and this is the color I turn.
When do you all become like this?”

6

A scene in which he is being shaken violently to recall an earthquake.
Leader: “When I am surprised. . .”7

He appears with a distorted shape, red and dark colors, and abewildered expression. Leader: “This is how I look, and this is thecolor I turn. When do you all become like this?”

8

Taro appears again. In this scene his body is relaxed. Leader: “WhenTaro relaxes, Koro will also have a peaceful color and a peacefulshape. Now let’s draw how Koro looks inside of each of you.”－151－Source 2

Methods for teaching breathing and muscle relaxation techniques(Children were moved inside after active outdoor play. The activity was carried out after helping them towipe away sweat and supplying them with water.)
Leader: “Now I am going to calm myself down. Now we are going to study our own minds. What we arelearning today has to do with breathing in and out, and how to tense and relax our muscles. Please get into
pairs of one child and one adult. Each pair please take a yoga mat, and let’s sit down on the floor.” Leader: “I have done a lot of fun things today. How do you feel now?”⇒ Children: “That was fun,” “I’m tired,” “I want to go home.” Leader: “How is your body doing?”⇒ Children: “I got sweaty,” “My heart is pounding,” “I’m out of breath,” “I bumped myself and it hurts.”
 Leader: “The body responds when you do something fun, do something exciting, get angry, or remember
something you didn’t like.” Leader: “I will give toys to everyone. First let’s try playing with this.” (Distributes a blow pipe to each
person.)⇒ Children: “What is this?” “I’ve seen these before,” “They have these in sweet shops.”
<Teaching the breathing technique> Leader: “To get the ball to float, I have to take a deep breath and then let it out little by little. Let’s try
practicing this. When you breathe in, let your belly fill with air, and then slowly breathe out. This is called
abdominal breathing.”(Pair with staff and practice abdominal breathing.)
 Leader: “Now I am imprinting in my mind the image of the ball floating. Next time, without using thepipe, I will close my eyes and in my head I will get the ball to float. Let’s lie down on our backs on theyoga mats, let’s darken the room, and now let’s quietly try it.”
<Teaching the muscle relaxation technique> Leader: “Next I will use my body a little bit. The point of what we are doing is to tense and relax yourbody. Still lying down, let’s try tensing both arms. Now put a little more strength into it. Tense yourshoulders . . . Now, all at once, let your body relax completely. Good. Let’s do it again.”<Bringing together the breathing and muscle relaxation techniques> Leader: “Let’s try breathing in and breathing out three times, and then tensing and relaxing our muscles
three times.” Leader: “How is your body doing?”⇒ Children: “I am sleepy,” “I am hungry,” “I have to go to the bathroom.”Leader: “Your feelings and your body are connected. Let’s do this when you feel excited, when you
remember something you don’t like, when you feel frustrated or your heart is pounding.”－152－

Fig. 1. Change in average value for PTSSC-15 before and after camp

In both cases, no significant difference was observed in the paired t-test.

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Family and community post-disaster recovery※Source: Japanese Association of Family Therapy, Japanese Journal of Family Therapy, Vol. 33,
No. 3, 63–68 (2016)

Miyagi Disaster Mental Health Care Center (MDMHCC)
Naru Fukuchi

I. Introduction
The Great East Japan Earthquake that occurred on March 11, 2011, had a magnitude of 9.0 and caused
catastrophic damage on the largest scale in our country’s history since measurements were first taken. Fiveand a half years later, in the area that was damaged most severely, almost all the debris from the earthquake
and tsunami has been removed, and the embankments for bulk construction are piled so high that theynearly block one’s field of vision. The scenery of the lively town has disappeared, and it is difficult even to
imagine that it will change in the future.
Public housing has been newly reconstructed in safe areas with solid ground, and people are steadily
moving in. Various volunteer organizations that began activities in the affected area after the disaster arewithdrawing one after another due to lack of funding, and the activity of this time has ceased.
Along with such changes in outward appearance, various psychological changes also occur within acommunity, and phenomena that are difficult to understand without deep consideration are occurring one
after another. I have been acting as a doctor treating individuals, but after the earthquake my work began totarget the whole community. In treating individuals, we read the background and development of thesubjects, draw out the mental dynamics from each landscape, and provide support in the recovery process.
Especially in the adolescent clinic, the establishment of identity (self-identity) is often a problem; exploringand establishing the self within the group is an important key to recovery. In supporting the recovery of thecommunity, I perceive that the same kinds of phenomena that occur in the treatment of individuals are
arising in this setting. In this paper I would like to give some additional thought and discussion to: 1) The
effects of the disaster on children and families, 2) its effects on the community, and 3) what is necessary forreconstructing mental health.
II. Effects on children and families
1. Understanding based on attachment theory
In considering the reaction and recovery process of children after a catastrophe, several attachment
theories make these things easier to understand. Bowlby (1980) used the term “attachment behavior” to referto the act of an individual who, sensing danger approaching, seeks protection from a particular person. 1)
This is the behavior of a child who has a frightening experience in daily life and cries and seeks hugs fromhis parents. Byng-Hall (1990) 2) referred not only to the attachment between two people but also the stability
and functioning of the entire family as a “secure family base.” In families where the secure family base isfunctioning, family members can support and overcome various crisis situations in cooperation with eachother. Powel et al. (2008) proposed the concept of a safety cycle, the “circle of security,” and by repeatedcorrespondence between the safe zone and exploratory behavior, children learn how to regulate theiremotions and behavior, and their mind and body develop in a healthy way. 3) Children practice repeatedly
while interacting with other children outside of their families and acquire skills to control their emotions andbehavior.
－154－

These theories are summarized and some modifications are shown in Figs. 1 and 2. As shown in Fig. 1,
attachment relationships are mainly formed by caregivers (primarily mothers), the need for security issatisfied, and the child initiates exploratory behavior. When he experiences various types of uncertainty andcrisis in the midst of his exploratory behavior, he returns to the safe zone and regains a sense of security.
Recharging his energy in the safe zone and then returning to exploratory action again, he gradually acquires
the ability to regulate his emotions and behavior. As shown in Fig. 2, through this process, the safe zone andtherefore the sense of security expands from the two-person relationship with caretaker to the family,
schools (including preschools and kindergartens), and the community. As people age, there are more
subjects who can feel secure spread across a larger geographical area.
2. Alteration of safety zone in emergencies
Generally, in a regional emergency such as a catastrophe, the balance in Fig. 1 is mostly concentrated on
the left side. The caregiver (mother) who is the object of attachment feels uneasy about the child moving outof her orbit, and strongly draws him toward herself. In the Great East Japan Earthquake, if rubble was notremoved from the area, it became impossible to be confident in letting children go outside. As long as
aftershocks continued, residents had to be ready to protect their children at any moment, so they kept themclose by. In areas where the fear of radioactivity remained, outdoor play was restricted to limit its effects.
There was also a significant change in children’s exploratory behavior. Rubble was scattered throughout thearea, rice was being distributed at a familiar playground, and temporary houses were sometimes built onschool grounds. The place where children could play safely had grown smaller, the cycle of safe zone andexploratory behavior ceased to function, and there were not enough places to practice regulating emotions
and behavior.
When these conditions persist for a long period of time, more children will have difficulty regulating theiremotions and behaviors within the group. As the area recovered, the imbalance in Fig. 1 gradually returned
to normal, and this cycle began to function smoothly again. To support the local population in the wake of amajor disaster, there is a tendency to focus on “counseling” as psychological care and the creation of asystem for providing it. Counseling alone, however, is inadequate. It is also important to ensure that children
have an environment in which to play safely so as to guarantee exploratory behavior, a space that allows
families to play with confidence and children to practice regulating emotions and behavior. In recent years
the importance of the playground has been explicitly recognized; manuals such as “Child Friendly Spaces”
on managing playgrounds have been created and workshops on this topic are being developed, mainly by
the Japan UNICEF Association.4) Because of these experiences, in the wake of the Kumamoto earthquakethat occurred in April 2016, various NGOs managed playgrounds in an effective way.5)
3. Expansion of safety zone
As shown in Fig. 2, the child’s safety zone expands as the child grows. Initially it starts with a bilateralrelationship with a caregiver, and then expands to include family members, educational institutions such aspreschools, kindergartens, and schools, and finally to a sense of security that extends throughout the wholecommunity and permeates the child’s entire worldview. If for some reason a child loses this sense of
security, it is thought that the person will instinctively seek a sense of security by turning inward. When alocal community loses its sense of security after a disaster, in Japan in many cases people will gather at
educational institutions. After the Great East Japan Earthquake, schools became crowded evacuation centers,
and when people had lost their usual sense of security, they bonded together with immediate family.
In families who had repeated conflicts due to internal discord, however, children tended to unite with aclose caregiver (mother). As the area recovered and the local community regained a sense of security, it wasobserved that the temporarily narrowed safe zones were gradually restored, expanding in an outward－155－

progression. The symbols of cohesion that represented the security each community sought varied greatly
according to local culture. In this paper it was a school (educational institution), but in some areas people
sought security at hospitals or temples. Trust in educational institutions is characteristic of Japan, while inmany other countries it coalesces around religious symbols, and in Christian areas people are often
evacuated to churches.

III. Effects on communities
1
Community dynamics
In addition to the dynamics of the entire family that envelop the child, certain dynamics arose within thecommunity as a whole. As time passed, the local community changed its attitude to one of accepting
external assistance, which in most cases is thought to be a characteristic defense mechanism (Fig. 3). The
doors were wide open immediately after the disaster, and there was a tendency to accept support without
limitation. Residents of the afflicted area needed all the help they could get, and supporters were eager tosupply assistance.
The support that the afflicted area sought at that time was mostly heavy work such as mud removal, andthere was no great obstacle to having supporters working in shifts of several days each. After a few months,
however, the harmful effects of accepting unlimited numbers of supporters started to become apparent andthe door closed tightly. At that time the support that communities were seeking had more to do with
communication skills, such as those who could facilitate social gatherings for discussion; now it was
important for supporters to build trusting relationships, provide a sense of security, and stay for several
months in a cycle. In addition, as time went on, the wariness gradually diminished, the doors opened again,
and communities came to accept supporters according to long-term plans. Thus with time the door of thecommunity was seen to open and close, and it was clear that supporters needed to provide assistance witha clear timeline in place.
When a crisis threatening the community arises, it often leads to an excessively cautious approach asprotective measures are put in place to present the same thing from happening again. In cases of solitary
death or suicide in temporary housing, there was a movement to work together to detect changes earlier so
as to prevent it from happening again. It was also observed that attention was paid to electric meter readings
and mail delivery, and alarms were installed in all the buildings to keep abreast of such an emergency
situation. Family members with disabilities experienced the difficulty of seeking understanding at
evacuation centers and were observed actively disclosing to local residents the obstacles they had already
faced during normal times.6) On the other hand, as in the case of super embankments, local residents became
uncomfortable with excessive vigilance, feeling that a high embankment in their area is not necessary, andsome areas opposed such measures. It was thought that residents would feel uncomfortable but that theirwariness would gradually dissipate over time. In this way, characteristic defense mechanisms arose in
response to factors that threatened the survival of the community, and this vigilance was repeatedly
strengthened or weakened over time.
2

Group identity
Various gatherings naturally occurred in affected areas. Many occurred spontaneously, mainly in
prefabricated temporary houses, and various ideas were considered for overcoming the crisis andstrengthening the local community. These gatherings took various forms, from tea parties to creative
activities. For example, some communities planned events such as do-it-yourself classes, cooking classes,
mah-jongg, and fishing to attract the participation of men who might be likely to withdraw from society. In
addition, traditional “festivals” rooted in the community have long been a foothold for recovery, and－156－

communities were observed mobilizing for this purpose, with each resident taking on a specific role forparticipation. Many “festivals” carry the meaning of worshipping deities, Buddhas, and ancestors withgratitude and prayer in order to benefit the spirits of the dead; residents are able to affirm their own origins,
rooted in local culture, by playing a role in these activities. Looking back at the long history of the humanrace, there are similar cases in other cultures, and these traditions seem to offer an important clue for therecovery of afflicted areas. In Ethiopia, the act of drinking coffee is a custom that includes spiritual elements
and education and expresses the spirit of appreciation and hospitality for others. Incorporating a coffee
ceremony at the milestones of life, including ceremonial occasions, is a deeply ingrained custom in daily life.
In Ethiopia, after a famine or border dispute, more than anything else local residents are known to gather
spontaneously to try to regain the habit of drinking coffee. In gathering the tools, roasting the beans,
grinding them in a mortar, drinking coffee according to ritual, and engaging in conversation, residents areable to regain a sense of everyday life. This example suggests that in a crisis situation, people can gather
together in accordance with local culture, confirm their respective roles, revisit their collective origins, andgradually regain the autonomy of which overwhelming external sources had deprived them. When a specificgroup or community goes through a trauma, utilizing its own culture is a clue to recovery. I feel that thiswill be a clue to recovery because it will gather people together according to their own cultural customs and“create a place” based on the difficult experience residents have gone through. To that end, it is necessary toknow about the culture and customs that local residents can utilize and actively incorporate them into local
activities.
IV. Rebuilding mental health① The specificity of disaster mental health7)

Here I would like to discuss strategies for rebuilding mental health. First, disaster mental health differs inmany ways from community mental health during ordinary times, and we will describe its special
characteristics (Fig. 4). A major disaster damages existing mental health, and its effects may be divided into
several parts. A “residual function” is a resource that is reduced in scale due to the impact of a disaster but
can be replenished through future creative ingenuity. “Cultivatable resources” are resources that have notbeen a central element of existing mental health but that could be developed and expanded for future local
recovery. An “unrecoverable function” is a facility or personnel lost in the disaster that can no longer be
included in calculations for planning future mental health. On the other hand, as a result of the disaster, there
will be many “inflowing resources” in the area, including the activities of various volunteer organizations
such as external medical and social service groups, NPOs, and NGOs.
The difficulty of disaster mental health lies in gathering and joining these pieces together to redraw the
future vision of mental in light of local circumstances. We will consider each piece within the context of theGreat East Japan Earthquake disaster. “Cultivatable resources” can be understood as the collective functionof local resident volunteers, such as district welfare officers and dietary improvement committee members,
as well as Youth Chamber of Commerce chapters and women’s associations. Clinics, hospitals, and otherinstitutions that were severely damaged by the tsunami cannot be included, and these can be considered“unrecoverable resources.” Volunteer workers who join specialized organizations in the disaster area andput down roots in the community are considered “inflowing resources.” In post-disaster mental health, thesituation in a community changes rapidly and significantly over time, and it is necessary to keep track of the
big picture when determining how to intervene.

② Post-disaster mental health tendencies
Psychiatric medical treatment in Japan is a hospital-centered system, in which the tendency for
professionals to wait for patients to come in for treatment is deeply ingrained. Therefore, there is a history in－157－which the academic study of psychiatric medicine as public health supporting regional mental health has notbeen sufficiently developed. After the earthquake, however, a movement has gained momentum of shifting
professionals to the area, conducting educational activities, and reaching out to high-risk local residents. In
other words, the project of strengthening existing communities is advancing rapidly. On the other hand, it isassumed that mental health suffers in the wake of a major disaster, and large-scale screening studies havebeen repeated many times. In other words, it cannot be denied that the field has narrowed due to excessive
monitoring in this realm. Residents selected by means of health surveys are “visibly high-risk,” whileclinicians do not end up reaching out to those who do not reply, those who are “invisibly high-risk.” Fiveand a half years after the earthquake, the number of temporary residents is decreasing each year, and thereturn rates for health surveys is expected to decrease accordingly; the use of this method of extracting highrisk individuals through a health survey is expected to decrease, and the number of high risk individuals
extracted by previous methods is therefore decreasing.
It is thought that there is a need to shift to a population approach, not only for “visibly high risk” cases but
also in order to focus on specific populations and areas. It is difficult to devise a strategy of population
approach that corresponds to the current state of the community by means only of supporters like the author
who are from within the community itself. It is necessary to take note of the characteristics of the region anddevise ways to bring it to life, and it is more difficult to notice local characteristics when you are a memberof the local community. To that end, we believe it is indispensable to cooperate with specialists inepidemiology and conduct analyses based on the theory and practice of mental health as public health. Is it
too much to say that psychiatry in Japan has been too dependent on the intuition of supporters andprofessionals who have developed direct support at affected sites? A major disaster is an opportunity toreview strategy and shift from having the user wait for treatment to bringing treatment to the area, from anemphasis on the high-risk approach to the development of a balanced strategy. I think it can be a first step tobuild a mental health system imbued with a scientific spirit of public hygiene.

V. Conclusion
Based on current activities, I am deeply convinced that technology is required to consider regional healthas a whole rather than pursuing technologies that address and treat individual mental health symptoms.
Rather than techniques of psychology, psychotherapy, or pharmacotherapy, we need the power to facilitate
public health ideas and groups. Also, more importantly, I think that there is technology that can connect wellwith local residents and other organizations that provide the same support. It is a posture to draw out the
feelings of the other person, honor and respect the other person, and cooperate without criticism. I deeply
hope to confirm once again what is necessary for community development and to transform this great
disaster into a turning point for mental health.

－158－

References
1) Bowlby, J. A Secure Base—Parent-Child Attachment and Healthy Human Development. Basic Books,
New York, 1988.
2) Byng-Hall, J. Attachment theory and family therapy: A clinical view. Infant Mental Health Journal,
Vol. 11, 228–236, 1990.
3) Powel, B. et al. The Circle of Security Project: A case study-“It’s hurt to give that which you did notreceive.” In Oppenheim. D. & Goldsmith, Douglas, F. (eds.). Attachment theory in clinical work with

4)

5)
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7)

children bridging the gap between research and practice. 2008; Kazui Miyuki, Kitagawa Megumi,
Kudo Shinpei, Aoki Yutaka. The use of attachment in the clinical treatment of children and caregivers(translation). Minerva Shobo, 2011.
Japan Committee for UNICEF, National Center of Neurology and Psychiatry, Journal of Mental
Health: Official Journal of the National Institute of Mental Health, NCNP, Japan. Informational
support centers for mental health in times of disaster: Child-friendly spatial guidebook. Japan
Committee for UNICEF, 2013.
Save the Children Japan, http://www.savechildren.or.jp/scjcms/sc_activity. php?d=2199 Children’s
Plaza Activities
Furusho Junichi, et al. Advances in the treatment of developmental disorders 25. Diagnosis andtreatment. 2013.
Fukuchi Naru. The current status and issues concerning mental health in disaster-affected areas.
The Japanese Journal of Hospital and Community Psychiatry, Vol. 55, No. 4, 15–17, 2013.

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Figure 4 Characteristics of post-disaster mental health－161－Five years after the 2011 Tohoku Earthquake andTsunami: Disaster psychiatry※Source: WPA, Child and Adolescent Psychiatry Section’s Official Journal
World Child & Adolescent Psychiatry, 10–12, 2016
Miyagi Disaster Mental Health Care Center (MDMHCC)
Naru Fukuchi

Dr. Fukuchi, first of all, thank you very much for agreeing to do an interview for “World CAP.” It is ourpleasure to interview you. Before we discuss details of your work in the Tohoku region, Japan, could pleasetell us a little bit about yourself?
I initially started working as a pediatrician in the northern area of Japan. I was mainly engaged in theassessment of developmental problems in infants and young children. A few years following my career as
a pediatrician, I changed my major to psychiatry and have since worked in the field of community mental
health ever since. I also obtained a Ph.D. in Public Health for suicide prevention in rural areas ofJapan. Shortly after the earthquake and tsunami in Japan in 2011, I went to the affected areas and provided
mental health care for the victims. Since then I have been deeply engaged in the field of disaster psychiatry.
I am currently working in the Miyagi Disaster Mental Health Care Center, the main facility focusing on thecare and the recovery of people affected by mental health problems caused by the Great East Japan
Earthquake of 2011.
Could you please describe how the earthquake and tsunami in March 2011 impacted the city and thepsychiatric hospital where you were working at the time? Could you also tell us what your role was for the
first couple of weeks and for the first couple of months, respectively?
At the time of the disaster in March 2011, I was working as a child psychiatrist in a hospital where I served
as the chief psychiatrist in the child psychiatry unit. Despite the fact that the hospital had been built just 4
years prior to the earthquake (and thus it was considered a new building), the damage due to the earthquake
was so tremendous that a large part of the ceiling fell down and the water pipes were ruptured, leading tosevere water leakage. I was relentlessly providing emotional support, and I continued treatment for 20
hospitalized children in the unit at that time. Because no information was available, the children were notaware of this unprecedented disaster immediately following its occurrence and did not exhibit any signs ofemotional disturbances. Along with serving as a physician, my other roles there were to provide them withaccurate information and brief psycho-education and to contact their families.
After I confirmed that the number of inpatients requiring emergent/urgent medical and psychiatric care had
decreased, I decided to go out of the hospital to provide mental health care for people in the community. I
joined the local support team and went around the disaster areas. We went to the evacuation sites and cared
for survivors. We wore pink parkas to identify ourselves as mental support team members and approachedthem to offer mental health support, but they declined our offer despite the fact that many of them obviously
seemed upset and confused due to this disaster. We did not realize that there was such a degree of stigma
against mental health services. We took off our pink parkas the next day and cleaned the floors ofevacuation sites so that people in the community could trust us and reduce their resistance to access tomental health services when required. Most of the evacuation sites were school gyms. There were some－162－

children who gathered near the power outlets at the evacuation sites and who played portable video games
all day.
They were mostly playing fighting games. I tried to talk to them, but most of them did not pay muchattention or even look at me. After many visits, they slowly opened up to me and their attitudes changed.
They told me that their parents were away to take care of their damaged houses and that their parents werevery busy getting the official documents required for financial support from the government. I thoughtchildren could not find anything to make them feel safe when their parents were unavailable; thus, they
seemed to be trying to escape into the virtual world. They seemed to be fighting with monsters just as they
were struggling to survive.
My role for the first couple of weeks was connecting survivors with mental illness to medical institutions
and giving survivors appropriate psycho-education. A couple of months later, my role changed. I started toassist supporters who did not have knowledge of mental health. I also began managing the Miyagi Disaster
Mental Health Care Center, the new facility that could provide people in the community with mental healthservices in the long run.
Please tell us what psychiatric problems, symptoms, and diagnoses you saw during those periods?
What were the challenges and obstacles in providing mental health support/care? How did you deal
with them?
We found some people who had mental health problems prior to the disaster and who had not been
receiving appropriate treatment. For example, they were socially withdrawn due to an autism spectrum
disorder or due to negative symptoms of schizophrenia. In some of the communities affected by theearthquake and tsunami, families of these individuals were ashamed of them and tried to hide them in theirhouses. Many of them, therefore, received no mental health care. However, given that all residents,
including these individuals, had to escape from the affected areas to survive, they ended up evacuating to theschool gyms and appearing in public. Most of them eventually returned to their destroyed houses or escapedin their cars due to their difficulties engaging with people in the community.
According to our data, the number of residents who started showing signs of mental disorders, including
schizophrenia and depression, shortly following the disaster and who received our support increased
considerably right after the disaster. Residents who did not initially show psychiatric symptoms and who
tried to endure their painful situation started exhibiting depressive symptoms a few years following thedisaster. The number of clients who have had depression after the disaster has been increasing these days.
The rural areas were most heavily affected due to this disaster, where insufficient medical institutions andpublic awareness of mental health disorders existed. Due to this lack of awareness, residents in these areas
had a strong stigma against mental illness and tended to refuse conversations with regards to mental health.
To overcome this challenge, we attended local events, such as agricultural events and festivals, tounderstand the culture of the community, and then through these events we could gain opportunities to
speak on mental health problems related to the disaster. We also arranged several social gatherings for the
residents, including tea parties, cooking events, and mah-jongg tournaments, where we attempted to provide
them with opportunities to learn about mental health problems.
Would you be able to describe the differences in psychiatric signs, symptoms, and problems thatyou currently see five years after the disaster in comparison with ones you encountered during the acute andsub-acute phases of the disaster?
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I met many individuals who talked about their emotional experiences at the evacuation sites. They vividly
described their experience in forceful tones. In hindsight, I think they were in a hyperarousal state at thattime due to emotional trauma. Traditionally, following their belief that affecting others by showing
emotions is rude, Japanese tend to hide their emotions. They often are not willing to speak to others about
their experiences and their feelings, even though they have just experienced tragic accidents or disasters.
Although huge numbers of residents were affected by the disaster, we were challenged by the fact that mostpeople did not desire to seek help from medical and psychiatric facilities. Younger elementary school
children started opening up and speaking about their experiences a few years after the disaster. Their parents
and teachers were surprised by this fact, because these children had been preschoolers who could not fully
express their feelings in the moment of the disaster because of their lack of verbal abilities. At that time they
instead showed behavioral problems, including excessive crying and enuresis. I think the process of
speaking to mental health professionals is important for these children to deal with their experiences and theassociated emotional trauma.
Could you please describe your current work and future projects you would like to accomplish at the
Miyagi Disaster Mental Health Care Center?
I would like devote efforts to support children, since they bear the future in the disaster-affected areas.
Although there are several ways to support their well-being, I think providing psychological education withthe aim of enhancing their resilience is most important of all. If they could appropriately acquire healthy
coping skills and subsequently adapt to any stress caused by the 2011 disaster, they would likely cope wellwith future potential difficulties and challenges. We have been consistently holding workshops for highschool students in some cities located in coastal areas where the earthquake and tsunami hit in 2011.
These workshops include discussions about how to rebuild their cities, lectures about how to cope withstress, and relaxation technique practice sessions. We also have been holding outdoor camp activities forelementary school children. For safety reasons, the camping facility is not located in coastal areas. The
camping programs include cooking, outside play, group talks, campfire experiences, and psychologicaleducation on disaster mental health. We use traditional Japanese toys, such as the “picture story” and“blowing pipe,” for psychological education. The psychological burdens on children following camp
participation seem to be reduced, suggesting that these activities might be useful for improving thepsychological well-being of children who experienced the 2011 disaster.
Photo 1: Jumping rope at camp

Photo 2: Psychological education session

Note: As published in original text

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