FY 2018 Miyagi Mental Health Care Forum Report

FY 2018 Miyagi Mental Health Care
Forum Report

Psychiatric Social Worker – Hiroyuki Kimura

Following the Miyagi Prefecture Reconstruction Plan, which set FY 2020 as the target deadline for reconstruction, the Miyagi Disaster Mental Health Care Center formulated a management plan in March 2017. Oneof the items contained in that plan was the Miyagi Mental Health Care Forum Project, a research program
aimed at contributing to future disaster countermeasures. The first iteration of the Forum was held in FY 2017;
we plan to continue holding it until 2020.
FY 2018 marks the second year of this event; we have retained the core theme—which was established lastyear—entitled, “Seven Years of Post-Disaster Mental Health Care Services and Future Goals,” along with oursubtheme “What We Can Learn from the Issues Confronting Our Communities.” We provide an overview ofthe event below.
1. Setting Up the Forum(1) Objective
The forum’s primary goal was to showcase reports on the progress of the activities and the issues
facing various cities and towns, the Miyagi Prefecture, and the Miyagi Disaster Mental Health Care Center, as well. Based on these reports and the ideas and findings of external speakers and attendees, wesought to begin a dialogue exploring the nature of future community psychiatric welfare at the prefecturaland township level.
(2) Date: Friday, October 26, 2018, 10:00 AM – 4:00 PM(3) Location:
TKP Garden City Sendai, 21F Halls C & D(4) Attendees: 130(5) Program
Title:“7 Years of Post-Disaster Mental Health Care Services and Future Goals”
Subtitle:“What We Can Learn from the Issues Facing Our Communities”
Chair:
Kazunori Matsumoto, Associate Professor, Department of Psychiatry and Neurology,
Tohoku University Graduate School of Medicine
Vice President, Miyagi Disaster Mental Health Care Center
Part 1
Practical
Reports

Part 2
Discussion
Part 3Presenters:① Kesennuma Health and Welfare Department, Health Promotion Division
Hiroko Koyama, Public Health Nurse
Ayaka Ogasawara, Psychiatric Social Worker② Ishinomaki Health Department Deputy Director and Welfare Department Secretary
Hatsuko Kutsuzawa, Public Health Nurse③ Iwanuma Health and Welfare Department, Health Promotion Division Chief
Ayumi Sugawara, Public Health Nurse④ Miyagi Prefecture Ministry of Health and Welfare, Disability Welfare Division,
Assistant Director of Mental Health
Yukari Oba, Public Health Nurse⑤ Miyagi Disaster Mental Health Care Center Vice President
Takeshi Yamazaki, Clinical Psychologist
Keynote Address：
Yoshiharu Kim, President, National Information Center of Stress andDisaster Mental HealthSocial Exchange－ 21 －

FY 2018 Bulletin, Issue 7(6) Event Operations
Sponsor:Co-sponsor:

Miyagi Disaster Mental Health Care Center
Miyagi Prefecture and the City of Sendai

2．Program(1) Practical Reports
Hiroko Koyama and Ayaka Ogasawara of the Health Promotion Division of the Kesennuma Healthand Welfare Department reported on the fact that support for socially isolated men had become a community-wide problem in their area. They also presented the results of a salon initiative that they hadorganized to combat this issue.
The Deputy Director of the Ishinomaki Health Department and Welfare Department Secretary
Hatsuko Kutsuzawa explained the mental health care initiatives her organization had initiated immediately after the disaster and continued to implement to this day. The issues she raised included a worsening trend in the health of individuals moved into restoration public housing; financial difficulties; childcare issues; and the exhaustion experienced by city officials.
Ayumi Sugawara, Chief of the Health Promotion Division of the Iwanuma Health and Welfare Department, explained the history behind the mental health care initiatives at her agency. She highlighted
issues such as the need to shift mental health care activities into the regular work as well as methods toapproach high-risk residents.
Yukari Oba, Assistant Director of Mental Health at the Disability Welfare Division of the Miyagi
Prefecture Ministry of Health and Welfare explained the status of the reconstruction process and theefforts being made by both the prefecture and other organizations. They also addressed the issue of
people’s growing mental health welfare needs and the complicated nature of the challenges facing ourcommunities.
Takeshi Yamazaki, Vice-President of the Miyagi Disaster Mental Health Care Center, presented areport detailing the center’s activities and what they can teach us about the issues our communities face.
(2) Discussion
There was an exchange of ideas between the presenters, the advisors, and the conference participantson the following themes: support for elderly men living alone; deteriorating family units; the future of
support systems; the passing on of our disaster experiences; and human resource development.
Afterward, in his keynote address, Yoshiharu Kim provided an evaluation of the ongoing initiatives
in various communities and locales and offered a commentary on the issues of suicide and PTSD.
For more details on this, refer to the Symposium Discussion Remarks below.
(3) Social Exchange
After the practical reports had been delivered and the discussion period had ended, speakers andparticipants engaged in information exchange. Many attendees participated.
3．Attendee Questionnaire Results
To gain useful feedback that would help in the planning of future events, we gave all attendees a questionnaire at the beginning of the event and received 55 responses.
Some of the sample responses are as follows: “I had the opportunity to learn about what’s going on in manydifferent areas—something I found very useful,” and “This should serve as a good point of reference for futurecountermeasures.” Many individuals expressed similar sentiments, and more than 90% of the attendees expressed their satisfaction with the event overall.

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FY 2018 Miyagi Mental Health Care Forum Report

4．SummaryWith “7 Years of Post-Disaster Mental Health Care Services and Future Goals” and “What We Can Learn
from the Issues Facing Our Communities” as the overarching themes, practical reports were presented, and a
discussion was held. Supporters from across many different fields participated.
The speakers reported on their experiences in the field and on what they encountered during their community support work. A common theme was that of elderly men living alone.
Presenters also provided insights into the many problems plaguing disaster-affected regions, such as a prolonged shortage of manpower and supporter exhaustion.
This, the eighth year since the disaster, is a year of development, according to the Miyagi Prefecture Earthquake Reconstruction Plan. As hardware maintenance and disaster public housing move-in programs progress,
disaster survivors’ circumstances continue to improve. However, this forum also highlighted some of the many
issues that remain.
It is vital for the future mental wellbeing and welfare of our communities that we share, at the prefecturallevel, and with supporters and specialists from different fields, the problems that have beset each phase of thereconstruction process. As we do so, we must continue to provide them with a space in which they can meet to
discuss these problems. It is why we believe that the forum initiative will only grow in importance in the years
to come.

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FY 2018 Bulletin, Issue 7

Symposium Discussion Remarks
Matsumoto First, we’d like to give the audience achance to ask the presenters questions and to share
their own opinions.
Ichijo (audience member) My name is Ichijo, andI’m with the Child Disaster Support Department at the
Tohoku University Graduate School of Education. I’dlike to know a little more about the ages and gendersof the individuals whose counseling cases were included in the materials presented.
Koyama The individuals we see at the Kesennuma
Health Promotion Division are mostly men in their
50s to 70s, I believe.
Kutsuzawa We don’t categorize patients by age very
strictly. Individuals who move into reconstructed andtemporary housing are generally elderly, and I thinkthat they comprise a large percentage of Kesennuma
residents. As a result, they tend to be in poor health,have heart problems, trouble sleeping at night, etc. In
short, I believe elderly individuals make up the bulkof our counseling cases.
Sugawara It is usually the case that individuals designated by health surveys as “needing support” are elderly. In the context of mother-child health and medical checkups, individuals raising children can also be
seen.
Yamazaki Immediately after a health survey, home
visits are quite common. As a result, we rarely meetworking individuals. Naturally, home-bound elderly
individuals are common, especially those in the 50s to
70s age range. People with alcohol problems are often
males who are in their 40s and 50s.
Recently, I believe we’ve had an increase in thenumber of children and young people in their 20s who
are receiving counseling, prompted either by theirown needs or by the government.
Matsumoto MDMHCC data shows an increase in thenumber of young individuals, especially at the Kesennuma Regional Center.
Katayanagi While their percentages haven’t beenhigh in the last two to three years, counseling caseswith school-affiliated teachers or parents have increased considerably. Complicated issues such as truancy, hikikomori, and difficulty adjusting to school, as
well as behind the scenes problems with parents andfamilies, have increased.

Kim We’ve had several cases with elderly males.
Could you maybe tell us a little bit about whether
males, who find themselves living alone in the aftermath of a disaster, have the same characteristics as
males who are used to living alone? Also, what haveyou learned about how they came to be living alone,elderly men in particular?
Mitsuura A lot of the residents at Kesennuma were
homeowners. We’ve seen cases where alcohol abuse
and other issues surfaced only after these individuals
were moved into temporary housing, and that too
thanks to their neighbors’ solicitousness, as they noticed their troubles.
Another pattern we’ve seen is that individuals who
relied on geographical and familial networks for the
support lost that support after the disaster disrupted
those networks.
Kutsuzawa Because different kinds of people live together in evacuation shelters, the individuals that you
spoke of get the opportunity to see how other married
couples live their lives. This helps them realize thatthe DV or alcohol abuse present in their previous relationships was not normal, and they end up taking
some time to decide how they would like to live witha future spouse.
Sugawara Although the disaster-affected areas of
Iwanuma were originally neighborhoods with lots oflarge households, we noticed that elderly couples
tended to move into container-type temporary housing,whereas young people chose to move into apartmenttype temporary housing, resulting in a kind of separation. I also think that alcohol abuse, which perhaps
goes unnoticed in the countryside, tends to surface
when individuals move into collective housing.
Yamazaki I suffered as a result of the impact that thedisaster had on my home in Higashimatsushima. It’s
my impression that it has become increasingly common for elderly individuals to be left alone, after
households in which three or even four generations
lived under one roof were split up by a disaster.
Matsumoto When familial and communal bonds are
weakened, men in the middle- to the old-age bracket
are often the ones that are hit hardest. I have often feltthat we can view this as a phenomenon where men,
who were once supported by their families or communities, are now surfacing in the wake of a disaster.

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FY 2018 Miyagi Mental Health Care Forum Report

Kim One thing to note is that these men are notindi-viduals who have simply grown older and areaccus-tomed to living alone for years on end. These
are men that lost their families and began living
alone for the first time in their old age. In otherwords, these el-derly men living alone are notaccustomed to that lifestyle at all.
Imano My name is Imano, and I am a member ofAshinaga. I work with children who have lost theirparents to a disaster. We have received several requests for counseling from the fathers of children
who lost their mothers in the disaster, saying that they
are “unable to work.” When men like this express theneed for support, where can we as administrators refer them so that they can get the information theyneed?
Koyama In Kesennuma, the Health Promotion Division can accept such cases. I would appreciate it if
you would give us a phone call before referring tosomeone.
Kutsuzawa Ishinomaki’s counseling services are always available. Our telephone counseling number islisted in the town bulletin, and we accept walk-in visits as well. We have also set up a support group formen in Karakoro station called “Ojikoro,” among
other things. Individuals have called this group directly and we have offered advice.
Sugawara One difficulty is figuring out what counseling desk the individual should visit. At Iwanuma,
there’s one in the city hall, another at the social welfare council, etc. However, some places do not makeit clear what sorts of problems they address, andsometimes residents can just get shunted around fromagency to agency. I think it would be truly wonderful
if more places were able to respond to the needs ofindividuals in trouble.
Yamazaki At the MDMHCC, we offer counsel to anyone emotionally affected by the disaster. For example, we offer telephone counseling to fathers whose
wives have passed away and are struggling withchildcare. Because we do not have consultation
rooms, it is often difficult for us to meet with clientsin person. Normally, we first provide counseling overthe phone, after which we make arrangements tomeet somewhere, and, if necessary, make a home
visit.
Oba At the prefectural level, any health care centercan provide such counseling. While the MDMHCC
is of course capable of doing so, in Ishinomaki, we
also have the Karakoro station program, etc. In termsof referring an individual to spaces and places where
men who live alone can meet, these programs differ
quite a bit from area to area.
Even in the early stages, we recognized that men weresusceptible to this; how we approach them has been
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an issue we are contending with.
Matsumoto I am sure we are all familiar with the concept of “disaster-vulnerable” individuals. However,having seen how vulnerable men are in the reconstruction period, I have a feeling that the question of how
we approach this population will become a central
theme of future post-disaster recovery efforts.
Kim Normally, when we refer to disaster-vulnerable
in-dividuals, we are referring to the acute period
immedi-ately after a disaster, and generally, the term
describes women and children. We rarely associate itwith men. The concept of vulnerability in thereconstruction pe-riod is a new one, and the work
done today has shown that men truly are vulnerable.
We must be cognizant of this going forward.
Ogasawara I have often felt that it is difficult to get
men to come in (for counseling). Of course, the content
of the support provided is important, but building a relationship with the individual through repeated visits is
also important. If anyone here is familiar with programs in other municipalities to encourage men tocome in, I would love to hear about them.
Kutsuzawa We were only able to set up a men’s clubin one area. When club members were living in temporary housing, the club was quite active, but not anymore. I had heard from individuals experienced with
the Great Hanshin-Awaji earthquake that individuals
with alcohol problems, individuals living alone, and individuals in their 50s and 60s were most at risk. As aresult, we were aware from the beginning that thesegroups needed more follow-up and we began thinkingof what we could do to meet their needs.
Initially, I just assumed that the club meetings were going to be a social sort of event with drinking and whatnot, but the neighborhood council informed us that theparticipants would like to learn more about diabetes.
So, we all sat down and put together a program to fulfill
that request.
Community supporters from the neighborhood watch
put together a really beautiful event, including providing non-alcoholic drinks in a “pub-like” setting, creating a shop curtain, and making the surroundings look
like a bar. About 15-16 people participated.
Sugawara Back when we had container-type temporary housing in Iwanuma, we held a cooking class formen at the support center. Rather than focusing on theadministrators, the supporters made the event all about“learning how to cook with other men,” and I heard theevent was popular enough to become a fixture in thecenter’s roster of programs.

FY 2018 Bulletin, Issue 7

Matsumoto Do you all have anything else to say or
ask?
Kutsuzawa I think child-related issues can pose very
big problems. Attitude surveys among residents foundthat 80% of women in their 30s and 40s were stressed.
Thinking about the future is no doubt incredibly
stressful; if you all have any clues as to how you think
the support process will function in the future, I’d love
to hear them.
Yamazaki Generally, we set up desks at the healthand welfare departments of the cities and towns that
we are in, and based on advice from public healthnurses, we’ve started to move into health care centers
and infant health clinics. We have decided that if parents of children receiving counseling have problemsof their own that they’d like to discuss, we will provide counseling to them as well.
Sugawara When I look back on what we have done,
I get the feeling that we have collectively focused our
support far too much on communities that were relocated as a group. Reconstruction happened relatively
quickly in Iwanuma, so I think our studies of how ourstyle of concentrating on group relocation committees will change in the future are ending prematurely.
What I am talking about are communities and neighborhoods that originally had rather strong social
bonds and were essentially moved en masse first to
emergency container-type temporary housing andthen into homes. I get the feeling that when thesecommunities begin living in new neighborhoods, theoriginal bonds of community that they’d sharedslowly weakened.
We must think about how we can construct and reconstruct these communities. I think that when it
comes to transferring the responsibilities of community and environment building from support centersto residents, it is important for us to collectively consider issues like how best to raise morale, and how tohelp and motivate residents to reach an understanding of the sort of community that they would like tobuild. Additionally, we have had the Care Center andother organizations dispatch supervisors, assist us
with case reviews, etc. However, regardless ofwhether they’ve lived through a disaster or not, people need support. I think we should also give somethought to what sorts of organizations and institutions will be able to assist us in providing such support in the coming years. I would like to hear fromprefectural people on this matter.
Matsumoto Correct me if I am wrong, but I believe
you’re asking about how to build a community in a
new locale and who should lead this process. Acrossthe world, a lot of value is placed on the idea of self－ 26 －reliance, accountability, and independence. However,at the end of the day, is it possible for these processes
to occur naturally and independently, or do they haveto be intentionally created? I think this is truly a difficult question.
Yamazaki I have realized that when trying to hold agathering for men, planning the right set of activities
can be difficult. We must make the event appear both
attractive and interesting. I’d appreciate any feedback
you all might have on what sorts of things were wellreceived during the male-oriented activities at Kesennuma, and what sorts of things were not.
Koyama I think our “Communication Mahjong” gamewas received quite well. A lot of the men at Kesennuma were fishermen, so we thought that they would
like doing activities that involved fine handwork. We
decided to conduct a papercut art event. But as theevent progressed, it became clear that some of the men
were unable to participate due to hand tremors, difficulty seeing, etc., and most were simply not interested.
We took that as a learning experience moving forward.
Finally, we have noticed that a certain number of people will come if food is involved, so this year, we haveplanned some simple cooking workshops, etc.
Yamazaki In Ishinomaki, the results of a disaster public housing health survey were disheartening. We discovered that the number of people living alone had
been increasing. During the Great Hanshin-Awaji
Earthquake, the problem of “death by loneliness” gota lot of attention. If I recall correctly, loneliness deaths
peaked in the seventh year after the disaster, and after
10 years, approximately 500 people had died of loneliness. I’d love it if anyone could share suggestions
with regards to mental health care guidelines and policies, such as how to follow up with individuals after
they’ve moved into disaster public housing, how tobuild new communities, and what some good countermeasures against death by loneliness are.
Kutsuzawa When I got off the Sanriku Expressway at
Konan, I saw that innumerable reconstruction public
houses had been built. The neighborhood watch, oursupporters, and social welfare council members patrol
these homes regularly to check up on cases.
So, rather than providing immediate assistance, we decided to help these people maintain their independence
by providing logistical, behind-the-scenes support. We
have just started contracting with an organization
called CLC in Sendai to provide follow-up support to
the whole Shin-Hebita area.

FY 2018 Miyagi Mental Health Care Forum Report

However, we have trouble noticing problems as andwhen they occur. Early on, when residents had justmoved in, we had not yet contracted with that agency.
And at the time, we had individuals dying from“loneliness,” although the specific definition of whatthat means can vary. Nowadays, we worry that suicide is starting to become a bit more prevalent. We’rein the middle of thinking and re-thinking our plans tocombat this, including turning to the neighborhood
watch for help with visiting, not just individuals thatneed follow-up support, but every house in the area
at least once every six months.
Matsumoto Although suicide rates have fallen
throughout the country by around 10% this year, Ishinomaki’s rates have fallen by only half that amount,with a 5% decline. Meanwhile, suicides in Miyagi
Prefecture fell drastically in 2011 and 2012, well below the national average, but returned to the samerates more recently. I think that as time passes, theissue of suicide should be cause for grave concern, atleast given current trends.
Matsumoto The MDMHCC was built to last for 10
years, in keeping with a plan. In terms of the future,
we heard earlier about psychiatric welfare and mental
health care activities. Rather than focus on the words
used to define these concepts, we have been shown
what sorts of functionalities will become necessary
in the coming years.
One point to note is the presence of difficult cases:
highly complex, intractable situations or individuals
in our communities who are either difficult to treat
directly or who require many, many visits before they
are resolved. Individuals with the skill required to address such cases, that is, with the specialized
knowledge required to provide advice in such environments are a functionality we sorely need. Furthermore, as cases get increasingly complex, rather thanaddressing them in one central location, it will become ever more vital for us to have multiple people
in multiple places who can respond to them. Until
now, we have provided support by requesting one
public health nurse to head out and provide support;
as we attempt to get more individuals in different professions involved, how will we implement the functionality we desire?
Finally, we have outreach capabilities. I believe public health nurses have been involved in-home visits
in the past. In any case, having just one individual ina small municipality deal with the vast array of potential causes, including difficult situations, individuals in dire straits, young people, children, alcoholabusers, and the elderly, etc., is incredibly unreasonable.
Given that the reports we’ve just heard have indicated that caseloads have increased twofold or more－ 27 －

at present and that support is gradually fading out, we
can predict that supporters and other public workers inmany municipalities have a hard time dealing withthem.
I would love it if people on the front lines, as itwere could let us know what sorts of things areindispensable to their practice, what things theywould prefer, etc.
Koyama I presented two cases earlier from theperspective of a group initiative, and I would liketo reemphasize the importance of groups to supporters; groups ensure that we do not end up feeling isolated or alone. I would be very happy if the
MDMHCC could continue to work alongside us
in the future.
Matsumoto The Kokoro Café is a collaborative
initiative that involves four organizations. This
collaboration is what makes it one of our best initiatives, in my opinion. I do not believe that similar resources existed before the disaster, but now
that the MDMHCC has entered the fray and functions as a hub, so to speak, this sort of connection
has become possible.
While it is sometimes difficult for connections
and collaborations to yield quantitative figures ordirect results, I would like to highlight the fact thatthey are nevertheless quite important.
Kutsuzawa After the disaster, we received support from many different professionals. However,I sometimes feel that local public health nurses
take things for granted in certain respects.
In reality, there was a significant increase in thenumber of public health nurses even before thedisaster; they hired psychiatric social workers as
well. However, in terms of technique, our skillsets
were simply not up to par. We had to have others
supervise us and conduct outreach activities together. It was also difficult to get this mindset totake root, as people would often just be satisfied
with the fact that the new generation of nurses had
been “brought up well” or whatnot. Therefore, I
think it will continue to be difficult to implement
substantial psychiatric welfare measures for sometime.
We have heard that caseloads have remained
high for several years—for example, the caseloads
at the Karakoro station initiative have hovered ataround 6,000 for some time now. I think it is important that we make some sort of effort—the specifics are not as important—to ensure that we cancontinue to provide support in the future.
The reality, however, as I have explained before,
is that there are times when the public health nurse
will need to take sick leave, or go on vacation, or
simply run out of stamina. I was affected by the

FY 2018 Bulletin, Issue 7

disaster, and I find myself hesitant to go to certain locations and unwilling to participate in disaster study sessions. I think it will take some time
for us to both addresses these issues and render
ourselves capable of maintaining public health innormal times. Thus, I would love it if the Karakoro Station and the MDMHCC, and other supporters could continue to assist us a little longer.
Matsumoto I noticed you mentioned sick leave; there
has been an increase in the number of individuals taking sick leave among our staff as well. Attitudes towards work practices are changing, and when it comesto the health of our employees, we can’t just ask them
to work harder. Given this, I feel that sometimes all
the people on the ground can do is just hope. As you
mentioned, at the moment, about one in every threepublic nurses is a young practitioner; it’s clear that asort of generational transition is underway. This is avery uncertain time, I’m sure, and as young newcomers enter the field, full of eagerness and drive, it’s important to ensure that they enter a workplace environment that allows them to remain motivated whilebuilding know-how.
Sugawara In terms of where to place the functionalities discussed before, I think prefectural healthcare centers are quite proximal to many municipalities. I think health care centers should be able towork with municipalities to understand what sort ofhealth issues affect their jurisdictions and demographics.
The MDMHCC works to address mental health issues in pregnant mothers, children, and even among
the elderly, but I do not think this system of doing
anything and everything can last very long. Prefectures have their mental health and welfare centers,
but it would be great if the center could maintain its
status as an institution with a slightly more specialized apparatus.
Oba Given the current circumstances, we at the prefecture believe that it will be difficult for us to allow
the MDMHCC to cease functioning in 2020 and thatseveral long-term initiatives are necessary. However,
because they are fulfilling the primary, secondary,and tertiary roles that municipalities, health care centers, and mental health and welfare centers are supposed to handle, when we speak of how we will continue to operate in 2021 and beyond, we need to consider what we will need to continue providing these
services.

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One topic that was brought up today is the growing
prevalence of difficult cases. I think that they will need
to be handled by interdisciplinary teams or by involving outside organizations and forming collaborative
support teams. While such efforts are necessary, tomanage them better, we will need to discuss what ourfoci will be, where we will concentrate our manpower,
and where we will direct our support.
Human resource development is another issue. Thisdisaster has allowed many different people to become
involved in many different ways. Once we consider
the fact that in 10 to 15 years, people will havechanged, human resource development becomes critically important: how can we continue to pass along ourknowledge while maintaining the levels of involvement that we have had to date?
The issue of what supervisors should the focusing
on has also been raised. I believe that it is important tohave this capacity. Key aspects of the prefecture’s primary, secondary, and tertiary responsibilities that cannot be returned, right away, to the purview of the agencies that are entitled to oversee them, should receive
some sort of special attention. I would love to hear
everyone’s opinion on what sort of functionalities are
truly necessary moving forward.
Yamazaki Two years ago, we surveyed disaster-affected coastal municipalities that brought up the question of exhaustion and other mental health issues
among municipal staff. Once the MDMHCC is gone,
will it be okay if we just dump all its responsibilities
on local authorities? If we do not come up with a clear
solution to this rather big problem, the transition will
not go smoothly. Simultaneously, we must also thinkof ways to reduce the exhaustion that municipal staff
experience.
Matsumoto Our conversations thus far have made it
clear that people “on the ground” are at their limits. At
such times, supervision or suggestions are necessary,
specifics aside.

FY 2018 Miyagi Mental Health Care Forum Report

Another point I would like to make is that, as I see
it, our conversations thus far have hinted at the ideaof preventive, early interventions. Rather than only
focusing on individuals who are already isolated, I
think we have spoken of expanding our efforts to include those that are at risk of becoming isolated.
Even in terms of alcoholism, we’ve discussed similar
approaches with regards to temperance programs or
γ-GTP-centric interventions. While responding to individuals in dire straits is its challenge, another challenge we must be cognizant of is how to prevent individuals from finding themselves in dire straits. I believe it is important for us to consider what sorts ofmeasures may be necessary for that respect as well.
(Discussion concludes)< Keynote >Matsumoto Now, we have a keynote address by
Dr. Yoshiharu Kim. Dr. Kim has visited Miyagi
Prefecture many times since the disaster and has
been a valuable mentor to us here as he provides us
with advice and guidance.
Kim First off, after listening to your presentations
this morning and based on our discussion just now,
I’d like to express my amazement at just how well
all of you have been able to grasp the issues facing
the residents in your jurisdictions. You are all
responding to so many different needs with somany different activities and initiatives. That is notan easy task.
Previously, at this forum, I’ve discussed many
dif-ferent things, including guidelines, disaster PFA,
how to interact with disaster survivors, etc. Most ofthese have been things learned from overseas
agencies com-bined with inputs that reflect thesituation in Japan. However, because medium- tolong-term initiatives were lacking, I think we wereweak when it came to creating a place that gave
people a sense of belonging during thereconstruction period. But the efforts that Japan iscurrently involved in, in terms of building this placeof belonging, are wonderful. I think if you were toshare the things you are currently doing, by translating your work into English, etc., the entire
world would be grateful.
It is often said that instead of medical support,
what people need is psychological and social
support. In other words, we should focus onorganizing social get-togethers, tea parties, places
that people can visit freely, where people in needcan reach out for help. In that sense, I am deeply
convinced that what I have seen here today is truly
wonderful.
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In our day to day lives, we hold tight to a misconception known as the normalcy bias: the mistaken idea thateverything about ourselves is good and normal. That is,
the idea that both ourselves and our environments willremain the way that they are at the moment. Indeed,without this bias, it would be impossible to go on living
at all. But today, we’ve seen so many slides that list
thousands upon thousands of casualties. The bereaved,
kin to these casualties, sit around us at this very moment, as do people who were injured alongside them.
People whose homes have been damaged, too. All of
you continue to work and live surrounded by this. Even
though somewhere along the way, such suffering andpain may have become the norm, I would like to remind you that they are not. I believe, from the bottomof my heart, that the fact that you all continue to be
devoted to your work amidst such circumstances is exceptionally worthy of praise.
But the truth is, this normalcy bias affects disastersurvivors, too.
I run an outpatient clinic in Tokyo, and I see patientsfrom disaster-affected areas there. Some suffer from
PTSD; some you cannot quite call PTSD patients but
are nevertheless quite troubled. When I ask these patients if they have taken advantage at the home of thesorts of counseling all of you provide, some of them
say no, and that they don’t intend to.
Of course, there is a stigma associated with seeking
psychiatric help, and I initially assumed that was why
people didn’t want to go. But after talking to these survivors in more detail, I found that when they’re athome, many of them don’t realize that their symptoms
are even symptoms. After all, everyone else they know
is in the same boat. After coming to Tokyo for work,and speaking to people there, they’re told that “it might
be PTSD,” or “you should go get some counseling,”
and then they come to see me. I’ve seen many people
like this.

FY 2018 Bulletin, Issue 7

The fact that the number of cases you all see is sohigh may also be a result of the fact that the doctors
and professionals that provide counseling in yourarea are just that skilled, and their efforts to spreadawareness of mental health are so effective that theresidents of your communities are now very selfaware.
Then there is the matter of suicides. Normally,anti-suicide measures are, at the national level, antidepression measures. We operate with the assumption that treating depression should decrease thenumber of suicides. But I am not sure if that holds fordisaster-affected areas. That is, is it possible for depression to set in and worsen to such a degree, and insuch a short period, right after a disaster has occurred? And do people with suicidal ideation appear
that depressed?
I’ve heard today that suicide rates in disaster-affected areas have surpassed pre-disaster levels. What
I have not heard is people talking about how, if we
had only implemented anti-depression measures or
distributed antidepressants more thoroughly, we’dhave fixed this problem. After all, in a world in flux,
people are kept anchored by constancy. And the besttether of all is a connection to your fellow man.
Those of us who work in these fields also hear a
lot about PTSD. PTSD has certain “flashy” symptoms, such as scary, startling flashbacks. Symptoms
such as nightmares, or the feeling that one has returned to the scene of the disaster. But recently, a different, more complex sort of PTSD has been recognized internationally. Rather than flashbacks ornightmares, this sort of PTSD is characterized bysymptoms including the following: difficulty calming down after being agitated, feeling emotionallyparalyzed or shutdown, feeling defeated, feelingworthless, feeling distant from others, and having
difficulty maintaining emotional intimacy with others.
What sorts of people do we see this type of PTSD
in? Well, one example is someone who has been exposed to rough circumstances since childhood orsomeone that has lived in adversity for a very longtime. While these circumstances may be slightly different from those of disaster survivors that have been
exposed to the stress of reconstruction for many
years, I hope these examples are at least of some use
to you all.
I have found that the people of Tohoku are very
persevering, almost to a fault. They will even go as
far as killing their own emotions to outlast theirproblems.

Continuing to do this for long periods causes your emotions to be bottled up inside. I think the alcohol problems
that were spoken of earlier are part of the same struggle.
Normally, one can suppress their emotions or desires andkeep things under control, but if something unexpected
happens, they get very perturbed, and their emotions either explode outwards or they turn to something like alcohol, etc. Their emotions are shut down, and they stay
distant from others. This makes it even more difficult forthem to express their emotions. They cannot form intimate emotional relationships with others.
So, then, what can we do to treat someone with these
symptoms? That very question has been the subject of agreat deal of research, and we’ve come to implement
many of these methods in our work. I would like to introduce all of you to some of them.
Therapy for these sorts of people begins with helping
these people discover their own emotions. There aremany types of emotions—positive, negative, unwelcome—but emotions themselves are a sort of compassthat we can use to direct our lives.
People that have borne significant adversity are sometimes unable to understand their own emotions. For example, in the case of an earthquake victim, we try to
speak of how they were before the disaster, and how they
have become afterward. How have their emotions
changed? Some say that they were more able to laugh at
small things before the disaster, but now, they hold back,and rarely expose their emotions. We ask them to monitor
their own emotions, to keep track of what they feel. For
example, the feeling of boredom at being home alone, orthe feeling of embarrassment when they go out into public. Stay in touch with your emotions, we tell them andreflect.
To understand what’s truly interesting about this approach, let’s take a look at one specific emotion. “Fear,”for example. The opposite would be “relief” or “peace ofmind.” The definitions here don’t have to be precise. Justgo with what you feel, we say. We then ask patients whatsort of emotions resemble fear, to them. People say anger
or sadness. Next, we ask what feelings resemble relief.
Joy, happiness. We continue talking about this while writing down what the patient says.
The order taken is of little importance. Strict opposites
and similarities are also very unimportant. The point is toremind patients just how many words we have, to express
emotion. There truly is a lot. You can even write themdown while looking at a list.
Going through this process of noticing emotions andremembering the words to identify them with facilitates
our next steps.

－ 30 －

FY 2018 Miyagi Mental Health Care Forum Report

Once we have amassed a substantial list of emotional words, we ask the patient to practice some simple breathing or relaxation techniques. Afterward, we
ask them what emotions they are experiencing. Thisdialogue proceeds much more smoothly after we’veprimed them, so to speak, to remember emotional
words via the previous exercise. I highly recommend
it.
If the individual can produce an abundance ofwords to describe emotions, the process of helping
them find ways to change outbursts of negative emotion into more positive ones will happen moresmoothly. For example, exiting the situation that is
causing them to feel negative emotions, going outside and taking deep breaths, recalling positive
events, etc. The individual then monitors the effectthese techniques have on their emotions. I thinkyou’ll be surprised at the kind of positive results you
can achieve by getting patients used to this exercise.
Recently, we have begun categorizing support fordisaster-affected people in one of three levels: 1, 2,
and 3. Level 1 is a psychological first aid. At thislevel, our priority is to make sure that the individual
is not hurt any further. We consider that when interacting with them, and we work to support their dayto-day living, to calm their emotional turmoil, and tosupport their recovery. Level 3 is a therapy for mental
illness, such as PTSD or depression. There haven’t
been many Level 2 cases so far, but these are individuals that do not have overt illnesses per se but may
have some lingering symptoms; we treat them bycoaching them to alleviate those symptoms over multiple sessions.
Next, I’d like to highlight the fact that it is incredibly important that we determine how we are going
to continue care for children in the future. Childhood
is a time of much adversity, even without the occurrence of a disaster. For example, one’s parents canbecome sick, or one’s father can be an alcoholic whorages at home, or one might have been forced tomove far away. People experience these and manyother adverse situations throughout their lives.
Research has been done in America to understandwhat effects these phenomena can have on individuals when they are allowed to pile up over time. Afterasking adults whether they endured a variety of adverse experiences when they were children, including psychological abuse, physical abuse, sexual
abuse, emotional neglect, physical neglect, disorderly or unclean home environments, etc., 11% of respondents said that they had experienced five or
more such adverse events. 33% indicated that they
had not experienced any such adverse events. Individuals that experienced high levels of adversity as
children were found to be more at risk of alcohol addiction and intractable depression as adults.
More shockingly, suicide attempts also increase.
Exponentially, in fact. Individuals who were children－ 31 －

during the disaster experienced it as an adverse event.
Our task moving forward is to try and prevent themfrom being exposed to further such events. An individual can recover from one or two adverse experiences.
To prevent the number of adverse experiences fromincreasing to four or five, we must try to prevent children from being exposed to severe stress, bullying,abuse, and other such things in society. In other words,
we must implement measures that psychologicallysafeguard such individuals. For this reason, even if wecannot directly address or treat disaster-linked trauma,
promptly addressing and minimizing other sources oftrauma will, in reality, allow children to benefit fromdisaster-related mental health care. There will be a continued need for such an effort for years to come, I think.
This is not to say that adversity in puberty or adulthood will not occur. However, I believe that attempting
to protect against them is a very effective way to minimize and mitigate the impact that disasters have onchildren. In that sense, this practice may become oneof the central pillars of post-disaster mental health carefor children.
Much of this address has revolved around some rather somber subjects, so I’d like to end on a softer note.
We often use breathing techniques as a way to manage
anxiety. However, since highly nervous or anxious
people are often unable to breathe smoothly, a pulmonary researcher has come up with an exercise that canhelp such individuals. It is called the Ra-Ta-Ta exercise.
You can find it on YouTube. I make use of it in mydaily practice, and those of my patients who have anxiety disorder have found that it helps them greatly.
Matsumoto Does anyone have any questions for Dr.
Kim?
Sugawara In my district, too, I had an experience
where a very cheerful, bright individual committed suicide the day after a disaster.
He was an elderly man who lived alone, and although he wasn’t receiving any psychological treatment,
he would always have a sort of “not me!” attitude. Our
supporters were quite shocked, and they asked, “Why
did he die, even though he attended all of our meetingsand events?” I just wanted to ask how you would recommend that we deal with such a situation.
This person even filled out our health surveys. Since
he was an elderly man living alone, he was of course
one of our support targets, and he even visited the comprehensive support center.

FY 2018 Bulletin, Issue 7

Kim Nowhere in the world has any initiative beenable to reduce the number of suicides to a flat zero.
In the case that you’ve just described, I’d like topoint out the possibility that what happened was not
the fault of whoever was assigned to that man’scase. Loneliness and isolation are risk factors for
suicide, but this per-son was socially active, as you
mentioned. This is true quite a difficult business. If I
had been in your shoes and had been meeting withand treating this man, I cannot say that I would
have been able to predict what happened.
Matsumoto We’ve thought a lot about whether weshould ask individuals that come to our salon activities to fill out questionnaires and the like. Have you
ever tried asking such individuals objective questions
in person?
Matsumoto Interviews alone do not usually reveal
enough, and during screening, we become unsure
about whether a person is feeling a certain way or not.
I feel that it could be useful to implement a regularmental health checkup for at-risk individuals using
something like the K6 scale.
Kin The issue with the K6 scale is that, if overused,people grow accustomed to it. The other issue is thatboth symptoms and risks need to be analyzed. For example, let us say that someone’s relative has recently
committed suicide. That isn’t the sort of accumulated
adverse experience that we spoke about earlier withregards to children, but if someone with that problem
had mentioned it while discussing current hardships,
then yes, they should be treated like someone at riskof similar behavior.
Matsumoto There’s also the fear that if the participant
in a counseling session does not, at some point, feel as
though they have gained something from the experience, they might consider it a waste of time and unhelpful, resulting in an unwillingness to come in forcounseling again.
I’ve come to believe that knowing how to respondto, address, and keep tabs on an individual’s progressin therapy constitutes an important skillset, one thatmust be shared.
Questions about death, in particular, are difficult tobring up in open, relatively public spaces. It is hard to
get someone to talk about such topics if we do notbring them up in a private, safe place with an opener
like, “How have you been recently?” In a group, because everyone’s having a good time, if we ask anyone“how [they] are doing,” they usually just respond withan “I haven’t been paying attention,” or something ofthat sort. So, to deal with these problems, we’ve had
to adopt a more discreet approach.

I wanted to ask if you had any experience supervising these kinds of approaches, or if you had a list ofsome sort you could share with us.
Kim I think one of the problems is that the people
that manage these events often try to push them to bebright and cheery affairs. But if a glum person
happens to at-tend such an event, they’d find it hardto divulge their gloomy thoughts, especially whensurrounded by all that happiness and cheer. That’s
why I think several different facilitators withdifferent personality types should oversee these
events. For example, you can have a bright andenergetic person lead the event, but you might want
to station a more reserved, moody staff member in theback. someone that views that day’s pro-ceedings as
pointless might be your best option.
Matsumoto I’m sure we’ve all heard of the conceptof peer pressure. When in a group with others, thepeer pressure, so to speak, to be optimistic andupbeat can be quite high. This can be a very goodthing for people emotionally capable of reciprocatingthat energy, but when it is difficult for someone toquickly align with the emotional state of others,
such environments can intensify their feelings ofsolitude.
I guess it is very important to have as manydifferent kinds of people involved; to engage withmany differ-ent kinds of people; to hear varied
opinions, and to move forward with the teams andgroups that sponta-neously arise from these mixed
scenarios.
Audience member I’d love it if you could share yourthoughts on how to wind down support, how to
entrust an endeavor to the next generation, and how totransfer the responsibilities that come with it to othergroups.
Kim As an administrative organization, closing ahelp desk or something can be done fairly quickly, but
to put an abrupt end to an activity or program israther care-less, in my opinion. If you do not make aneffort to en-sure that some aspect of these programs
lives on—per-haps in a different form and managed
by a different group, one that has succeeded the first—the loss of the program itself can often be upsetting
enough to cause its participants a new sort of trauma.

Matsumoto The ripple effects of the Great East
Ja-pan earthquake will persist for some time, and the
pro-cess by which the individuals, communities,
cultures, and societies affected by it heal—with
therapeutic sup-port or by some other means—will
also continue for some time. Wounds that needhealing will continue to come to light, and those thattreat them must continue to do so, perhaps without－ 32 － end.

FY 2018 Miyagi Mental Health Care Forum Report

Kim I am a doctor, and as a closing remark, I’d liketo speak a bit about the Level 3 care I mentioned
earlier, for the treatment of PTSD. Although thisisn’t some-thing people in my field usually telleach other, the bottom line is that if you allcontinue to fulfill your roles, much of what we’ve
discussed today can be treated. No matter how
many years pass, these wounds can and will heal andpeople will be able to recover. You must be
optimistic that there is a path to healing, somewhere
out there. If you do, you will find it.
Matsumoto I think we’ve got to be cognizant of thefact that even though we’ve been operating for quite
some time now, for most people affected by the disaster, the most important phase of the recovery process is just beginning. People are living in post-disaster public housing, people who must build newcommunities and raise their children in new environments. Grade school truancy in Miyagi Prefecture isamong the highest in the entire country. Suicide rates
are quite high, too. Our ten-year deadline is artificial
and meaningless. We needed to have some sort ofdeadline, or our sponsors would have gotten mad.
That ten-year figure is just a number, and in terms ofhealing trauma, it has no real basis or reasoning behind it.

I think it is important that we do not become preoccupied with it. In the truest sense, what all of you observe
so very closely on the ground is the process itself. Whatever surfaces in those situations are where
treatment ought to be directed. And as Dr. Kim says,
with your in-tervention and support, there is more thanenough room in those places for healing and recovery.
I think what Dr. Kim is trying to say is that even
if there isn’t a clear end in sight, healing ishappening. While things are getting better, we must
continue to con-sider what support may be required in
the coming years. I am grateful to everyone for teachingme so much today. I would especially like to thankeveryone that presented, for taking time off from workin their home regions to come all the way here. We arevery grateful for your sup-port. And thank you to Dr.
Kim as well, for taking time out of his busy schedule
to participate in this event.
(End)

Symposium Summary
The symposium entailed a question-and-answer session that was meant to facilitate a discussion on the topics
presented in the first half of the forum. Afterward, a keynote address was delivered. The symposium’s key
takeaway points have been summarized below.
1.

Support for elderly males living alone has become a pressing issue in several places, and various initiatives to combat this problem are underway.

2.

While we need to evaluate how best to consolidate and wrap up disaster-related support efforts, we mustalso be aware of manpower shortages and exhaustion among workers in our communities.

3.

Caseloads remain high, and the need for supervisors is also quite high. When wrapping up disasterrelated support efforts, the functionalities they provided must be maintained.

4.

The number of adverse experiences a child has lived through is related to their future risk of alcohol
addiction, depression, and suicide attempts. Keeping these experiences to a minimum is important.

－ 33 －