In Japan, rice is life. It is the core of the Japanese diet and its importance cannot be overstated. After the Fukushima meltdown, since radioactivity in rice grown in the irradiated ground is not visible to the naked eye, tests must be conducted to determine its levels of radioactive cesium. If the levels are too high, the rice can’t be sold. As a result of tests instituted by the government, shipments of rice from an extensive area around Fukushima prefecture have been banned after the tests revealed they contained levels of radioactive cesium that exceeded safe levels. It is the first time the government has banned shipments of rice since the March 11 earthquake and tsunami that badly damaged the Fukushima Daiichi nuclear power plant.
A larger issue remains. Health problems faced by the Japanese people after the meltdown, particularly mental health problems, did not appear to command the same degree of importance with government officials, farmers, and the people at large. The negative effects of the meltdown are not limited to just the harm caused by radiation levels present immediately after the Fukushima disaster. Simply living through this catastrophic disaster caused severe and persistent shock and trauma.
A corollary can be made to the experience of the Fukushima survivors and the experience of the hibakusha, the people of Hiroshima and Nagasaki, termed the “explosion-affected people” or “people of the bomb.” Over a half a century after the atomic bombings of Hiroshima and Nagasaki, the victims who were in the vicinity of the bombs, even if they were not exposed to radiation poisoning, continued to suffer intense psychological stress and poor mental health. As a result of these findings, the Japanese government has made financial aid available for individual mental healthcare to the hibakusha and has also begun a campaign of public mental health promotion for the affected individuals.
Yoshiharu Kim and his fellow authors hope that their study will also help further educate and broaden the understanding of the conditions of the victims of the Fukushima disaster. However, despite the attention the Japanese government directed towards the victims of the Hiroshima and Nagasaki atomic bombs, it is unlikely that people with mental health issues resulting from the Fukushima nuclear disasters will receive similar attention. Even if they receive financial aid for treatment, Japan’s media has reported that there are fewer than 20 psychotherapists in the country specializing in PTSD to treat them.
Japan is not alone. The Western Pacific was beset with natural and manmade disasters in 2011 including, floods, earthquakes, tsunamis and radiological disasters. WHO (World Health Organization) officials said in October that they are expecting incidents of mental health problems to rise dramatically in the Western Pacific region. They noted that children, the elderly, and people with disabilities would likely be the worst affected with PTSD (post traumatic stress disorder) and depression resulting from these disasters. Tufts University’s Dr. Wang Xiangdong and regional leader for WHO in the Western Pacific, makes a strong case for the importance of identifying and treating people with mental health issues. He argues that “the general mental health of the [affected] population is not getting the attention it merits. Mental health measures should be integrated into the total post-disaster response package…[They] are among the most significant and lasting impacts of disasters and calamities.”
A very useful article on the post-Fukushima mental health crisis, its symptoms, onset and treatment, and the social ills that confront sufferers, “Fukushima: a chance to reform Japan’s mental health care system,” appeared in the online journal Japan Today, on October 25, 2011. The article was pulled off the web two days after it was posted. Some important facets of the article are:
• Top WHO official, Shekhar Saxena, has said that Japan should use a higher rate of mental health problems after the Fukushima nuclear accident to update outdated attitudes toward depression in the country.
• Speaking at the World Health Summit in Berlin, Shekhar Saxena, from the mental health division of the World Health Organization, said the mental aspects of disasters tended to be ignored.
• Officials have previously warned of an increase in depression cases in a country where this illness still carries a stigma.
• It is only recently, that urban areas of Japan have begun to tackle the taboo surrounding depression, a condition euphemistically known as “heart flu.”
• After a disaster such as the Fukushima, the prevalence of severe mental disorders, such as psychosis, increased from 2-3 percent of the population to 3-4 percent, said Saxena.
• More mild mental disorders like depression have increased from one in ten to one in five, he added.
• Treating such disorders is best done within the community rather than in medical institutions, he said.
• “In Japan, mental health care is largely undertaken by specialized institutions whereas it is more effective.
• “We recommend for Japan to utilize the opportunity presented by the disaster to actually change the system to make it more community-oriented,” Shekhar Saxena argues.
• Another expert, Shunichi Yamashita, from Fukushima medical university, said the tragic war-time history of Japan has sparked greater anxiety than might have been the case anywhere elsewhere in the world.
• “People in Japan are very much aware of the risks from radiation from the atomic bombs in Hiroshima and Nagasaki, so they worry more,” said Yamashita.
• Yamashita, who moved from Nagasaki to Fukushima to assist in the response to the accident, said Japan needed an “unprecedented effort” to monitor the health impact of the disaster.
• “There are uncertainties about the risks of chronic low-dose radiation exposures for human health but there is no alternative than to take the responsibility of monitoring the health condition of people around Fukushima,” Shunichi Yamashita said.
How can we define the affected area? As in the case in much of rural Japan, the economy in Tohoku had been in decline for decades before the tsunami. The area was marked by depopulation, aging, chronic underinvestment, and by decades of neglect from the central government. It is now desolate, marked by debris and rubble, containers from ocean going vessels cast up on land, with one lone pine tree which has somehow managed to survive. Who are the survivors? About one in three are more than 65 years old, and 22 percent are impoverished.
They are rural people, fishermen and farmers whose livelihood has been taken from them. The survivors are living in makeshift shelters and high school cafeterias. Their anxiety and distress is evident. They can’t sleep- they have nightmares. They relive the terrifying moments during the disasters. Yet they are also reluctant to discuss their distress. Because throughout their lives they have been taught to be stoic, to internalize their feelings. Television has in part changed all that. In a Minamisanriku evacuation center, an 82-year-old survivor said “I saw people being swept away right in front of me. One person was screaming, help me! But I couldn’t help.” He only just managed to save himself as a huge black mass of water smashed into his home. Now all he has left are the nightmares that haunt his sleep.
What is the biggest mental health challenge facing the people of Fukushima? Fear of exposure to radiation, anger against TEPCO (Tokyo Electric Power Company) and the Japanese government, uncertainty about the future, sadness at having to desert their land, jobs and community. In addition to the elderly, those survivors especially vulnerable to PTSD are children. Fortunately, the children’s shelter administrators are wise in the ways of the media.
When a reporter visits one of NGO Mercy Corps’ evacuation centers, he is told no photographs of children’s faces. No video. No interviews with children. The staff member speaking with the reporter said that this evacuation center has been especially frequented by journalists wanting to talk to survivors. Every time someone wants to do an interview, she said, it takes a survivor back to the trauma of those terrible days. And those feelings can be especially hurtful and harmful for children.
The American NGO, Mercy Corps, is working with its partner Peace Winds Japan to help Japanese children and adults recover from the emotional effects of a large-scale disaster. Their team is now also exploring ways to build support groups for parents, grandparents and other community members.
Psychiatrist and PTSD specialist, Norihiko Kuwayama, has said that he believes “post traumatic stress disorder will become a big problem. And I think that is related to Japanese culture which subscribes to the view that it’s best to let sleeping dogs lie. So instead of talking about the tsunami people carry it in their hearts. They believe society does not want to know their problems, that it will perceive sufferers as weak.” Kuwayama believes that it is crucial that Japan changes the way it thinks about mental health and about PTSD.
In October, the health ministry in Miyagi Prefecture found that more than 40% of disaster survivors appeared to suffer from sleep disorders. Subsequently, the ministry’s mental health counseling hotline has been flooded with 1,300 calls. Miyagi’s Hello Work job counselors have been referring to psychiatrists, callers ostensibly seeking work but essentially distraught over their experiences with the tsunami and earthquakes. The Hello Work employment agencies now hold weekly counseling services for job seekers.
Miyagi survivors’ mental strain has seriously affected local residents’ lives. According to a survey by the Cabinet Office, 16 people committed suicide in June as a result of the disaster. Prof. Ichiro Tsuji at Tohoku University, an expert in public health said, “Survivors are highly likely to suffer from mental problems after such traumatic experiences as losing family members, friends and homes.”
There is dissension about the nature and characteristics of “mental problems,” PTSD, or whether the word “depression” more truly characterizes the nature of survivors’ suffering. There are also disagreements about the ideal locus and nature of treatment for the remaining survivors. In Justin McCurry’s recent Lancet article, “Japan, the aftermath,” he stated that Japan’s health system is ill-prepared to address the long-term mental health problems triggered by the disaster. Many Japanese and most Westerners would agree with this statement.
Yoshiharu Kim, director of adult mental health at the National Institute of Mental Health in Tokyo, disagrees. He states “valuable lessons about post-disaster mental health have been learned since the disasters, the earthquake at Kobe in 1995 and Niigata in 2006. In 2001, the National Center of Neurology and Psychiatry issued national guidelines for post disaster mental health, and several thousand caregivers have been trained in traumatic stress counseling over the past few years. The directors of most mental health centers have attended lectures in post disaster mental health care. As a result, responses to the present disaster were very rapid, allowing prompt scheduling and dispatch of mental health-care teams to the devastated areas.”
Yoshiharu Kim’s statement does alter one’s perception of the availability of mental health care available to the survivors. It also appears that the numbers of community based models for psychiatric care and the numbers of disaster-trained therapists recommended for Japan by WHO official, Shekhar Saxena are far more robust than one might think.
Medical personnel at this year’s many disaster sites were discouraged from immediately counseling survivors in the belief that it would not prevent post traumatic stress disorder and may in fact increase a person’s risk. Teams were told to counsel only those with existing mental health problems or those displaying obvious signs of distress. “After treating the previously mentally ill people, the mental health teams started to take care of the new victims of the disaster,” Yoshiharu Kim said. Eight months on, Kim says hospitals and clinics in Japan have so far seen no increase in the number of patients with depression or posttraumatic stress disorder.
Yoshiharu Kim, Justin Kenardy, an Australian psychologist, Matthew Yoder, an American psychologist, and Naoto Kawabata, an American-trained Japanese psychiatrist have also reported promising alternative ways of dealing with PTSD. Last year, Justin Kenardy at the University of Queensland in Brisbane, Australia, found a new approach to the treatment of post-disaster trauma, a version of cognitive-behavioural therapy (CBT). The technique involves four to twelve psychological sessions, administered at least a month after the trauma. By this time, most survivors will have begun to deal with the stress of the event in their own way, leaving those most at risk of PTSD more readily identifiable.
CBT is currently being given to victims of the tsunami who show symptoms of PTSD. Kim expects the first scientific studies of the effects of this strategy to be published within the next few years. On the other hand, a new twist on the “traditional” or American form of PTSD treatment, could make community mental health therapy more effective within isolated and remote rural areas. This method was developed by Dr. Peter Tuerk, and his colleague, Dr. Matthew Yoder. Both psychologists returned in May from Japan, where they successfully used their PTSD program to help the victims of the earthquake and tsunami combat anxiety disorders.
One therapy in which Yoder specializes is telemedicine, or providing therapy over video-conferencing equipment. “With the radiation disaster, there was a big area where no one was going,” Yoder said. “So to be able to use telemedicine therapy, for a physician to be outside of the evacuation zone to be treating people inside the evacuation zone, was a unique application of this therapy.” Naoto Kawabata is another psychologist who has become convinced that the mode of PTSD is not adequate for the situation in Fukushima and has developed his own.
Kawabata, a Japanese psychologist working with traumatized Fukushima families, is the President of the Kyoto Institute of Psychoanalysis and Psychotherapy (KIPP) and Professor of Psychology at Kyoto Bunkyo University. Kawabata studied advanced psychotherapy and psychoanalysis at the William Alanson White Institute in New York City. Kawabata, as a result of his experience as a first responder at the 1995 Kobe earthquake, questioned whether and how western theories of trauma treatment could be translatable for Japanese victims. He volunteered to join a support team to work with Fukushima teachers and children. Kawabata’s comments on his work:
In Aizu-Wakamatsu, Aizu-Bange and Inawashiro we found that in addition to the stress induced by the disasters, the stress level in the shelters was very high because grandparents, parents and children are living in one small room together. Old people who lost their routine work and chores just lie down the whole day and are very depressed. They have no idea about how long they will have to stay there. We recommended organizing some recreation activity there [and] the next team put that plan into place. What approach are you using to help? I have found that the Post-Traumatic Stress Disorder (PTSD) model does not fit this situation. I am developing a different model, which call the ‘systemic-psychodynamic’ model of disaster aid. We need psychologists who will think together with parents, teachers, and children in Fukushima from a systemic and psychodynamic point of view.
Other observations made by Kawabata:
• First we must establish a relationship with the community.
• then we have to find out what victims need and offer help.
• or come up with some [way] to resolve their most urgent problems.
• [We can] talk to people in depth and ask about their experience of the disaster.
• After establishing a relationship, we can propose interventions such as screening tests, individual counseling, group counseling or organizational consultation…But we have to be careful not to be intrusive.
• Very often it works better to provide supervision and consultation for staff who are already working in the community.
• The goal is to help the system to recover and raise the level of mindfulness.
It’s clear that survivors in Fukushima, beset by many forms of disaster related stress, need quality institutional mental health care. Unfortunately, mental health care facilities are currently scarce in Fukushima. Virtually all facilities within the evacuation zone of the Daiichi Nuclear Power Plant, have been shut down since 3/11. Finally, constructive assistance for the survivors of the disasters at Fukushima will be coming in the form of a sophisticated mental health system. In August 8, 2011, five months since 3/11. Japan Society awarded the Japan Medical Society of America (JMSA) a three-year grant to support Kokoro no Care programs in Fukushima. The new health system should serve as the nerve center for psychiatry and psychotherapy for the region.
In October 2011, Dr. Shinichi Niwa and his “Kokoro no Care” team at Fukushima Medical University in cooperation with Japan Society, began building a new mental health care system for the area. Their main goals:
1. Provide ongoing therapy and support for patients with preexisting mental health conditions.
2. Provide early intervention for disaster related depression and Post-Traumatic Stress Syndrome (PTSD).
3. Reduce cognitive functional decline in displaced elderly residents.
4. Prevent expected rises in the suicide rate and “lonely deaths.”
5. Decrease hospital admissions for mental health.
Dr. Niwa and his team opened a temporary mental health clinic at Soma Public General Hospital with the support of many volunteer mental health specialists and other medical staff. In the next phase, Dr. Niwa and his Kokoro no Care team are planning to establish two multidisciplinary satellite mental health care outreach teams as well as a day care center in order to better serve the needs of Soma and Minami Soma.
Little has been written about spiritual or religious counseling for traumatized survivors. However, the Dalai Lama recently paid a visit to Nihon University just 100 km away from the Fukushima Daiichi nuclear plant. Some highlights of his talk, “Natural disasters may increase because of changing global ecology. But it will not completely destroy the world. The world will remain for thousands of years. But our complaints will never end. Everyone among nearly 7 billion human beings have something to complain about. Don’t worry. Be optimistic.”
At a later conference in Tokyo, the Dalai Lama told his hosts that nuclear power is an important solution for underdeveloped countries still grappling with basic energy poverty.