Post Disaster Mental Health in Japan: Lessons and challenges
by: Yukiko Tanisho, Anne Smith, and Hiromi Murakami*
Today marks four years since the Great East Japan Earthquake of March 11, 2011. The "triple disasters" -- earthquake, tsunami, and the nuclear reactors’ meltdown -- generated significant psychological stress for the affected population: physical relocations, loss of family members, and loss of income. And March 11 severely tested the efficacy of disaster response policies associated with mental health that Japan had put into place after the earthquake in Kobe in 1995. In this commentary we present three observations about the shortcomings of Japan's disaster response policies specifically with reference to post-disaster mental health services, and offers concrete recommendations for strengthening future responses.
First, it has become very clear in the past four years just how different 3/11 is from Kobe. 3/11 affected a sizeable northeastern coastal region with massively complex “triple” disasters that impacted coastal areas as well as rural communities. The tsunami was the foremost cause of 16,000 deaths, (2,600 people are still missing) but resulted in a very low injury rate. The earthquake struck Tohoku region on Friday afternoon when family members were dispersed, in schools or at work, which was far more disruptive emotionally than the Kobe earthquake, which struck in the early morning. (The far more typical disaster is the 1995 Kobe earthquake, a single, urban-centered event, with relatively low loss of life but a high injury rate.) Rapid-response Disaster Medical Assistance Teams (DMAT) did not exist at the time of Kobe. They did deploy swiftly after 3/11, but were also withdrawn rapidly, since physical injuries were so limited. One week after 3/11, newly-created mental health teams swiftly deployed psychiatrists to carry out focused short-term activities. However, these interventions had limited long-term impact. Rather what was truly needed were ample numbers of social workers and community outreach experts to assist victims in coping with socio-economic stress, trauma and survivor guilt, all of which require sustained, long-term care.
Secondly, it has become apparent in the past four years that much more effort is needed to address the enduring stigma in Japan surrounding mental health services. Indeed stigma remains arguably the highest barrier to accessing mental health services in Japan. The stoic citizens of the Tohoku region have suicide rates well above the national average, reflecting a strong reluctance to access mental health services, as well as minimal available assistance. In the aftermath of 3/11, there was a critical need for mid-to-long term monitoring and focused care for those populations at risk of PTSD, through increased outreach support by trained personnel that reached beyond psychiatric specialists. Especially challenging has been meeting the potential mental health needs of the 230,000 people who to this day remain dislocated from their homes, including 120,000 from Fukushima prefecture, the area most severely impacted by nuclear radiation, and where domestic abuse, alcohol, and suicide are especially acute. Yet that was limited, since Japan places inadequate emphasis on therapists, social workers, and public health nurses, and there is no established official policy for managing highly stigmatized, traumatized populations. To this day, debate over how best to confront stigma persists among psychiatric specialists.
Thirdly, the current process of capturing and analyzing data about the post 3/11 disaster mental health response is haphazard and risks losing important lessons learned that can be relevant for the future in Japan and elsewhere. Disaster-related mental health measures lack clear goals, making evaluating outcomes difficult. The Japanese mental health community is reluctant to put into force clear evaluation measures, for fear they will increase stress on an already traumatized population and raise ethical issues in the collection of personal data. The current arrangement under which the national government covers most of the costs associated with responding to severe disasters weakens the incentives for any party to assess how effectively mental health activities have been. One result: the central government’s 3-year funding for post-disaster mental health will soon come to a close, without any clear idea of how to tackle these long-term mental health challenges without knowing clearly the lessons learned with respect to mental health services.
Japan’s experience could be used to create better disaster response mechanisms and processes as well as help shape international disaster-response. It is a time for Japan to engage in a stronger commitment to tackle issues from 3/11.
- Inefficiencies and misallocation of resources have plagued Japan's response to victims' mental health needs in the aftermath of the 3/11 disasters. Japan has yet to address issue of sectionalism, or problems associated with specialists deciding each disaster policy. To facilitate effective resource allocation and inter-agency coordination, the government must clearly designate a single authority to assume responsibility for disaster management.
- Japan must redouble its efforts to address stigma associated with mental health care seeking behavior. Maintaining disaster victims' community ties and social networks is essential, as the Kobe earthquake demonstrated that victims' dislocation from their communities further exacerbated their mental problems. Japan should widely adopt training guidelines, such as WHO’s Psychological First Aid (PFA) which do not require mental health providers in emergency situations to have any specialized psychological or psychiatric expertise to allow volunteers to quickly enter the disaster areas and connect survivors with available resources
- Finally, it is essential to build plans for monitoring and evaluating disaster response mental health services into the initial costing, budgeting, and appropriation processes. To this end, Japan should adopt an internationally-standardized method including measurement tools and a system for sharing anonymized data between governments, institutions and other essential stakeholders. By setting measurable clear-cut goals and appropriate evaluation tools, Japan can introduce more effective systems and increase its capacity to deal with the next disaster.
*This commentary is based on a study conducted by Yukiko Tanisho, Anne Smith, senior associates at the Health and Global Policy Institute, and Hiromi Murakami, adjunct fellow at the Center for Strategic International Studies.