How Japan will survive psychological fallout of crisis

Eventually the debris will be cleared, the radiation will fade and the nearly 200,000 people in temporary shelters will find new homes. But memory of the most powerful earthquake to strike Japan in recorded history, the devastating tsunami that followed and the worst nuclear emergency since Chernobyl will persist. The most enduring consequence of the ongoing crisis in Japan will not be medical, financial or environmental: it will be psychological.

Barbara Lopes-Cardozo remembers the screaming. One of the founding members of Doctors Without Borders, she was in Colombia in 1985 just after the Nevado del Ruiz volcano erupted, killing more than 23,000 people. She administered anaesthesia to those who survived, some of whom shrieked and howled from the terror of flashbacks.

The experience helped convinced her to focus her career on mental healthcare in emergencies and disasters. "I think it has been a mistake in the past not to focus on mental health," she says.

K. A. S. Wickrama of Iowa State University in Ames, who studied survivors of the 2004 Indian Ocean earthquake and tsunami, agrees. "Recovery of physical infrastructure is one thing – but recovery should also focus on psychological processes, on the social infrastructure."

Types of trauma

In the past three decades, psychologists and psychiatrists have published numerous studies on how disasters influence mental health. A 2004 review suggests that in the year following a technological disaster – such as a plane crash – between 25 and 75 per cent of survivors develop post-traumatic stress disorder (PTSD) – the symptoms of which may include flashbacks to the trauma, as witnessed in Colombia by Lopes-Cardozo. Following a natural disaster, PTSD seems somewhat less prevalent; but that may be because it is often easier to identify the direct victims of a technological disaster than, for example, the victims of an earthquake that affects a large area (Epidemiologic Reviews, DOI: 10.1093/epirev/mxi003).

The crisis in Japan is both natural and technological, which suggests that some PTSD can be expected. The problem will probably be compounded by "radiation anxiety" – the stress caused by the dread of radioactive contamination. Some researchers have suggested that, for most people, the widespread fear of radiation is more harmful than the radiation itself.

The workers who have risked their lives at the damaged Fukushima Daiichi nuclear plant may be particularly at risk. A study published in 2008 compared the mental health of 295 men who helped clean up the Chernobyl plant in Ukraine after the 1986 disaster and 397 people who lived in the same areas as the clean-up workers but did not work on-site: it found that the former group suffered higher levels of depression and anxiety, and contemplated suicide more frequently (Psychological Medicine, DOI: 10.1017/s0033291707002371).

But a study by Wickrama published last year offers reasons for optimism. He investigated the role of community participation in the mental health of mothers from 325 families in southern Sri Lanka who were affected by the 2004 tsunami. In many developing nations, mothers are the primary caregivers of their families – a role that leaves them more vulnerable to mental health problems.

Wickrama found that mothers who believed they were part of a supportive community were at lower risk of PTSD and depression. What's more, those who formed grass-roots groups to distribute emergency relief and construct housing and roads benefitted psychologically as well as materially (International Journal of Social Psychiatry, DOI: 10.1177/0020764010374426).

Cultural strength

Japanese culture encourages familial intimacy, which will be an "important social resource", Wickrama says. News reports of the behaviour of the Japanese evacuees confirm they possess what psychologists and sociologists call a collectivist orientation: a belief that the welfare of the community overrides that of the individual.

But Japan has not always embraced psychological counselling and mental healthcare, points out Joshua Breslau of the University of California, Davis. He was in Japan in 1995 when the Kobe earthquake struck. "The idea of responding to mental health problems was new – some people embraced it, some people didn't." He remembers people using a Japanese phrase (kokoro no kea) that translates as "care for the heart" as a way of promoting mental health awareness.

Today, Japan has organisations like the Hyogo Institute for Traumatic Stress, which opened in 2004 and is currently sending mental health experts into the Sendai region to counsel evacuees who have lost their homes. But Wickrama points out that many developing nations lack such resources, and depend on counsellors supplied by foreign organisations, who typically disappear after a few months.

Lopes-Cardoso has recognised this failing as well: "We need to train primary health professionals to give basic psychological care," she says. What concerns Lopes-Cardoso even more, however, is the need for psychiatric therapy based on rigorous scientific studies for the aftermath of disaster.

"We are doing major mental health surveys, but we still don't have nearly enough research," she says. "In all disaster situations we find that mental illness increases – what we need to do now is develop proper psychological first aid based on research."

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