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Abstract

The Japanese concept of “kokoro no kea” (care for the heart/mind) plays a crucial role in shaping disaster mental health response systems. Following the 2011 Great East Japan Earthquake and tsunami, and the subsequent nuclear plant accident, the government quickly implemented kokoro no kea initiatives. However, many locals reported reluctance to seek support from kokoro no kea teams. This article explores therapeutic governance in response to these disasters, a multifaceted, disavowed, and diffusive mode of governing. It highlights how recovery politics emphasized solidarity—referred as “kizuna” (social bonds)—while also gendering and pathologizing women’s fears and anxieties regarding radiation exposure. Through a narrative review of ethnographic studies, this analysis demonstrates that kokoro no kea is not simply a static post-disaster mental health and psychosocial support system; rather, it is an open, fluid, and evolving process where diverse actors—such as politicians, men, women, health professionals, and religious practitioners—interact with socio-political forces and cultural values, creating unique pathways for individuals and communities to foster connections, build trust, and nurture resilience in coping with psychological pain and loss.

Keywords

psychosocial support mental health disaster kokoro therapeutic governance

Introduction

In Japan, a country prone to a range of natural disasters, such as earthquakes, tsunamis, typhoons, and volcanic eruptions, “kokoro no kea” (care for the heart/mind) has become a familiar concept and practice to address psychological impacts of disasters, such as grief and trauma. According to the Cabinet Office Government of Japan (2012), kokoro no kea aims to support disaster victims by reducing mental health symptoms such as PTSD and depression so that individuals feel part of a reconstruction community.

On March 11, 2011, the Great East Japan Earthquake devastated the Pacific coast of north-eastern Japan. The earthquake and tsunami largely affecting Iwate and Miyagi prefectures, together with the nuclear meltdown of the Fukushima Daiichi Nuclear Reactor, resulted in nearly 20,000 deaths and 2,600 missing persons. Right after the disaster, Disaster Psychiatric Assistant Teams (DPATs) were dispatched for immediate psychiatric support and coordination. Similar to the deployment of kokoro no kea after the 1995 Great Hanshin-Awaji Earthquake and the 2004 Niigata Chuetsu Earthquake, a year after the 2011 Great East Japan Earthquake, three “Kokoro-no Kea Centers” (disaster mental health centers) were established in the Iwate, Miyagi, and Fukushima prefectures (Seto, 2019). A university in Iwate prefecture and non-profit organizations in Fukushima and Miyagi prefectures, funded by the reconstruction budgets from the Japanese government operated these Centers to provide mental health and psychosocial support to the affected communities, coordinating with other organizations (Seto, 2019). Furthermore, nonprofit organizations, such as “The Bridge of Mind of Iwate” in Iwate prefecture, “Kara Koro station” in Miyagi prefecture, “Mental Health Outreach Clinics Nagomi” in Fukushima prefecture, also provided psychosocial support without governmental funding (Seto, 2019).

Despite this government mobilized support to provide kokoro no kea through the Basic Act on Disaster Management, mental health service providers and volunteers from kokoro no kea teams often reported feeling unwelcome in temporary housing or among residents’ communities (Epstein, 2022; Gagné, 2020; Gerster, 2019; Ozawa-de Silva, 2021). These mental health service providers were not always welcomed “not only because nobody wanted their help but because the help they were offering was a technical, material type of help” (Ozawa-de Silva, 2021, p. 209).

Health professionals’ unsuccessful implementation of “kokoro no kea” has been critiqued for its underlying clinical psychological approach, which focuses on individual psychological distress (Matsumura, 2017). In contrast, more casual social activities such as “teatime gatherings” (ochakai), “radio group exercise” (radio taiso), and workshops on creative arts were popular among temporary housing residents (Gagné, 2020; Matsumura, 2017; Ozawa-de Silva, 2021). Indeed, social capital, defined as the resources for information and support that individuals and groups can access through their connections was found to be a critical protective factor against the after-effects of psychological trauma and involuntary resettlement following the 3.11 disasters (Kawachi et al., 2020). Rebuilding social connections is a crucial ingredient in disaster resilience (Aldrich & Meyer, 2015).

The importance of social capital in the disaster recovery support was widely recognized and reflected in the public discourse for disaster recovery. Kizuna (絆: social bonds) was selected as the kanji character of the year following the Great East Japan Earthquake and subsequent tsunami and nuclear meltdown in 2011. Kizuna was a ubiquitous rhetoric that became the national slogans for the recovery of Tohoku region and Japan as a whole country. While generating a sense of solidarity and community cohesion, the idea of kizuna successfully mobilized recovery effort and resources. The reported popularity of informal social activities such as “teatime gatherings” (ochakai) over psychological counseling provided by the kokoro no kea team indicates the local acceptance of activities that nurture kizuna (Gagné, 2020; Matsumura, 2017; Ozawa-de Silva, 2021).

At the same time, once the term kizuna started to be used by politicians and mass media to call for unity to support the affected regions, it adversely affected the trust and the citizen-state bond particularly among the people in Tohoku (Aldrich, 2019). Kizuna is a source of social capital attained through relationship building, which involves trust and power among various actors and institutions. Local dynamics and political tensions in kizuna-based disaster recovery process were a part of the complex realities of post-disaster daily life.

In the post-disaster settings, simply applying therapeutic practices based on assumption of emotional vulnerability among those affected by disasters risks overlooking individuals’ resilience and their own strategies for coping with distress (Pupavac, 2004). Therefore, I review the literature to explore how the current disaster mental health system that offers kokoro no kea was created, and how kokoro no kea was situated and practiced in the post-3.11 recovery process. I also interrogate who and what other socio-economic and political forces shaped the unique experiences of suffering, resilience, and care of individuals and communities, which may not be fully captured in the current form of kokoro no kea, by applying Pupavac’s concept of therapeutic governance.

I first briefly describe the Japanese concept of kokoro and the history of establishing the post-disaster mental health support system, today known as kokoro no kea. Then, I present the context in which the collective recovery effort was mobilized by the popularized motif of kizuna (bonds) in order to investigate how the heightened spirit of solidarity and altruism masked feelings of distress, anger, and isolation. Next, by focusing on how women experienced and expressed their fear and anxiety regarding radiation in Fukushima, I explore what may be missing in the current kokoro no kea practices in understanding women’s fear and concern over radioactive contamination. I highlight how mothers engaged with science not only to protect their children and families but also to assert their political agency, while women’s emotions and voices were often depoliticized and pathologized in the male-dominated recovery politics. Lastly, I demonstrate the emerging role of religious practitioners as part of kokoro no kea, providing spiritual and religious care to the bereaved people in the unique Japanese context where the majority claim to be without religion, yet they continue to practice rituals from Buddhism and Shinto (Cavaliere, 2019; Saito et al., 2016). I contend that kokoro no kea is not simply a static Japanese post-disaster mental health and psychosocial support system based on the Western concepts of trauma and PTSD, but rather an uncertain and evolving process of healing and recovery for individuals and communities, in which diverse actors interact with socio-political forces and cultural values, fostering support, connections, and resilience. This review adds a contextualized and nuanced understanding of the current landscape of kokoro no kea, presenting new insights into the dynamic social processes of shaping kokoro no kea in post-disaster settings.

Research Methodology

I conducted a narrative literature review focusing on ethnographic studies in disaster-stricken communities affected by the 2011 Great East Japan Earthquake and tsunami. A narrative review is a scholarly report of a wide variety of literature that describes the topic’s current status, including interpretations and critique (Sukhera, 2022). Narrative reviews are useful for providing a detailed, nuanced understanding of current evidence from multiple perspectives (Sukhera, 2022). I searched literature using Google Scholar with keywords, such as “kokoro no kea,” “mental health,” “psychological,” “psychosocial,” and “post-disaster” alongside “Great East Japan Earthquake.” I included peer-reviewed articles and books containing ethnographic studies that documented personal and community experiences of the post-disaster recovery process. Ethnographic methods reveal unique insights about culture, diversity, and context, with emphasis on contextualized meaning, relationships building, and social processes (Case et al., 2014). I also reviewed online reports of kokoro no kea activities both in English and Japanese and included relevant studies using the references cited in the retained publications.

Conceptual Framework

After the 1995 Hanshin-Awaji Earthquake, the global idea of trauma and the diagnosis of PTSD led to the creation of a localized mental health response system in Japan called kokoro no kea. This dynamic historical process draws my attention to the concept of therapeutic governance. Coined by Vanessa Pupavac (2001), therapeutic governance refers to a mode of control and management of individual emotions and community psychology through psychosocial interventions that exercises the power of expert knowledge, leading to a creation of new relationships between the state and its citizens. Using the concept of therapeutic governance, Pupavac critiqued psychosocial programs in humanitarian interventions, arguing that the needs of recipient communities are homogenized and pathologized, while a Western framework is imposed to control people’s way of coping with risk and insecurity, thereby illegitimizing recipients as political actors (Pupavac, 2001; Rehberg, 2015). Pupavac’s concept is useful because it draws attention not only to cultural considerations but also to issues of control, power, and the political implications of particular mental health and psychosocial support (Rehberg, 2015). For instance, Yang (2018) presented how a particular socio-cultural, institutional, and historical context shapes a unique mode of control over private psychological issues such as depression and suicide faced by government officials in China. In the current paper, the concept of therapeutic governance guides my analysis of the landscape of kokoro no kea practices for people affected by the Great East Japan Earthquake in 2011.

Results

Birth of Kokoro no Kea in the Context of Post-Disaster Support

Kokoro (心) is a ubiquitous term that has multiple meanings including heart, mind, soul, intention, emotion, and thought (Breslau, 2000; Doi, 1986; Lebra, 1992). A Japanese anthropologist, Takie Sugiyama Lebra, characterized three levels of self in relation to kokoro. First, the social, “outer” self at the basic level; second, the “inner” or reflexive self which centers around the kokoro; and third, the “boundless” self where the boundary between subject and object, self and other, or the inner and outer self disappears to be an empty self (Lebra, 1992). While these three dimensions are not mutually exclusive, she highlighted that inner-self is inaccessible and unattainable even to the person to whom it belongs (Lebra, 1992). Unlike Western psychological approaches that attempt to express “true self” to find a “real self,” attaining “empty” state of mind by accepting things as they are (arugamama) is the main tenet of Morita therapy, one of Japan’s indigenous psychotherapeutic approaches (Balogh, 2020; Lebra, 1992). The underlying philosophy of Morita therapy is rooted in Zen Buddhist principles that focus on the body-mind interconnectedness and acceptance of reality as it is (Balogh, 2020). On the other hand, Japanese psychiatry developed by largely relying on the Western classification model, with less attention to the indigenous approaches and traditional ideas about the body and mind (Kitanaka, 2006).

Kokoro is a polysemous word with prevalent connotations and positive tones often used in various slogans, advertisements, song lyrics, and given names: it covers the thinking, spiritual, and emotional state of a person when referring to his/her inner world, as well as presents traditional cultural values and a connection with the Japanese socio-cultural environment (Nakaya, 2019). In the post-disaster settings, by combining the familiar term kokoro with the English word care (kea), the phrase “kokoro no care” popularized mental health services and psychosocial support for people in the post-disaster context. However, prior to the Hanshin Awaji Earthquake, which killed nearly 7000 people in January 1995, the term referred to specifically to hospice care for nonreligious patients who were suffering from emotional or spiritual anxiety due to terminal illness (Benedict, 2016, 2018). In the context of hospice care, “kokoro no kea” is provided as “spiritual care” to create an environment where patients feel comfortable and cared for. Unlike spiritual care in Western settings that generally refer to religious or existential support provided to patients, the ambiguity of what spiritual care refers to has created room for a range of meanings and practice of spiritual care in Japanese hospices (Benedict, 2018). It is important to distinguish “spiritual care” from “religious care”: The former is provided by lay people, including doctors and nurses, whereas the latter is typically offered by religious professionals in the form of religious rites based on religious doctrine (Takahashi, 2021). This distinction is significant given the general perception of religion in Japan. In March 1995, the sarin gas attacks on the Tokyo subway by the apocalyptic New Religion Aum Shinrikyo killed 13 people and injured thousands. This incident resulted in a strong mistrust in new religious movements and a shift towards using terms with weaker connections to traditional religious vocabulary such as supirichuaru (spiritual) or kokoro (heart/mind) rather than shūkyō (religion) (Cavaliere, 2019; McLaughlin, 2013). While spiritual care is distinguished from religious care, it is practiced as kokoro no kea without clear distinctions between physical or psychosocial forms of pain: hospice staff routinely offer spiritual care complimentary to other forms of care such as foot massage, and chaplains often engage with patients through social events and activities such as tea gatherings and gardening to work through their spiritual concerns and anxieties (Benedict, 2016, 2018).

The 1995 Hanshin-Awaji Earthquake marked a turning point in popularizing the concepts of trauma and PTSD not only among clinicians but also among the general public in Japan (Goto & Wilson, 2003). During the 1980s, trauma primarily referred to physical injury (gaisyō) as opposed to psychological trauma (shinteki gaisyō) and the translation of the DSM-IV that was made available in 1994 did not prompt clinicians’ attention to PTSD (Goto & Wilson, 2003). Nevertheless, right after the 1995 Earthquake, researchers and volunteers from the U.S. “la[id] the political and technological foundation for identifying PTSD as an unaddressed social problem” by introducing debriefing for the prevention of PTSD and trainings for health care professionals (Breslau, 2000, p. 183). Both Japanese and non-Japanese health professionals called for a broad cultural change, critiquing Japan’s lack of psychological assessment and mental health support for disaster victims. This led to an expansion of the territory of psychiatry: the new framing of kokoro no kea, which adopted the term kokoro (heart/mind), replaced the term seishin (精神), which means “psyche,” “psychiatry,” “mental health,” and “human spirit.”(Breslau, 2000). The introduction of the term kokoro advanced psychiatrists’ agenda by broadening their objective of treatment from severe mental illnesses to more generalized forms of psychological distress, while obscuring the fact that only a small number of people actually develop severe symptoms (Breslau, 2000).

In this context of localizing the global idea of post-disaster trauma and PTSD, the Japanese government allocated resources to establish Hyogo Institute for Traumatic Stress (Hyogo-ken Kokoro no kea sentaa) to advance research and teaching about kokoro no kea as well as provide mental health services (Breslau, 2000). The English translation of the institute, “traumatic stress,” appears to indicate its particular focus on PTSD, while the Japanese name of the institute, Kokoro no kea sentaa, gives the impression that services that encompass a range of psychological distress are offered. The Japanese media also disseminated the words “trauma,” “PTSD,” and “kokoro no kea” on a daily basis, popularizing those trauma-related terms through the message that anyone could suffer from mental illness as a consequence of traumatic events such as an earthquake (Benedict, 2016; Goto & Wilson, 2003; Kokai et al., 2004). Through the mass media that succeeded in making the term kokoro no kea known to the public, the need to provide mental health care after disasters became widely understood.

Considering the various needs of mental heath and psychosocial support for people affected by disasters, three-tiered services were designed based on the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007). Kokoro no kea is a coordination response that consists of: (1) mental health services provided by professionals such as psychiatrists, psychologists, and psychiatric social workers to continue pre-disaster mental health services for patients with psychiatric disorders, as well as for those who develop acute stress disorders; (2) psycho-social support provided by nurses, psychologists, and health workers to help individuals in the community respond to and prevent traumatic stress through Psychological First Aid, psycho-education, and monitoring; and (3) long-term social support at the family and community levels provided by NGOs, volunteers, community leaders, schools, social workers, and psychiatric social workers. The manuals for kokoro no kea during the natural disasters are developed by different ministries including the Ministry of Health, Labor and Welfare and Ministry of Education, Culture, Sports, Science, and Technology, as well as many prefectures of Japan both those affected by major natural disasters and those less prone to them.

Kizuna-Driven Recovery Politics

After the 2011 Great East Japan Earthquake and tsunami, kokoro no kea teams started to provide psychiatric services as well as counseling services in disaster-stricken areas. In parallel, kizuna (social bonds, solidarity) emerged as a recurring theme which gained momentum in envisioning Japan’s “recovery” from the disasters at a national level. Although it was a familiar term often used in popular cultural artefacts, such as songs, anime, and manga, even before 3.11 (Samuels, 2013), kizuna represented the government and community approach to rebuilding disaster-affected communities. This was reflected in slogans, such as “Social Bonds” (Kizuna), “Connected” (Tsunagaru), and “United we stand!” (Ganbaro Nippon!), which emphasized the importance of strengthening existing relationships and fostering new relationships to support each other. Under these prevailing national slogans, the fast recovery of infrastructure, restoration of utility, and efficient removal of debris were globally praised, representing the imagined collective identity of Japan and showcasing solidarity and resilience of Tohoku region (Gerster, 2019).

While appearing many times in the media, advertisements, event names, and posters as a motif of disaster recovery, “Kizuna” was centered in recovery politics at multiple levels. The fundamental principles articulated in the Basic Law for Recovery from the Great Eastern Japan Disaster were focused on solidarity; other recovery plans developed by each affected prefecture similarly emphasized “community building” (Samuels, 2013). The authoritative power invoked through kizuna was even found in a government statement entitled “Kizuna: The Bonds of Friendship” issued by the Prime Minister Kan in April 2011, one month after 3.11; the statement expressed gratitude for the generous support and solidarity provided by assistance from all around the world (Prime Minister of Japan and His Cabinet, 2011).

The nationwide collective response to the disaster, promoted by emphasizing kizuna, strengthened citizen-to-citizen bonds but weakened citizen-to-state bonds (Aldrich, 2019). What appeared to generate altruism and a spirit of community support through a sense of “suffer[ing] together” had the unintended effect of masking the emerging internal divisions in the communities (Gagné, 2020; Samuels, 2013). As Gagné (2020) termed it, a “politics of sameness” emphasized social bonds, creating the impression that everyone was suffering the same thing together. In reality, each individual had faced varying degrees of material loss and psychological damage. For instance, knowing that some were affected more than others, many people in Natori City, Miyagi Prefecture are reported to have refrained from asking for help or expressing their psychological distress or bereavement (Gagné, 2020). Also in Fukushima Prefecture, the binding effects of social bonds created an atmosphere where people felt silenced in their oppositions against the government’s handling of the nuclear plant disaster, as the government chose to filter the information it released to the public (Aldrich, 2019; Gerster, 2019).

While the politics of sameness stressed solidarity and strengthened kizuna for community healing and rebuilding, a “hierarchy of affectedness” emerged among those who were experiencing the damage and recovery to unpack these differences (Gerster, 2019) (see also Brady et al., 2021). As people experienced, perceived, and expressed their damages and losses differently, they repositioned themselves to describe and share their experiences, ultimately impacted social relations and access to compensation payment (Brady et al., 2021; Gerster, 2019). Gerster (2019) found that even when people were unaware of how others were affected, they still considered themselves as being “only marginally affected,” while some who lost their family members did not want others to feel bad about their situation. By 2018, as the reconstruction continued, individual and regional differences in recovery processes, including compensations, became noticeable, leading to feelings of abandonment, loneliness, isolation, and unsettled feelings (Gagné, 2020; Ozawa-de Silva, 2021). In this context, the overwhelming emphasis on social cohesion would not only prevent people from expressing their emotions, but also hinder criticism of the government regarding their disaster management and recovery processes (Aldrich, 2019; Gerster, 2019).

Silencing and Pathologizing Women’s Radiation Fear

The nuclear plant accident in Fukushima demonstrated unique and complex mental health and psychosocial consequences that the kokoro no kea team faced. While various psychological responses to the 3.11 triple disasters were reported, fear of radiation and anxiety were particularly prominent among those directly and indirectly affected by the nuclear power plant accident in Fukushima (Harada et al., 2015; Sugimoto et al., 2014). While the poor disaster management due to failures in communication by the Tokyo Electric Power Company (TEPCO) and the Japanese government caused profound distrust toward the government (Maeda et al., 2019; Sekiya, 2012), failure to receive timely and relevant information was a source of distress particularly among pregnant women and mothers of young children (Slater et al., 2014). In this context, the kokoro no kea provided to mothers with fear of radioactive contamination included phone-based counseling as well as information sessions about topics of “radiation fear” (Seto, 2019). Nevertheless, a range of anxieties were reported, including concerns about food safety, outdoor safety, effects on fetuses, effects on children, radiation exposure, economic problems, and distrust of information disclosure (Yoshii et al., 2014). Also, Lee (2022) pointed out that mothers, who made a decision to leave their husbands alone and voluntarily evacuate their place of residence with their children for their safety, experienced feelings of remorse for separating their families contrary to social expectations of keeping families together. On the other hand, better mental health outcomes were reported among evacuees from communities near the Fukushima Daiichi nuclear power plant who remained in contact with neighbors from their old towns (Aldrich, 2019). As such, the positive effects of kizuna (i.e., social connections) were evident in reducing anxiety, depression, and fears over radiation. In line with this recognized role of social connections, a non-governmental organization, the “Association for Establishing a New Psychiatric Care, Health and Welfare System in Soso,” was founded in November 2011 to take over the role of the kokoro no kea team at Fukushima Medical University. This organization provided a range of informal social activities, such as art workshops and cooking, to prevent isolation among youth, the elderly, and evacuees, creating a space for connecting with others (Médecins du Monde Japon, 2019).

In addition, the Radiation Medical Science Center for the Fukushima Health Management Survey started to conduct a survey to understand the physical and mental health conditions of residents affected by the nuclear power plant accident. The center also provided mental and medical support, telephone counseling, and information about the health effects of radiation. Despite this support, some residents reported experiencing negative emotions and anger towards medical professionals and public health officers (Ohtsuru et al., 2015). Contrary to the initial aim of the thyroid screening programme, which was to reduce excessive anxiety, the screening results are reported to have caused unnecessary fear among people who were examined (Shibuya et al., 2014). Regarding the widespread fear and concern, a number of ethnographic studies identified an emerging new form of kizuna, characterized by the activism of mothers in Fukushima and other parts of Japan, alongside state and male control over the emergence of a political subject.

After the nuclear plant accident, many women struggled to find information due to the government’s failure to provide timely updates about the nuclear threat and the potential dangers of radiation. Mothers’ frustration and distrust towards the government, coupled with their desire to protect their children became a driving force for women to enact a new social identity in “citizen science” where the public is involved in generating knowledge for advocacy. They were actively involved in developing practices and social networks to minimize their radiation exposure, such as measuring the level of contamination of radioactive materials, establishing citizen radiation measuring organizations, and organizing study groups to develop private safety standards and learn about cooking techniques to minimize risk (Kimura, 2019; Löschke, 2022; Slater et al., 2014; Sternsdorff-Cisterna, 2015). For instance, Kodomo-tachi o Hōshanō kara Mamoru Zenkoku Nettowāku (the National Network of Parents to Protect Children from Radiation) was established by mothers after the Fukushima Daiichi nuclear disaster. Its aims included abolishing the new annual radiation exposure limit (20 mSv) set by the government and supporting the volunteer evacuees who were struggling to secure their living in the new places (Löschke, 2022). As such, transforming the existing favorable image of mothers and their apolitical identity in everyday life to women’s participation in activism was achieved after the Fukushima Daiichi nuclear disaster (Dawood, 2024; Löschke, 2022).

The prevalence of fūhyōhigai (harmful rumor) and stigma towards Fukushima and its products affected the local economy (Maeda et al., 2019; Sekiya, 2012). In this context, some women were empowered by transforming their fear and desire to protect their families from radiation exposure and by engaging in activism (Kimura, 2019; Slater et al., 2014; Sternsdorff-Cisterna, 2015). However, local residents, including teachers, neighbors, and even family members, often viewed these women’s anxiety and fear of the unknown effects of radiation as irrational or paranoia (Kimura, 2019; Slater et al., 2014). This local people’s lack of compassion for women was also reflected in the expert statement (Slater et al., 2014). Dr. Nishi, a professor of psychiatry at Fukushima Medical University, commented: “It is natural for people to experience anxiety when facing radiation exposure, even at low levels. Here the important thing is to be ‘accurately’ afraid: people should pay attention to scientific facts, and avoid danger appropriately, but not be unduly frightened” (Niwa, 2014).

How women’s voices of concerns over food contamination by radiation were treated in society was situated within the context of post-disaster nation-building. While the government and the nuclear industry blamed fūhyōhigai for causing tremendous economic damage, they tended to portray expressions of consumer concern about food contamination as a source of fūhyōhigai, responsible for inflicting suffering on affected communities and undermining their economic vitality (Kimura, 2019; Slater et al., 2014). In addition, in the male-dominated Japanese society, most heads of institutions, including local government bodies, corporations, residents’ associations, and town councils of evacuation centers, were men (Lee, 2022). For these men, who take the responsibilities as breadwinners for their families, women’s expressed health concerns about radiation risk were viewed as a threat not only to economic stability but also to their masculine identity, leading to the dismissal of women’s fears (Morioka, 2014).

When women’s fears were perceived as irrational, their behaviors and feelings were even pathologized in some cases. In an ethnographic study by Slater et al. (2014), some mother’s concerns were dismissed by teachers, neighbors, and even family members as shinkeishitsu—characterized by irrational fear, nervousness, self-absorption, and instability. Many mothers reported being labeled as “crazy” due to their overly nervousness. In Japan, shinkeishitsu has both popular and psychiatric meanings. In popular terms, it describes a person who is overly sensitive to certain aspects of the immediate environment—“nervous,” “worrisome,” and “anxious”—the sufferer is believed to be disposed to the “nervous” disorder by temperaments at birth, although the disorder is not necessarily seen as serious (Russell, 1989).

In the post-disaster context of Fukushima where solidarity was the motto for community rebuilding, shinkeishitsu was used as “an accusation in ways that pathologized the women who spoke up. As in the case of other pathologies, there is an implicit questioning of the fitness of the person to participate in the community” (Slater et al., 2014, p. 505). By labeling women who spoke up about the dangers of radiation and opposed the government and the nuclear industry as shinkeishitsu, their identity-making as activists empowered by scientific knowledge was hampered.

Religious Practitioners as Emerging Actors in Kokoro no Kea

The 3.11 disaster marked a turning point for Japanese media to shed light on the post-disaster relief efforts of religious organizations. Such relief work was also provided after the 1995 Hanshin Awaji Earthquake. However, the Tokyo subway sarin gas attack by the Aum Shinrikyo cult that shocked Japan and the world a few months after the Earthquake, undermined religious contributions while public skepticism prevailed (Graf, 2016; McLaughlin, 2013). In contrast to the missed opportunity after the 1995 Earthquake, various scholars in religious studies described religion in the Japanese post-disaster context as “re-presenting as a type of post-disaster therapy that has more in common with clinical” models than public worships (McLaughlin, 2013, p. 310).

In the wake of the 3.11 disasters, the responses of various religious organizations, including Buddhist, Christian, Shinto, and others, extended beyond mere provisions of material aid and meeting the ritual needs of the dead and the bereaved, while new affiliations emerged between Buddhist organizations and citizens with no previous religious ties (Graf, 2016; McLaughlin, 2013; Saito et al., 2016). Religious professionals gradually began to provide kokoro no kea in municipal funeral halls, temporary housing units, and hospitals (Berman, 2018; Saito et al., 2016). In contrast to the 1995 Hanshin Awaji Earthquake, the positive media coverage of religious activists that valorized priests transformed the prevailing images of Japanese clergy, as contributions to social reconstruction through their relief work in the form of volunteer and kokoro no kea became more widely recognized (Graf, 2016; McLaughlin, 2013).

What contributed to changing the public image of religion beyond the religious practice for the dead was Kokoro no Sodanshitsu (Counseling Room for Heart), a multireligious relief project affiliated with Tohoku University based in Sendai, Miyagi Prefecture. This initiative involved collaborations with medical professionals, licensed counselors, and academics (McLaughlin, 2013). The training consists of lectures focused on folk religion, regional culture, and interreligious dialogue, as well as practical work such as Café de Monk (a mobile coffee shop for attentive listening) and walking tours (Tohoku University, 2012). The project aimed to train religious professionals to become “interfaith chaplains” (rinshō shūkyōshi) by equipping them with techniques for providing kokoro no kea in public places, such as hospitals and temporary housing units in disaster-affected areas. The emphasis was placed on working together beyond denominational differences to make rinshō shūkyōshi available to support anyone in need, regardless of their religious beliefs (Saito et al., 2016; Tohoku University, 2012).

Berman (2018) pointed out that, by adopting the World Health Organization’s (WHO) definition of health, “a state of complete physical, social and mental well-being, not merely the absence of disease or infirmity,” rinshō shūkyōshi transformed suffering and pain into medicalized, non-religious language. Framing suffering and health in terms of the global institution’s definition allowed rinshō shūkyōshi to incorporate a wide range of support while suppressing religious differences (Berman, 2018). At the same time, what rinshō shūkyōshi are expected to provide is not necessarily as equivalent to clinical psychological support. The aim of Kokoro no Sodanshitsu or the rinshō shūkyōshi, was not necessarily focused on making a distinction between clinical and religious: rather, the emphasis was on local beliefs and practices, which have shaped Buddhism in Tohoku region over the centuries (Graf, 2016; Saito et al., 2016). Furthermore, there were numerous reports about sightings of people who had died in the disaster, including hearing voices of those who had died, seeing them, and feeling the presence of the dead (Yama, 2019). In the devastated area in the city of Ishinomaki in Miyagi prefecture, taxi drivers reported encounters with the spirits of the dead (Yama, 2019). In response to these reports of ghost sightings, religious practitioners who were consulted by those troubled by ghosts in the disaster-affected areas provided active listening, performed rituals to purify clients, offered moral guidance, and promoted self-care (Takahashi, 2016). As such, Dr. Okabe Takeshi, an expert in palliative care and the head of the Kokoro no Sodanshitsu, elaborated the role of rinshō shūkyōshi in providing kokoro no kea:

One extreme example would be that many people in the disaster areas are claiming to see ghosts. They know that they can’t tell it to the doctors. If they do, all that will happen is that they will be regarded as mentally ill, and the doctor will give them medication. Consequently, religious people hear information that we doctors don’t, and when a sutra is read, the ghosts somehow stop appearing. I wonder why (laughs). I realized that when in charge of at-home or regional care, I must consider myself a member of a team in which medical and religious professionals are both part of an equal partnership (Tohoku University, 2012)

For people who lost their family members, houses, land, and everything in their lives, religious practitioners were aware of the need for spiritual and religious activities to heal their grief and pain by listening to their stories, including their encounters with the spirits of the deceased (Cavaliere, 2019; Saito et al., 2016; Yama, 2019). In response to this urgent need, religion has played a role in developing a new type of emotional care, as individuals sought help from religious practitioners in temples or shrines, despite the availability of other support providers such as social workers or public health nurses (Saito et al., 2016; Takahashi, 2016). In this way, religious practitioners became emerging critical actors of kokoro no kea.

Discussion

The current analysis of therapeutic governance in the landscape of kokoro no kea after the 2011 Great East Japan Earthquake reveals fault lines resulting from the multi-layered effects of political, cultural, and social factors. While communities may respond to a disaster with mobilization and increased solidarity, the level of people’s distress and suffering influences those social responses, which reflect the local dynamics of politics (Kirmayer et al., 2010). This article has shown that recovery politics, which stresses solidarity and generates a sense of collective suffering, has an unintended effect of silencing certain voices. In Fukushima, women’s frustration with the government’s disaster management and their radiation fear were gendered, policed, and pathologized, viewed as barriers to the recovery efforts of the government and communities to address prevailing fūhyōhigai. At the same time, the Japanese religious context, the WHO’s broad definition of health and the ambiguity surrounding the definition of kokoro no kea allowed religious practitioners to provide support those who were grieving the loss of their loved ones while trying to maintain spiritual connections with them.

Double-Edged Sword Effect of the Kizuna-Focused Recovery Policy: Homogenization of Suffering

Pupavac’s concept of therapeutic governance highlights how psychosocial programs can homogenize individuals’ and communities’ unique experiences by emphasizing their vulnerability that requires therapeutic interventions, while overlooking political and social circumstances, cultural beliefs, and previous experiences of adversity (Pupavac, 2004; Rehberg, 2015). The current analysis of the context following the 2011 Great East Japan Earthquake sheds light on the double-edged sword of the kizuna-focused political initiative for reconstruction, which results in the homogenization of diverse experiences and complex needs among individuals and communities in the Tohoku region.

In the post-disaster recovery effort for community building, kizuna-focused programs were promoted by influential figures, including government officials and famous athletes, and discourses emphasizing solidarity and social cohesion prevailed. The emphasis on solidarity in national slogans appeared to be aligned with Japanese cultural values and concepts of selfhood. In the Japanese cultural context where relationship harmony and emotional support are highly valued, social capital plays a crucial role in coping with collective trauma such as disasters by strengthening community solidarity and social cohesion (Somasundaram, 2014). Also, as the self is viewed as interdependent and connected to family, clan, and community, this cultural emphasis on interconnectedness between self and others fosters sympathy for others, which correlates with one’s ability to improve the self (Kirmayer, 2007; Kitayama & Park, 2007). Belonging to a group is a central component of interdependent identity (Kirmayer et al., 2018). However, the stress on solidarity often masks the complex reality of recovery processes. In the case of the 2011 Great East Japan Earthquake, the geographic zones of impact defined by Japanese governments set the level of affectedness at household and neighborhood levels including access to support and monetary compensation. However, such public classifications failed to account for the complexities of loss and disruption experienced by those affected (Gerster, 2019). On one hand, individuals attend to others and prioritize harmonious relationships with them (Kitayama & Park, 2007). On the other hand, as people position themselves by comparing themselves to each other, their pre-disaster life, and to others affected by disasters in other locations, they may develop a hierarchy of affectedness, which ultimately influences how they make sense of their disaster experiences and generate internal afflictions (Brady et al., 2021).

In the rebuilding process, governance mechanisms fostering social connections not only with Tokyo but also with organizations such as NGOs and foreign groups at the prefectural and municipal levels made a difference in bringing resources and support for large-infrastructure project, and integrating the organizations and residents into recovery (Aldrich, 2019). On the other hand, the politicized effort surrounding the prevailing slogan of kizuna amplified the masking effect: in the politics of sameness, where the idea of suffering together aimed to foster feelings of solidarity and community building for rapid recovery, people are pushed to fit in and avoid (or minimize) social friction and conflict (Kirmayer et al., 2018). Caught in the hierarchy of affectedness, silence could have become a way of navigating the collective climate of solidarity and community cohesion for rapid recovery even when kokoro no kea was offered. In the Japanese cultural context where the emphasis on interconnectedness between self and others shapes self-identity, the feeling of community solidarity might have been attained and maintained by prioritizing feelings of others and suppressing one’s own suffering.

Gendered and Pathologized Radiation Fear: Control Over Emerging Motherhood Activism

Women’s fear and anxiety about the health impacts of radiation after the Fukushima nuclear power plant accident were recognized as the need for kokoro no kea. In response, kokoro no kea provided safe places and opportunities for individuals to stay away from the epicenter of the accident, along with information sessions and a range of collective social activities (Seto, 2019). However, once women’s fear transformed into a political voice, it became pathologized and depoliticized within the community, viewed as a threat to local economic recovery and disaster management dominated by male figures. Pupavac argues that methods of therapeutic governance constrain recipients’ responses and behaviors, framing them as vulnerable and limiting their ability to demand action from the community and state (Rehberg, 2015). In the case of Fukushima, while practices of kokoro no kea did not depoliticize women’s emergent role as political activists, what appeared to be missing in the approach was understanding of how women navigated a multi-layered power structure within families and communities to foster a new form of kizuna. Patriarchal cultural and gender values often overshadowed their emotions and voices, even pathologized their concerns in some cases.

While the government’s failure to distribute relevant information affected all of Japan, the division of power and roles based on gender values within Japanese families unevenly influenced health risk perceptions and attitudes between women and men, leading to the gendering and pathologizing of women’s emotions (Morioka, 2014; Slater et al., 2014). For many women, active engaging with science by measuring the radiation level was part of their responsibilities as caretakers in the Japanese cultural context where caring for families was a prevailing assumption of gender roles (Kimura, 2019). Furthermore, enacting maternal responsibility through the rhetoric of protecting children allowed them to voice their own concerns about safety and assert their role as political subjects (Kimura, 2019; Sternsdorff-Cisterna, 2015). On the other hand, men were reported to be less concerned about radiation, often interpreting impact more as a threat to financial stability than to physical well-being (Morioka, 2014). This perspective was strongly shaped by their sense of breadwinning responsibilities in Japan’s corporate-centered socio-economic structure (Morioka, 2014).

In a society where women were often stereotyped as scientifically illiterate, engaging in measurement activities to provide accurate radiation information had the potential to empower women as activists. However, such opportunities were not necessarily realized (Kimura, 2019; Sternsdorff-Cisterna, 2015). Declines in sales of products from Fukushima and its surrounding prefectures, driven by consumer beliefs in potential contamination, complicated by the government’s control of fūhyōhigai pushed women to make difficult choices in complex social and political processes. When the kizuna was stressed for community rebuilding, women’s discussions about radiation risks in order to protect their children were seen as contradictory to the community effort, leading to mother’s “perceived conflict between a good mother and being an activist” (Kimura, 2019, p. 343; Slater et al., 2014; Sternsdorff‐Cisterna, 2015). While men saw the radiation risk as threats to economic stability and their masculine identities as breadwinner shaped by the gendered division of labor and cultural values, women’s voices were dismissed as irrational and even pathologized as shinkeishitsu (Morioka, 2014). This tendency to blame women for expressing their fear and anger diverted criticism away from the government’s responsibilities in disaster management, including their lack of transparent information disclosure. Whereas Pupavac critiqued how psychosocial programming pathologized communities’ needs through imposing a Western intervention framework (Pupavac, 2004), in the post-3.11 context of therapeutic governance in Japan, it was the patriarchal culture that pathologized women’s fear, anxiety, and anger towards disaster management, simultaneously depoliticizing mothers’ new identities and emerging roles as political actors.

Definition Ambiguity Around Kokoro no Kea and Added Spirituality

Kokoro no kea is designed to be provided through a three-tiered pyramid model in line with the with the IASC guidelines, which aims to facilitate an integrated approach to provide mental health and psychosocial support (MHPSS) along a continuum during emergency situations (Cabinet Office Government of Japan, 2012; Suzuki & Kim, 2012). However, the broad and vague definition of “mental health and psychosocial support” in the global IASC guidelines has been criticized (Aggarwal, 2011), and this ambiguity also reflected in the practice of kokoro no kea. The ambiguity continues generating confusion among mental health professionals as well as the general public (Suzuki et al., 2015; Yamaguchi, 2018). For health professionals, kokoro no kea is often referred to as mental health services to address clinical conditions, while the general public tends to vies it more broadly, not necessarily confining it to specialized or clinical care (Suzuki et al., 2015).

Such ambiguity has created room for religious practitioners to draw attention to the need for spiritual and religious care for the bereaved, helping them maintain emotional bonds (kizuna) with the deceased as part of kokoro no kea after the Great East Japan Earthquake—an aspect that was not present in the current system of kokoro no kea (Saito et al., 2016). Providing such spiritual support was the perfect opportunity for religious practitioners to redefine the role of religion beyond ritual performance for the dead, which subsequently improved the public image of religion. In collaboration with academics and clinicians, these practitioners, despite their religious differences, underwent training to gain a new identity as rinshō shūkyōshi (Tohoku University, 2012). The emphasis on transcending denominational differences not only prevented proselytizing and fund-raising activities for specific religious groups but also aligned with the national slogan of kizuna (McLaughlin, 2013; Tohoku University, 2012). The incorporation of religion into therapeutic governance of post-3.11 kokoro no kea was further facilitated by the WHO’s definition of health, which recognized the multifaceted nature of suffering, translating people’s suffering and affliction into non-religious terms (Berman, 2018). Building on the practice of compassion, spirituality was added to what was initially conceived as kokoro no kea to provide mental health and psychosocial support in post-disaster settings. In addition to the media’s contribution of disseminating positive images of religion, wide acceptance of rinshō shūkyōshi was made possible in the particular Japanese context of religion where the majority of the population are secular, yet attached to folk beliefs rooted in traditions (Takahashi, 2016).

Conclusions

Kokoro no kea, originally used in hospice care, has now been widely used to mobilize a disaster response system that provides a wide range of mental health and psychosocial support in Japan. As social capital, encapsulated in the concept of kizuna, is a critical factor in fostering resilience (Aldrich, 2019; Aldrich & Meyer, 2015), people were constantly seeking social ties and bonding rather than solely relying on the formal kokoro no kea offered by health professionals. At the same time, the current review highlighted the complexities in building true kizuna as seen in the homogenization of individuals’ suffering through the political rhetoric of kizuna. Also, women’s creation of new kizuna by transforming their radiation fears and anxiety to a collective political voice faced pathologization and depoliticization. In response to the needs of the bereaved people who desired to create and remain spiritual kizuna with the deceased, religious practitioners took opportunistic practices to offer kokoro no kea. These independent phenomena seen after the 3.11 disaster demonstrated what was missing when we see kokoro no kea simply as a disaster mental health response system. Kokoro no kea is not simply a static Japanese post-disaster mental health and psychosocial support system that was created based on the Western concepts of trauma and PTSD; rather, it is an open, fluid, and evolving process where diverse actors with different degrees of power (e.g., politicians, men, women, health professionals, and religious practitioners) interact with socio-political forces and cultural values, creating unique pathways for individuals and communities to foster connections, build trust, and nurture resilience to cope with, heal from, and recover from psychological pain and loss. The ambiguity in the global frameworks such as the IASC guidelines and the WHO definition of health as well as the concept of kokoro no kea leaves room for constant questioning of what the practice of kokoro no kea refers to. At the same time, politicians, NGOs, health and religious practitioners as well as the media continue creating and disseminating new ideas about practices of kokoro no kea. For instance, during the recent pandemic in Japan, kokoro no kea became seen as self-care practices, including temple meditation, relaxation, and mindfulness practices such as yoga, while the Japanese Ministry of Health, Labor, and Welfare publicly supported it to cope with the increasing stress during the COVID-19 pandemic (Cavaliere, 2021).

As demonstrated in this analysis, a fluid concept and ambiguous definition of kokoro no kea continues providing room for researchers to explore how social, political, and historical factors in a particular cultural context interact to create certain forms of care and response to suffering at individual and community levels, but also for various actors to be part of disaster care and support beyond psychiatric and psychological services. By unpacking the concept of therapeutic governance within a particular socio-cultural context, we can gain critical understanding of local dynamics of power and social processes, which affects the individual and collective suffering and healing.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sakiko Yamaguchi

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The Faultline of Kokoro no Kea : Mental Distress and Post-Disaster Psychosocial Care After the Great East Japan Earthquake

Abstract

Keywords

Introduction

Research Methodology

Conceptual Framework

Results

Birth of Kokoro no Kea in the Context of Post-Disaster Support

Kizuna-Driven Recovery Politics

Silencing and Pathologizing Women’s Radiation Fear

Religious Practitioners as Emerging Actors in Kokoro no Kea

Discussion

Double-Edged Sword Effect of the Kizuna-Focused Recovery Policy: Homogenization of Suffering

Gendered and Pathologized Radiation Fear: Control Over Emerging Motherhood Activism

Definition Ambiguity Around Kokoro no Kea and Added Spirituality

Conclusions

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

References