The Tōhoku Theater Project in Postdisaster Japan: An Exemplar for Addressing Community Mental Health in the Context of Disaster

Following a tradition of engaging theater to address critical social issues (5), the Tōhoku Theater Project was developed in partnership with the United States–based social impact theater company, Theater of War Productions (https://theaterofwar.com/about). Based on the methodology of Theater of War Productions, the Tōhoku Theater Project presented four community-specific, theater-based performances to address the mental health needs in postdisaster Japan. The performances focused on destigmatizing mental illness, increasing awareness of psychological needs, strengthening coping behaviors, enhancing emotional well-being, and fostering community resilience. Japanese theater companies and community groups, and TELL Japan—a Tokyo-based, nonprofit mental health organization serving Japan’s international community—were engaged in adapting each performance. The collaborative coproduction of the four performances with Japanese theater and mental health professionals ensured cultural appropriateness and relevance. Adaptations included moderating the intensity of the performances; adapting themes to focus on family, loss, and coping in uncertain times; attending to language nuance and translation; and limiting the number of participants to increase comfort and encourage audience engagement.

Four performances comprising four components were conducted: a dramatic reading of plays or other literary texts; a response panel of community members, who connected their experiences to the performance; a facilitated discussion led by a trained local facilitator; and dedicated time to share national and regional mental health resources. Themes varied based on the priorities of each community and covered grief, loss, misunderstanding, displacement, and the impact of the disaster on relationships. After each performance, participants received information about national and regional mental health resources, empowering them to take steps to seek additional support as needed.

The first performance was presented in English by American and Japanese actors to expatriate and Japanese individuals living in Tokyo. Although the epicenter of the disaster was Tōhoku, the repercussions were dramatic throughout the country. The Tokyo expatriate community had shared experience with relocated Tōhoku survivors in Tokyo, because both groups were far from home and disconnected from support systems. A theatrical rendition of the biblical story from the Book of Job was selected for the first performance. The story of Job is one of a righteous and prosperous man who loses everything in the span of a single day. The approximately 60 participants included community members from the Tōhoku and Iwate regions, local Japanese and expatriate residents, community group leaders, members of local councils, and public officials involved in the recovery process. The themes for facilitated discussion centered on severe material loss and life changes resulting from the Tōhoku disaster.

The remaining three performances were presented in Japanese by Japanese actors. Two performances were conducted in Tokyo with women of the displaced Tōhoku community. Because of physical devastation and the unknown risks associated with potential continuing radiation exposure, many Tōhoku families relocated to Tokyo, either by mandate or voluntarily. In situations where families were not mandated to leave but where significant devastation existed, many women and children relocated to Tokyo while their husbands remained in Tōhoku to work. Approximately 30 women attended each of these two performances. The second performance featured the Japanese Noh play Sumidagawa, which tells the story of a ferryman who meets a “mad” woman and learns that she is grieving for her son, who was sold into slavery and passed away years ago. The discussion themes centered on grief, loss of one’s home and local culture, and resilience found in the wake of that loss. The third performance utilized Michael Weller’s Fifty Words, a contemporary American play about a couple whose marriage is severely stressed, teetering on the verge of either breaking up or deepening bonds. The discussion themes centered on the strains the Tōhoku disaster placed on relationships, couples, and families.

The final performance was conducted in Tōhoku and designed for nurses in Fukushima City. The 23 nurses who attended were not only caregivers to those affected by the disaster but also community members of the affected Tōhoku region. Dramatic readings of eight poems written by North American and European nurses were performed to capture important themes related to the challenges of being a nurse and caretaker, including caretaker fatigue, lack of resources for providing community support, and the need for self-care.

In each of the four performances, qualitative feedback was collected during the discussion sessions. Participants also consented to complete short pre- and postperformance surveys about their psychological and emotional experiences vis-à-vis the Tōhoku disaster and their postdisaster journey, perception of community coping, relevance of the performance, views on seeking mental health care, and perceived barriers to accessing such care. Responses were translated into English by trained experts, and notes were analyzed for key themes in the English transcripts.

During the guided discussions, all four performances received positive feedback from participants about the culturally relevant nature of the presentations. Participants expressed that they understood their own emotional experience more fully and felt increased empathy for disaster victims, greater desire to support others, and greater understanding of the variation in experiences. One common theme was expansion of participants’ understanding of how to cope with difficult situations in relation to the Japanese cultural norm of distress as a sign of weakness. In written qualitative responses, participants stated that they learned a lot by seeing the disaster through different perspectives presented in the performance and discussions.

After the Book of Job performance, participants completed a survey question that asked them to “describe something in the performance that changed their ideas about coping after a disaster.” Japanese participants, in particular, reported that they realized that not expressing oneself after a disaster and simply saying, “Let’s look forward,” was not sufficient to help people recover. Although Japanese respondents described that they do not typically express their emotions in open dialogue, they recognized, via the performance, that expressing emotions can facilitate healing. One Japanese respondent stated, “Japanese are not used to expressing feelings openly, but I learned the importance of doing that.” Some participants noted how unfamiliar it might be for Japanese individuals to voice their emotions in a group and, even more difficult, among individuals who might be suffering more in comparison. Participants also reported the importance of sharing information about support services and encouraging those suffering to seek help. Several reported a need for more mental health programs to support affected individuals from Tōhoku.

Several key themes emerged from the two performances designed for Tōhoku women living in Tokyo. One common theme that emerged in the discussion was the misunderstanding of grief. A number of attendees described a “gap” between different groups postdisaster, alluding to misunderstanding of how grief, loss, and distress affect individuals differently. Pre- and postsurveys identified differences in intensity of reactions to the Tōhoku disaster, which participants attributed to either “personality” or access to resources, including economic factors and social supports. Displaced women also described the impact of the disaster on personal relationships. One attendee reported, “I’m worried that my partner, my family [relatives], and I have different points of view toward the Fukushima nuclear power plant. They go parallel and never meet each other,” indicating that the disaster affected her relationship with family members “a great amount.” She also wrote that the performance challenged her ideas about postdisaster relationship problems: “Although there are some difficulties, depending on how I see myself and interact with my partner, it may be possible to improve our relationship. The play made me think in this way.”

Participants also endorsed in their survey responses that they thought seeking mental health care would benefit those affected by the disaster; however, many affected people actually viewed seeking professional mental health care as unacceptable. This perceived divide between the need for mental health care and discomfort with seeking mental health services also existed in participants’ lived experiences, because only a few of those surveyed reported seeking any help, professional or otherwise. In response to the survey question about whether the performance “challenged or changed” their ideas about coping with disaster, several participants reported that the performance helped them realize that “talking out” their concerns with others could provide relief. In addition, the women discussed significant stresses and concerns related to the reluctance of their husbands to discuss these issues and seek mental health support.

The 23 nurses who attended the fourth performance in Tōhoku described feeling emotionally affected by the poems and found the discussion helpful; the performance created a healing space that enabled them to express their feelings more openly, share their experiences with others playing the same caretaking role, and reframe their perspective. The nurses reported increased recognition of the importance of self-care. One nurse stated, “In my everyday work, there is no room for myself, but I realized that it’s okay to ask for help and also found that being able to ask for help is another important skill, too.”

Despite the impact of the disaster on well-being, many nurses emphasized the necessity of, and their commitment to, providing ongoing care. Nearly all of the nurses highlighted obstacles to health care delivery in the wake of the disaster, including the lack of community health providers, insufficient basic health care infrastructure, difficulty contacting displaced family members, and ongoing confusion and anxiety about the effects of radiation and prolonged displacement. These concerns are consistent with other findings on the aftermath of the Tōhoku disaster (1, 2). The situation was further complicated because some individuals reported elevated levels of distrust in the disaster aftermath in the owners of the Fukushima Daiichi Nuclear Power Plant and Tokyo Electric Power Company as well as the Japanese government (6).

Survey responses from the nurses indicated that 20 of the 23 nurses reported feeling at least “a little” affected by the Tōhoku disaster, both professionally and personally, and 10 reported being affected “quite a lot” or “a great amount.” Many nurses described changes in their professional duties to provide emergency care and basic necessities for the community and respond to anxieties brought on by radiation exposure. One nurse reported, “[There was] more work related to the radiation; therefore, our regular work became less and less.” Examples of personal impacts included separation from family, adverse effects on family health, and feeling as if there was “no lifeline” for support. One respondent also reported feeling “worried about the future and being a target of discrimination” because of others’ fears of being “contaminated” by people from Tōhoku. The nurses also reported psychological distress associated with secondary trauma and described associated burnout and compassion fatigue (7).

Overall engagement across all four sessions was high. The first session was conducted in English with an international, multilingual audience that was familiar with community programs of this kind, and a wide range of individuals voluntarily engaged in the large group discussion. The subsequent groups were smaller and conducted in Japanese. On the basis of community input, the decision was made to limit the program to a smaller number of participants in order to increase engagement. These sessions required skillful facilitation to initiate discussion themes, given the novel nature of the experience for most of the Tōhoku participants. Once begun, the dialogues of these three groups flowed and evolved to cover a range of significant and meaningful themes.

The Tōhoku Theater Project created a safe environment for active engagement in open and honest discussion about the difficult issues facing Japanese communities in the wake of the March 11, 2011, natural and nuclear disasters in Tōhoku. The performances promoted healing dialogue, healthy coping, and resilience; engendered empathy and understanding of mental health needs among community members; destigmatized help seeking for mental health concerns; and assisted people to make connections to local, regional, and national mental health resources.

Although each performance differed in its target audience, several common themes regarding mental health and mental health care in Japan were addressed across all groups, including reluctance to burden others with psychological distress, experiences of grief, and lack of coordinated care programs to address psychological distress in the wake of the disaster. Importantly, people were not always aware of where to seek help and what to discuss. Participants expressed that they valued the safe space for open discussion of priority themes. Although not typically viewed within Japanese culture as a primary means of relieving psychological distress, “talking out” one’s concerns was seen by multiple respondents as a new way of providing relief and an essential step in facilitating the healing process, building individual and community resilience, destigmatizing seeking of mental health care, and potentially connecting those who need it to mental health services.

Themes that emerged are consistent with key recommendations from public health studies about the impact of the Great East Earthquake, including to expand the local health care workforce, identify barriers to seeking mental health care postdisaster, reduce stigma around seeking mental health care, develop comprehensive and publicly available health care resources, and address the gender differential in help seeking favoring female involvement (8, 9). As a community-based program, the Tōhoku Theater Project did not provide specialized mental health services; however, information regarding the limited resources available was shared with participants at the end of each performance. The success of the project highlights the ability of art—and particularly theater performance and open discussion—to promote psychological healing and well-being and suggests the potential for this approach to be expanded by using additional local community-based theater programs in response to disasters. The experience of the Tōhoku Theater Project has the potential to inform strategies that engage the arts as people navigate other global public health crises, including the current COVID-19 pandemic.