COLUMN ONE : After Kobe, Healing the Psyche of Japan : Western counseling is helping a stoic society recover from the quake. Many hope this will open up the mental health system the way the Vietnam War did in the U.S.

In the aftermath of January’s devastating quake, Shigeo Tatsuki wondered whether Western trauma counseling would work in a society where emotions and pain tend to be repressed and psychological treatment itself is still shunned.

But when an Israeli trauma psychologist took him and others through a drawing exercise during a recent seminar on healing techniques, Tatsuki found himself in tears as he sketched his own desire for hope in a picture of a blue sky peeking through a thorny rosebush.

“When I cried, I felt the process of healing and realized how much I needed help,” said Tatsuki, a Kwansei Gakuin University sociologist who today is leading regional efforts to expand mental-health education through seminars and a cable TV program. “I was much impressed that these techniques could alleviate stress by helping us to feel.”

As experts from around the globe have flown here to share healing techniques born of their own wars, disasters and atrocities, the people of Kobe are finding that such techniques do work--even in Japan.

With small smiles and big hugs, quiet confessions and tearful release, the people are beginning to heal themselves.

Five months after the earth heaved and killed 5,500 people in the Kobe area, an American social worker, Kelly Lemmon-Kishi, brings teddy bears donated by well-wishers throughout the United States and tells entranced children at a YMCA preschool to hug their new friends whenever they are scared or sad.

At a temporary shelter, Yoshio Hirata, 93, tells psychotherapist Kazu Kobayashi that he has no pleasures left in life. But even as his brow furrows with the pain of his wife’s death from complications after the quake, he is happy for this rare chance to talk and does so, nonstop.

Hiroko Minami sponsors trauma specialists from San Francisco to lecture at her nursing school and ably uses the techniques herself: Just two weeks ago, one of her nurses came to her feeling blue and ended up pouring her story out in tears--the first time the distraught woman had had a chance to talk about herself rather than listen to others.

In one of the quake’s most striking reverberations, Kobe has launched a wave of public education and volunteer training about mental health on a scale unprecedented in Japan. Many here hope Kobe will be the catalyst for de-stigmatizing psychological care among the Japanese, much as the Vietnam War did for Americans.

“Twenty, 30 years ago in the U.S., mental illness was a secret, and going to see a psychiatrist was a family shame,” said Lemmon-Kishi, president of the Kansai International Assn. of Counselors and Psychotherapists. “But Vietnam helped Americans understand that people who had gone through a horrible war would have emotional reactions they couldn’t control. I hope Kobe will give birth to the same thing in Japan.”

It may, thanks to a widespread focus on what people here are calling kokoro no kea --mental care--and post-traumatic stress disorder. The phenomenon was first identified among Vietnam veterans reliving the war through nightmares, flashbacks, insomnia and irritability.

Post-Traumatic Stress

The disorder has since become universally accepted as a normal reaction to major traumatic events, such as wars or natural disasters, said Bob Baker, clinical coordinator for the Veteran Administration’s National Center for Post Traumatic Stress Disorder in Menlo Park. Treatment methods aim primarily at helping people express suppressed emotions and teaching them how to stop disturbing thoughts, control nightmares and manage sleep.

Nowadays in Kobe, those once-alien concepts are on their way to becoming more widely recognized. For instance, the Asahi Shimbun, a leading newspaper, has published 17 stories on “mental problems” and 109 on counseling this year, compared to 10 years ago when it ran no stories on mental problems and three on counseling.

While some media coverage has portrayed the symptoms as a fearful new disease equivalent to cancer or AIDS, most has not: The influential state-run NHK-TV network recently broadcast a lengthy special on mental care that introduced post-traumatic stress disorder and other concepts to a national audience.

The Japanese government has decided to open a research center on the disorder in Kobe and 12 regional clinics to offer counseling services. The Hyogo prefectural government has also decided to place counselors in all public schools--another landmark move.

In recent years, counseling has become a bit more acceptable. Japan’s urbanization has weakened family and community ties that used to sustain people in times of emotional need, and big cities give people cover to seek help in anonymity, experts say.

Kobayashi, for example, says her practice has increased from three patients a day when she started 16 years ago to 10 to 20 today. Overall, there were 9,873 psychiatrists in 1992, up from 5,102 in 1972.

But seeking professional counseling is still largely shunned as shameful proof of abnormality. Those without friends or family in whom to confide may drink. Others, Minami said, express their frustrations through anger--resulting in bullying, domestic violence and child abuse she suspects are far higher than commonly reported.

As a result of such taboos, Kobe’s intense focus on mental health as a normal and legitimate concern could represent a watershed for Japan.

“These are new things for Japan,” said Naotaka Shinfuku, who heads Kobe University’s International Center for Medical Research and the newly formed Mental Health Support Network. “In the past, disaster victims were given physical checkups, but not much attention was paid to the needs of their psychological care. The [Kobe] earthquake has broken some of the stigma attached to this.”

Kobe’s physical recovery is humming along, with nearly all train lines restored, half the town’s 74,000 damaged buildings demolished and all temporary housing expected to be completed by July for the remaining 25,000 evacuees. But the emotional trauma, experts say, still lingers.

It is debatable, for instance, how much people will actually use all of the new services planned. Most here agree that Kobe survivors, especially the elderly, may not take the trouble to visit counseling clinics outside their neighborhoods.

Instead, activists have proposed an array of alternatives to bring the care to the people: neighborhood drop-in centers similar to those set up for Vietnam veterans, consultation corners in housing shelters and activities that lend themselves to relaxed exchanges.

Volunteer Yoshiko Sato approaches quake evacuees as she distributes a local newsletter. Kobayashi, the psychotherapist, coaxes conversation from elderly shelter residents by making friends first at karaoke events. Psychologist Kyoko Nakatani uses massage to relax her patients; nursing educator Minami tries to draw people out while giving medical checkups.

These specialists and others say that Japanese are just as eager to talk about their experiences as anyone else, provided the approach is tactful and care is taken to build trust over repeated visits.

“We know Japanese are much more withheld than Western people, and certainly men won’t show their emotions easily,” said Reuven Gal, a renowned Israeli trauma expert who shared healing techniques with mental-health experts at Tatsuki’s seminar. “But the inner emotions--the pain, fear, anxiety--I believe are universal among people of any culture who go through severe trauma.”

Gal, chief psychologist for the Israeli Defense Forces, has worked with war victims in his own nation, Northern Ireland and the former Yugoslav federation. His recent seminar here on such indirect counseling methods as drawing and storytelling was so successful that he had the experts--quake survivors themselves--sobbing on his chest.

Shiho Takubo was one of them. The psychiatric nurse found herself releasing pain stemming not only from the quake but from the death of her mother seven years earlier. “I thought I forgot about that, but suddenly in the workshop it came up and I burst into tears,” Takubo said.

Baker and Lemmon-Kishi use allegory--a tale about a teddy bear who helped San Francisco recover from a quake--to give Kobe children a sense of control over events and a bright outlook.

Baker and his wife, Barbara, organized a campaign that collected more than 10,000 teddy bears from Americans throughout the United States. For Baker, a former combat Marine, tending to the children of Kobe helped him close a circle begun more than two decades ago when the Vietnamese war orphans his unit adopted in Hue were massacred by Northern troops.

“There’s a part of us that has experienced the immersion in death, and we know there is help because we’ve been through it,” Baker said. “We want to share that.”

Demystifying Care

By demystifying mental care, specialists here say they hope the quake counseling will result in expanded services for others in emotional need.

Currently, experts say, much of Japan’s mental-health care is confined to severe disorders such as schizophrenia. Although some counseling is used, many treatments consist of little more than psychiatrists dispensing medicine in sessions said to average 10 minutes.

For those needing help with temporary crises, such as divorce or the death of a family member, there is not an effective network of services--or even a system to license psychologists, therapists or social workers as is done with psychiatrists. Although officials are trying to craft a licensing system for such specialists, efforts are bogged down in debate over whether to place them under the supervision of doctors, said Minami, president of the Hyogo prefecture College of Nursing Art and Science.

As a result, the image of psychotherapists remains clouded, and their services are not covered by national insurance.

But the biggest barriers to widespread use may still be psychological and cultural. In a society that values conformity, people don’t want to single themselves out as different, experts say. An admission of distress also destroys “face,” or outward appearance, which is valued in Japan, Minami said.

Some Japanese balk at seeking help because doing so puts them in debt to others--lowering their status and requiring a future reciprocal favor, said Kobayashi, the psychotherapist. In addition, a sense of humility--one that discourages people from troubling others with their own problems--inhibits emotional release, she said.

In the quake’s aftermath, Kobayashi said, some people trying to vent their feelings were told to “do your best without complaining--there are people worse off than you.” Minami recalled one nurse telling a grieving patient who had lost a leg: “It’s just one leg. Be thankful you have your life.”

And many Japanese pride themselves on tacit communication, the ability to discern each other’s feelings without having to articulate them. Raw displays of emotion can cause discomfort. These values lead some mental-health specialists to argue that counseling is not appropriate for a people raised to endure calamity in stoic silence.

Minami recalled one meeting in which a U.S. mental-health expert was explaining trauma care to Japanese psychiatrists. One man, who had lost his father in the quake, vehemently objected.

“He said we shouldn’t encourage people to talk, because the wound had almost healed and talking about it would pull the scab off and start the bleeding again,” Minami said.

The Kobe quake wrought psychological damage on a scale not seen since World War II, posing both formidable challenges and rare opportunities. And here and there, little by little, the people of Kobe are meeting them.

A restaurant owner shocks his Japanese friends by pouring out his story in tears to Baker, a stranger.

“There is something magical about disasters in how they open people to opportunities to grow,” Baker said.

Chiaki Kitada of The Times’ Tokyo Bureau contributed to this report.