key: cord-0851077-8m3kdpbp
authors: Shibusawa, Tazuko; Ishii, Chikako; Nakamura, Shinichi; Tamura, Takeshi; Watanabe, Toshiyuki
title: The COVID‐19 Pandemic and Families in Japan
date: 2021-03-10
journal: Aust N Z J Fam Ther
DOI: 10.1002/anzf.1438
sha: a895196127952e1bfa91f197d4a357ad7645db0d
doc_id: 851077
cord_uid: 8m3kdpbp

This paper, which is authored by members of the Japanese Association of Family Therapy (JAFT), describes the COVID‐19 pandemic in Japan from a family systems perspective. The authors are active members of JAFT and include current and past presidents and officers. We describe the course of the pandemic and the ways in which government policies to mitigate the pandemic have affected Japanese families. Challenges that affect Japanese families include the inability to participate in family and social rituals, prescribed gender roles that specifically affect women, high suicide rates, and prejudice against those who are at risk of spreading the infection. The need to shelter in place has also forced family homes to function as a workplace for parents, classrooms for children, and day care services for frail elders, which has resulted in psychological distress among individuals and conflicts among families. We discuss ways that therapists have worked with Japanese families using online therapy.

The first outbreak of COVID-19 was reported in Japan in January 2020. By mid-December 2020, close to 180,000 people had tested positive for the virus (Ministry of Health, Labour, & Welfare, 2020a) . Compared to other nations, rates of COVID-19 infections have been relatively low in Japan. For example, while 7,237 people per 100,000 contracted the COVID-19 virus in the United States in mid-January 2021, the number for Japan was 257 people per 100,000 (Johns Hopkins University, 2021) . Nevertheless, many families in Japan have been affected by the pandemic. Government policies to mitigate the spread of infection has resulted in increased rates of unemployment, changes in work and family life, school closures, social isolation, and forced separation among family members. This article is authored by the members of the Japanese Association of Family Therapy (JAFT). We first present a brief background of the COVID-19 pandemic in Japan and the effects of the pandemic from a family systems perspective. We then discuss ways in which clinicians have been providing interventions for families affected by the pandemic.

The initial COVID-19 outbreak occurred in January 2020 when the virus was transmitted by Japanese and international visitors who entered the country from Wuhan, China. The government was able to contain the spread of infection at the time, but a second outbreak occurred in March 2020 as a result of people entering the country from Europe and the United States (Nikkei Medical, 2020) . As a precaution, all educational institutions from elementary schools to universities were closed for two months starting in February 2020. At the end of March, the International Olympic Committee and the Japanese government decided to postpone the 2020 Summer Olympics and Paralympics. In April 2020, a state of emergency was declared by the government and people were asked to refrain from leaving home and to shelter at home. Employees were encouraged to work from home, and most public venues such as museums and sporting arenas were closed (Cabinet Secretariat Office, 2020a) . In efforts to mitigate the pandemic, the government defined high-risk environments as places with overlapping 'three Cs': 1) closed spaces with poor ventilation; (2) crowded places; and 3) close contact settings.

The new environment created by the COVID-19 pandemic has been stressful for Japanese families. Many families have been forced to alter their daily lifestyle because of the shutdown of schools, daycare facilities, and workplaces. Homes have had to function as offices for teleworking parents, as well as childcare centres and classrooms for children who were not able to go to school. Families with frail elders were required to provide 24-hour care in their homes when geriatric daycare services were suspended temporarily. Japanese residences in urban areas tend to be limited in space. An average three-bedroom apartment for Japanese families is around 70 square meters (753 square feet) and living quarters that are limited in space can lead to stress among family members (Kim & Zulueta, 2020) . Furthermore, many Japanese families have struggled with the growing financial burden of the pandemic. According to one study, more than 85% of families either have experienced or were expecting income cuts, and 47% of workers feared losing their livelihoods. Contract workers, the self-employed, and students have faced the greatest challenges (Kim & Zuleta, 2020) .

The pandemic has had an especially profound effect on marginalised populations and those who were vulnerable before the pandemic. As Slater (2020) notes, many non-governmental organisations that operated soup kitchens, daycare centres, and other support services were forced to close or scale back their services due to the COVID-19 and Japanese Families ª 2021 Australian Association of Family Therapy pandemic. While a cadre of volunteers are often available following natural disasters in Japan, volunteers were not available because of the infectious nature of the virus.

Currently, there are close to 2.8 million foreigners in Japan, making up 2.24% of the population (Ministry of Justice, 2020). Most are permanent residents; the next largest cohort are workers who enter Japan as technical intern trainees and students. Many foreign workers on work and trainee visas were left without a job when their worksites closed down. The technical intern trainees mostly come from China, Vietnam, Indonesia, the Philippines, and Myammar, and are brought to Japan to cover the perennial labour shortage (Ministry of Justice, 2020). Many technical trainees lost their jobs due to , and yet were unable to return to their home country due to travel restrictions. Although the government has instituted financial and health support, most companies have not provided support for their employees, and many have struggled with financial hardships (Tran, 2020) .

Women as a whole have also faced special challenges in the face of the pandemic. Compared to Western nations, gender roles tend to be more clearly divided in Japanese families with the woman in charge of the household. Mothers continue to shoulder the burden by doing 80% of the housework (Miura, 2020) . During the pandemic women have had to juggle childcare, their own work, and housework in addition to taking care of husbands who work from home.

Stay-at-home measures have resulted in an increase in domestic violence both globally and in Japan (Suga, 2020) . The United Nations has referred to domestic violence in the era of COVID-19 as a 'shadow pandemic' (Mlambo-Nguka, 2020) . In Japan, as the pandemic unfolded, there was an increase in the number of consultations for domestic violence. In Spring 2020, the All Japan Women's Shelter Network, an umbrella organisation of domestic violence services, urged the government to increase support for victims of domestic violence (Suga, 2020) . In response, in April 2020, the Japanese government set up a 24-hour domestic violence hotline in 10 different languages (Cabinet Secretariat & Gender Equality Bureau Cabinet Office, 2020a).

Rituals foster connections among family members (Imber-Black & Roberts, 1998) . In Japan, family life centres around rituals that celebrate life-cycle transitions. When a child is born, families celebrate on the seventh day following the birth to commemorate the naming of the child and go to the shrine on 30 th day to pray for the health and longevity of the child. Families also take children ages three, five, and seven to Shinto shrines to pray for their well-being. Other rituals related to life-cycle transitions include 'coming of age day' for youth when they turn 20 years of age. For older adults, the 60 th , 70 th , 77 th , 80 th , 88 th , 90 th , and 99 th birthdays are celebrated by families as important milestones. Rituals around life-cycle transitions often include visits to a photo studio to take family photos, renting or purchasing kimono (traditional costumes) for the occasion, and family meals at a restaurant. Rituals mark the transition of life stages, as well as social and family roles, and affirm family cohesiveness.

An important part of family rituals centres around deceased ancestors. Buddhist rituals support continuing bonds and active interactions with the deceased, which in turn maintain family structure and intergenerational cohesion (Klass, 2001) . Twice a year, at New Year's and in August, family members are expected to travel to their family homes. Ancestral spirits are considered to return to the family in August during a period called 'obon,' and families gather for ceremonies at temples and visit the family cemetery. Such rituals and family gatherings nurture a sense of family history and tradition among the younger generation and strengthen multigenerational connections. Since the outbreak of the pandemic, however, Japanese families have not been able to travel or gather for family rituals. This has become a disappointment for the older generation (grandparents and great grandparents) who are not able to see the younger generation, many of whom live at a considerable distance. Elders are left with anxiety about the weakening of multigenerational connections.

Other rituals commemorating life-cycle transitions include school entrance and commencement ceremonies. Many students have been affected by the cancelation of school-related ceremonies. In other cases, the ceremonies have been scaled down and many students have been disappointed that their graduation ceremonies were restricted to only students in their grades. None of the other students or parents were able to attend to celebrate. Restrictions in school activities have resulted in fewer opportunities for students in all grades, from kindergarten to universities to form bonds with their classmates and under and upper classmates.

Workplace rituals have also been eliminated. Ceremonies welcoming new workers have been cancelled as have end-of-year parties for employees to get together. More importantly, companies are no longer able to hold retirement parties to mark the transition of the closure of a person's career and to express gratitude for their service, all of which diminish group morale.

In July 2020, a woman called one of the authors (Watanabe), a psychiatrist who works at a psychiatric outpatient clinic. The woman asked for an appointment for her fianc e who could only come in after clinic hours. The author met with the 30-yearold man who worked in the sales department of a kitchen equipment company. He was often reprimanded by his supervisor because his sales were going down. He was diagnosed with depression and was advised to take time off of work. The man responded by saying that he could not take time off because he would get fired. He asked for prescriptions to help him with his insomnia and thanked the physician for his help, stating that just talking was helpful. He told the author that he would be okay and smiled and left with his fianc ee. However, four days later, after being reprimanded by his boss, he committed suicide. From a biopsychosocial systems perspective, we can see how the economic downturn has affected the business system and in turn affected individuals.

As with the situation with Mr. A, a major consequence of the pandemic in Japan has been the sudden increase in the number of suicides. Japan has historically had one of the highest suicide rates in the world. For example, in 2016, the suicide mortality rate was 18.5 per 100,000 compared to the global average 10.6 per 100,000. The high rate has been attributed to long work hours, academic pressure, social alienation, and stigma towards seeking mental health services. In 2003, when the number of suicides increased in Japan because of the economic downturn, the government and medical organisations implemented various suicide prevention campaigns. As a COVID-19 and Japanese Families ª 2021 Australian Association of Family Therapy result, suicide rates have been decreasing since then, and the lowest number of suicides was recorded in 2019. However, the number of suicides has been on the rise since the pandemic. For each month since July 2020, suicide rates have exceeded those of the corresponding months in the previous year. In October 2020, the number of suicides was 2,158, which was larger than the total number of deaths from COVID-19 for the entire year up to then (Ministry of Health, Labour, & Welfare, 2020b). The increase in suicides in Japan, especially among women, has been noted in the international media (CNN, 2020).

Women have historically had lower rates of suicide compared to men. However, in October 2020, the number of suicides among women increased by 83% compared to the same month of the previous year while male suicide rates increased by 22% over the same period. One reason for the increase in suicide rates among women since the pandemic is the economic downturn. The pandemic has devasted workplaces that employ large numbers of women, including the service sector, retail, and travel industries. Many women work part-time and do not have the security of fulltime employment. In August 2020, 1.2 million part-time workers lost their jobs, and of this group, 840,000 were women. Women also experience increased responsibility and anxiety about the health and well-being of their children and elder family members. As noted previously, women also bear the heaviest responsibility for the functioning of the household (Cabinet Secretariat & Gender Equality Bureau Cabinet Office, 2020b).

As mentioned previously, schools were closed for two months following the first wave of the pandemic, which affected children and their parents. Not going to school was stressful for children as they were not able to socialise with their peers. According to a survey conducted by the National Centre for Child and Health Development, among 10,676 elementary, junior, and senior high school students and their guardians, 73% of students exhibited signs of stress due to the pandemic during the months of September and October 2020. Thirty percent reported not wanting to attend school (National Centre for Child & Health Development, 2020) . There also appears to be a correlation between the anxiety of children and their parents. For example, the authors are aware that psychiatric clinics report cases of mothers with germaphobia who stop allowing their children to attend school because of fear of infection. Children with special needs have also been affected by the pandemic. One of the authors (Watanabe) worked with a boy who had been stable and doing well at school. The boy developed difficulty adjusting to being at home every day and started to have temper tantrums and episodes of verbal abuse towards his parents. As a result, his parents increased the amount of medication for ADHD.

The COVID-19 pandemic has increased anxiety among people who already struggle with anxiety disorders such as germaphobia and obsessive-compulsive disorders (Asmundson et al., 2020) . History of treatment for psychological treatments is the most significant risk factor for exacerbations of psychological distress (Yamamoto et al., 2020; Zhao et al., 2020) . Studies indicate that loneliness, long periods spent at home, poor health status, deterioration of relationships with family, high-level concerns about COVID-19including sleeplessness, deterioration of household and work conditions, and academic difficulties --are associated with psychological distress (Yamamoto et al., 2020; Zhao et al., 2020) .

Another factor that has affected stress levels and mental health among Japanese is prejudice and discrimination towards COVID-19. We have observed that patients at psychiatric clinics also report that they don't want to be the first patient with COVID in their communities or their workplaces. For example, in May 2020, a high school student who attended school near one of the author's clinics found out that he had COVID and dropped out of school because of fear of being stigmatised.

A population that is extremely vulnerable to psychological distress is healthcare workers on the frontline. Shortages of medical personnel have resulted in long work hours. In addition to witnessing patients die alone without loved ones, inadequate supplies of PPE and fearing risk of infection have resulted in depression, anxiety, and post-traumatic stress disorders. Social stigma has also affected healthcare workers in Japan. Healthcare workers have been denied rides in taxis. Some have not been able to place their children in childcare centres because the facilities fear infection (Makino & Takebayashi, 2020) .

Japan has traditionally had a sense of group cohesiveness or group consciousness that distinguishes between insiders and outsiders. Known as the village society mentality (mura shakai ishiki), this has propelled discrimination against those who have COVID or who are suspected of spreading COVID infections. Cars with licence plates from Tokyo or Kanagawa prefecture, which have had the highest incidence of the virus, have been vandalised when parked in areas in the countryside. Small rural villages have also resented people from urban areas visiting their families in the villages for fear that they will transmit the infection. In addition to group stress, we have seen how people's anxiety and unhappiness have transferred to scapegoat those with the virus. The government has implemented a working group to focus on ways to decrease COVID-related prejudice and discrimination (Cabinet Secretariat, 2020b).

Ambiguous loss and family resilience. One of the authors (Ishii) has been conducting systemic family therapy with families who have issues with loss and grief. This section will describe working with families facing the pandemic from the perspective of ambiguous loss and resilience.

The introduction of the theory of ambiguous loss and interventions in clinical practice in Japan goes back to 2011, following the Great East Japan earthquake. Japan is used to natural disasters, especially earthquakes. However, the losses experienced in the 2011 earthquake differed from the previous devastating earthquake, the Hanshin Awaji earthquake, which occurred in January 1995. Both involved earthquake disasters occurring along the coast, but the 1995 disaster hit in a concentrated urban area after which people experienced grief about the death of loved ones. In the 2011 earthquake, families lost members because of the tsunami and they did not know their whereabouts for a period of time. Furthermore, many were forced to move out of their homes and villages because of radioactive contamination. As noted earlier, traditional Japanese culture supports people experiencing death in the family through rituals that are performed among relatives and the community. However, COVID-19 and Japanese Families ª 2021 Australian Association of Family Therapy losses faced by the tsunami and danger of radioactive contamination were very different. Resolutions to the problems were nowhere in sight, and people were not able to envision a futureit was as if people were lost in a fog. Because the characteristics of this loss fit Dr Pauline Boss's concept of ambiguous loss (2006), four members of the Japan Disaster Grief Support Project went to study with Dr Boss in March 2012 to receive training on ambiguous loss and interventions based on the concept. The interventions are based on systems theory and support families to stabilise and 'live well' with resilience in the midst of losses to which people cannot predict an end (Boss & Ishii, 2015) .

We had been working in collaboration with the JAFT to introduce and widen the concept of ambiguous loss and accompanying interventions in Japan. Ten months after the publication of family therapy approaches to disasters from the perspective of ambiguous loss, the COVID-19 pandemic hit Japan (Kurokawa et al., 2019) . We decided to apply concepts and interventions based on ambiguous loss in working with families that face challenges in their daily lives and losses in relationships due to the pandemic. In the following we provide discussions of clinical practice with such families who have been affected by the pandemic.

Case study: Parent-child issues. A mother sought assistance for herself and her 10-year-old son who had increasing conflicts at home due to sheltering in place. The mother and son were seen in online therapy sessions. It appeared that there was an 'ambiguous loss' in the psychological connection between the parents and their son. The conflicts were hypothesised as the family members' expression of their pains over this loss. The goal of the therapy was to increase resilience in the family and to help them become stable and 'live well.' The therapist and family drew a genogram of the family before and after onset of the pandemic, and drew lines representing family relationships to explore changes that had occurred. It became evident that the son had lost opportunities to socialise and communicate with other children, and to play outside to engage in athletic activities. The son had been doing his homework on his own, but the mother started to pay more attention to his studies, which the son found overbearing. The father had become extremely busy with work because of the pandemic, and the son lost the connection of spending time with his father on the weekends. The son also had a babysitter who had helped with his care since he was two years old, but his interactions with the helper were no longer experienced as relaxing. The son had lost a sense of satisfaction with his life. The mother used to be very involved with her professional career and there was a sense that she had lost the sense of well-being that she derived from her work and workplace. She was no longer able to socialise with her co-workers and have her own time in a non-mothering role. Having more time with her son and observing his study habits also made her more anxious.

Both the son and the mother were reacting to a situation in which there was also no ability to predict how long these circumstances would last, and each expressed their reaction to the losses. The therapist supported each family member by empathising and validating 'the family's pain' (Shimosaka, 1994) , and supported ways that each could listen to each other in an online environment. At times the therapist asked the mother and child to sit together in front of the screen to observe the interactions between them; at other times, she asked them to sit separately at separate screens, when the therapist found it important to provide a safe and trusting environment for the son with his headset on in front of his own screen. The therapist also reframed how they responded to developmental tasks of transitions in the family life cycle and invited them to discuss their resilience as a family. When incidents between the mother and the boy were reported, the therapist empathised with the ambivalent feelings they were experiencing. Then she asked if they noticed small changes in communication patterns which enabled the family to calmly 'live well.' For example, when the therapist recognised some signs of change, she asked them to compare their interactions in recent arguments. Then the boy reported that the mother responded a little differently, especially in the tone of her voice. In turn, they reported that the son made funny faces instead of crying.

Small verbal and non-verbal interactions can cause families under stress as a result of the pandemic to perceive the gaps and differences as larger than they actually are. However, their reactions to one another can be recognised as signs of changes in the parent-child relationships. We can understand these as important steps for families to 'live well' in the midst of the crisis caused by the pandemic. Talking about this with the family enables them to recognise and embrace their resilience.

Case study: Primary caregiver of a parent with dementia. A woman in her late 40s was providing care for her mother, who was in her late 70s. The daughter sought therapy because of communication problems and relational conflicts with her siblings around sharing caregiving responsibilities for their mother, who had dementia. The client was seen in online therapy sessions. The client lived with her husband and daughter, and her mother lived next door. The mother had developed dementia two years earlier. The siblings lived far away, some overseas, and the mother used to visit them and stay with them every few months before the onset of the pandemic. The daughter used to visit her mother daily and did not experience caring for her mother as a burden because the mother had the help of home health aides and helpers. However, after the onset of the pandemic, the client no longer felt safe having home health aides and other helpers provide in-home support. It was also impossible for her to depend on her siblings to take turns caring for her mother, so the client ended up becoming the sole caregiver.

During this time, the mother's symptoms of dementia worsened, and problems surfaced between the client and her siblings. The client was facing loss with the realisation that the siblings could no longer function as a caregiving unit. Not being able to predict how COVID-19 would progress, she did not feel that she could rely on her extended family or community services for support. In therapy sessions, we discussed if there were ways to approach the new reality, and to communicate with those around her. The client realised that she had taken on so much responsibility so as not to burden her husband or daughter and could not make time for herself for something as simple as taking a walk. The client started to make plans for how to ask her husband and daughter for help. She had never been able to discuss the financial burdens that she had incurred in taking care of her mother with her siblings, but through therapy she was able to think about how to communicate with her siblings about this. The client reported feeling lighter, though the situation around her did not revert to the way it was.

These two cases illustrate the understanding of challenges families face as a result of the pandemic through the lens of the theory of ambiguous loss, and ways to explore family resilience and support long term. Therapists also face exhaustion in the midst of the pandemic. At times, therapists have experiences similar to those of their clients, such as feeling as if they are living surrounded by thick fog, and it is important for therapists to care for themselves as well.

The pandemic has forced separation of family members because of travel restrictions. The separation makes it difficult for family members to understand each other's situation, which can provoke anxiety. As discussed previously, families who live in different geographical areas in Japan have not been able to get together during vacations or to partake in family rituals. Travel restrictions have also posed challenges for Japanese who live abroad. Currently, there are over 1.4 million Japanese nationals who live outside of Japan (Ministry of Foreign Affairs, 2020). Travel to and from Japan was halted between the end of March 2020 and the beginning of September 2020. Many Japanese have not been able to return to Japan because of the pandemic, and this has created anxiety because they are not able to see their families. Some are not able to return to Japan for medical and psychiatric treatment. For those who need therapy, the availability of online therapy with therapists in Japan has been helpful.

For example, one woman in her 40s who lives in Europe sought therapy from one of the authors (Tamura) in Japan. The woman had been experiencing palpitations and anxiety since the summer. She received SSRI and sleeping pills from a family physician in her community but sought therapy in Japanese. The precipitating cause of her anxiety was her inability to return to Japan because of COVID. The client had been living outside of Japan for the past 10 years but had been able to return to Japan twice a year for month-long visits. The client was able to maintain her psychological balance by returning to Japan and staying with her parents and other family members. The client had developed panic disorder and depression after she lost a friend nine years ago, but she had been able to recover by returning to Japan and staying with her family. The client's life in Europe was comfortable on the surface, but she missed living in Asian cities. The client felt that people were disconnected from her because she was Asian, and there were biases and prejudices against Asians in Europe. The following illustrates a clinical case with a couple who lived in two different countries by one of the authors (Tamura).

Case study: Therapy with a couple in two different countries. In August 2020, a father in his 40s contacted a therapist by email because of concerns about son in the fifth grade who refused to go to school. The father, a Japanese national, currently works in Europe for a Japanese company. He was under stress because of lockdown and was struggling with insomnia and stomach aches. The wife and son lived in Japan. They had had marital problems, and the father called because the son had stopped going to school because of COVID-19. The father wanted to talk to his wife about this situation online, but she refused to speak with him and would only respond to the father via text messages. The father was concerned because he was abroad and was not able to interact with his son, but his wife was not willing to talk to him. The father sought therapy as a way to communicate with his wife.

The first session was conducted with the father using the Zoom platform. The father stated that his wife told him that his response to their son's refusal to go to school was a source of stress for her and that she was fearful of her husband. The wife and son were supposed to move with him to Europe, but she broke her promise and did not move, which was stressful for the father. The therapist expressed empathy towards the father and asked that he ask his wife to join him online.

In the second session, the therapist met the husband, who was in Europe, and the wife, who was in Japan. The wife stated that her husband's worries about their son was a burden. Her husband only scolded the son and it was causing pressure on the son. She felt that their son's refusal to attend school was temporary, and she did not want to be burdened by her husband's anxiety. The husband stated that he did not know how to interact with his wife and son. The couple seemed able to converse in a calm manner with the therapist. The wife agreed to continue couples therapy online.

Most of the cases discussed in this paper were conducted online since the onset of the pandemic. Online family therapy sessions have enabled families who live in separate geographical areas to connect. There has been an increase in online therapy. Clients have also started to become used to online sessions because of the increased use of online meetings for their work and in their personal lives. Many therapists in Japan are finding that therapy can be conducted effectively via online. As in the case of the couple living apart in Europe and in Japan, new communication patterns were facilitated through online therapy. Communicating with each other online created less burden and stress than face-to-face interactions for the couple, enabling new communication patterns to develop. As noted by Burgoyne and Cohn (2020), online therapy can help reduce the intensity of tensions among conflicted couples.

At the time of writing, Japan was undergoing the third wave of an increase in COVID-19 infections. As with many other countries, current increases in infections are the result of loosening of restrictions and opening of businesses. Although vaccines are expected to become available to a large portion of the population in Japan by spring 2021, it is difficult to predict the outcome of the current pandemic on the health and financial well-being of the country. The long-term consequences on families are yet unknown. Sheltering at home has caused conflicts for many families; at the same time, it has helped other families become closer. For example, although the mass media in Japan have perpetuated the notion of 'corona divorces' due to the stress of COVID-19, statistics have so far not provided evidence for this. In fact, one study conducted by an insurance company reports that 20% of couples surveyed reported that their marriage had improved because of spending more time together (Japan Times, 2020). Some men have also reported that spending time with their families has brought them closer to their children.

The pandemic has brought enormous challenges worldwide. But it has also provided opportunities for many families to reassess their priorities. Since the onset of the pandemic, the JAFT has posted on our website suggestions for ways for families to cope with the pandemic from the perspective of family resilience. It is our hope that we can continue to help families increase their resilience in the face of the enormous challenges brought on by this pandemic.

ª 2021 Australian Association of Family Therapy

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