[Special Three-Way Conversation] Living with Anxiety in the COVID-19 Era

Today, under the theme of "Living with Anxiety in the COVID-19 Pandemic," the three of us have been able to gather online like this.

I would like to start by putting into words what each of us is currently feeling and thinking about the anxiety of the COVID-19 pandemic through our own individual experiences.

Since I have been talking about this online in various places, I'll try talking about something I haven't mentioned elsewhere. I think the way people experience this pandemic differs greatly depending on who they live with.

For example, if there is a small child in the same house, you feel you must protect that child at all costs. Or, an older person might feel that the younger generation should be prioritized over themselves. I believe people are significantly affected by the specific circumstances they are placed in as a "private individual."

I wanted to start by saying, based on my experience so far, that the way someone living alone perceives COVID-19 is quite different from someone in a large family.

That part is difficult to talk about with others. For instance—and this is a hypothetical—if you live with an elderly person who is ill, you feel very strongly that you don't want to bring the virus into the house. While such things actually have a major impact on one's way of thinking, they are often hard to say out loud.

That is a very important point. If we don't think based on the "self" in that way, it ends up becoming a sort of academic abstraction.

Yes, it's a touchy subject. Because everyone is different.

For the sake of the readers, may I start with a general overview?

Yes, please go ahead.

The first time I realized that the COVID-19 pandemic was different from a normal disaster was, rather belatedly, when a letter arrived on February 5th at the English-language journal of the Japanese Society of Psychiatry and Neurology, where I serve as editor-in-chief. At that time, Wuhan was under lockdown, and the Japanese government was repatriating citizens one after another on chartered flights. Amidst that situation, news quietly broke that a quarantine officer working at the airport had committed a mysterious suicide.

The author of this letter was an expert in disaster mental health. While mentioning that incident, the author wrote that this disaster was different from the natural disasters we usually imagine; it was a disaster known as CBRNE. CBRNE is a general term for special disasters involving emergencies caused by Chemical, Biological, Radiological, Nuclear, and Explosive materials.

The point was that unexpected problems were lying in wait—problems beyond the mental health measures for disaster victims that we had previously envisioned and prepared for, such as during earthquakes like the Great East Japan Earthquake or floods in the Shinano River basin.

The primary reason is that the cause of this disaster cannot be perceived by our five senses. We know the cause is a virus, but its nature was initially uncertain, making it easy for anxiety and fear to intensify. It's not just the fear that you might get infected yourself, but also the anxiety and dread that you might pass it on to someone else.

That's true. It's two types of anxiety.

Secondly, because there were no effective medicines to stop this infectious disease, we were forced to practice social distancing—physical distancing—to reduce opportunities for contact.

Furthermore, due to the "stay-at-home" requests to refrain from going out, many people had to work or study from home, and businesses like restaurants were forced to close. In addition to the stress of having to suppress normal behavior, many people faced economic hardship, losing their income and livelihoods as a result of restrictions on daily activities.

If these multiple layers of suffering are prolonged, it could have a devastating impact on mental health.

The policy brief issued by the United Nations on May 13th was titled "COVID-19 and the Need for Action on Mental Health." It stated that unless mental health measures are made robust in every country, society will not recover quickly even after the pandemic is suppressed by the power of medical sciences. It emphasized the need to firmly implement mental health measures for society to recover.

Normally, reports like this come from the WHO, but the fact that this came from the UN carries a weight in the message and implies a level of resolve that we must accept.

It is said that people all over the world share a certain common sensation regarding this new coronavirus. No matter how careful you are, you don't know when you might get infected, and I think everyone is going about their daily lives while harboring common anxieties, fears, worries, bewilderment, and restrictions.

Also, those who are unfortunately infected and fighting the disease, as well as those who have recovered, continue to feel anxious and uneasy about whether their bodies have fully returned to normal. Furthermore, I believe people commonly share the anxiety, distress, and hurt surrounding the various emotions and words directed at them by those around them because they were infected.

In particular, regarding this vague anxiety about the possibility of being infected or having been infected, I think one key point is how one can settle that within oneself as an anxiety that can be managed.

The feeling of "I don't want to get infected" is certainly at the base, but recently the shape of the virus has become clearer and knowledge about treatment methods is gradually accumulating, so I think there's a part of people that feels it can't be helped if they catch it.

However, with this coronavirus, I think more than anything, everyone has a very strong desire not to become a perpetrator. Rather than the anxiety of getting infected themselves, it's the anxiety that they might pass it on and cause trouble for others. This anxiety of "not wanting to be a perpetrator" is something many people voice.

In the culture of this country, people are extremely anxious about the possibility of becoming an infected person and passing it to others. I cannot deny that state of consciousness, and I think it is very strong.

That might be a point where we differ from people overseas. As a cultural theorist, I'm interested in these things. In a study by Professor Asako Miura of Osaka University, an international comparison reported that the percentage of people who think getting COVID-19 is one's own fault is significantly higher among Japanese people. In this country, becoming an infected person makes one feel extremely lonely. I feel there might be a problem specifically because of the nature of this country.

People live with the anxiety that they might lose their place in society because they caused trouble for others. You could call it peer pressure. I also have that anxiety about what would happen if I were the only one to catch it while everyone else is healthy.

I agree completely. The fact that one harbors the anxiety of infecting someone else and potentially driving them to death is a major difference from a normal disaster. Moreover, the closer you are to someone, the closer the physical distance, so the risk of infecting them becomes higher.

In Japan, there has been a strong emphasis on "self-restraint." Because of this, I suspect many people felt as though they were being told, "Neither getting infected nor infecting others is permitted."

After the state of emergency was lifted, infections at nighttime entertainment venues involving hospitality in entertainment districts were frequently pointed out. It seems there was a flood of criticism that some people going to such places were spreading the infection and were "outrageous."

Currently, after retiring from the university, I live a double life, residing in the countryside of Shinshu while also working in Tokyo. In rural areas, the number of infected people is very low.

In Tokyo, hearing that 100 or 200 people were infected daily makes one think, "Again? I'd better keep being careful." But in rural areas, it is announced how many people tested positive in which municipality. In other words, it is sometimes possible to figure out exactly who it is.

When that happens, I've heard stories of stones being thrown at houses that produced an infected person, or posters being put up, making it difficult to live in that area and leading families to flee in the middle of the night. The anxiety people feel triggers prejudice and blame, with the thought that "the infected person must have done something outrageous."

This isn't limited to COVID-19; it's the same with sexual violence, where people tend to assume the victim was also at fault.

As Dr. Kitayama mentioned, while saying "self-restrain" in a Japanese society with strong peer pressure works effectively to curb the spread of infection, I believe there is a non-negligible problem in that it gives rise to arguments about the responsibility of the victims.

I'm glad Dr. Kamba went that far. I think there is a "fantasy of sameness" unique to Japan where, in a place where most people live similar lives, have similar faces, speak the same language, and share the same culture, if one person becomes different, they are viewed as a different species and excluded—and this is more than just about catching a disease.

I felt that in the phrase "PCR testing and isolation," but on the other hand, that is effective for infection prevention. So, people quietly suppress the "different" parts of themselves—the impulse to go out to the nighttime districts. And then they view the people who do go as a different species. This mechanism is functioning very effectively, but at the same time, it is driving people to misery. I want to be aware of this duality and talk about it.

In psychoanalysis, which is my specialty, we have the idea of becoming conscious of these feelings rather than capping them. It's easier to respond and think if you are conscious of them. If we think together, good wisdom might emerge. However, we often try not to think about it. In other words, the psychology of taboo comes into play.

That's why I'm here today, hoping we can talk about such things if possible.

Mori: Earlier, I spoke about common anxieties, and I recently had an experience that I think is very much connected to what Dr. Kitayama just said about "being conscious of feelings in psychoanalysis." It was an event that made me deeply realize, through talking directly with someone, that I myself had been feeling anxious.

Since this April, it became difficult to conduct face-to-face interviews in psychotherapy. There was someone I was corresponding with via email as a substitute, but after about three months, we were finally able to meet in person. However, the infection situation still required caution, so when I asked, "What should we do from here?" the person said without hesitation, "I'll come next week too."

Since that person uses multiple forms of public transportation to get here, I had assumed they would be afraid of COVID-19 infection and would prefer to continue corresponding by email. But I realized that, in fact, I was the one who had become timid.

In other words, I took an attitude of being considerate, thinking the other person would have anxiety or fear, but I realized it was an anxiety or fear within myself that I hadn't been very conscious of. It was the moment I truly felt that it was inside me.

By interacting directly with people, things like anxiety or fear that I had been vaguely mentioning became clearly recognized as how they were being experienced within myself.

I see, I understand well.

Another thing: in the spring semester at the university, all classes were online. In a class of about 100 students called Applied Clinical Psychology, where students from first to fourth year were mixed, I had them divide into groups of four or five to freely discuss "what they are currently experiencing regarding COVID-19" and have each group present.

It seems that friends you just pass on campus and say "Yo" to are called "Yo-friends," and they said they stopped meeting those kinds of friends with whom they just exchange greetings entirely. They said a world was born where they only meet special people who have been "sifted through"—people they make a point of meeting online because it's this specific person or friend. They no longer have to meet people they used to see while being a bit cautious, or people they wanted to keep at a distance.

But the students felt various things as they reflected on "themselves who are sifting." Sifting others might mean that they themselves are also being "sifted." This led to various very delicate exchanges of words among the students. Among them, they also spoke of the feeling that emotional connection is indeed lost online.

It left a deep impression on me to see the students questioning themselves, wondering "Is this okay?" regarding their somewhat biased (?) online interactions with hand-picked friends, while expressing those feelings honestly.

I think Dr. Mori just provided a very valuable perspective on mental health measures in an era forced into remote interaction.

When we provide mental healthcare in conventional disasters, we go to the side of those who have been affected. For example, I think that worked well during the Great East Japan Earthquake.

Everyone predicted that suicides would surge after the Great East Japan Earthquake. While they did increase in some affected areas, we were able to prevent a surge. Since it was clear who the victims were, public health nurses from local health centers or social workers visited every single home in evacuation centers, temporary housing, and even houses that escaped the disaster to find high-risk individuals and provide thorough emotional care. Volunteers including psychiatrists and psychologists from all over the country participated in those activities. Since Tohoku is a medically underserved area, those activities continue even today.

This kind of mental health system also functioned during the subsequent Kumamoto Earthquake and heavy rain disasters in various regions, but this time we don't know who the victims are or where they are. Even if they can be identified, providing face-to-face assistance is difficult.

In the world of mental health measures, how to close the psychological distance while maintaining physical distance between people has become a major challenge. I think we need to create technological innovations and a culture that uses them appropriately.

That's true. I had been giving online lectures or using webinars to talk with experts since before COVID-19, but I feel that it's getting a lot of attention now, and the number of people participating with interest is increasing.

There is the issue of what to do about people who have no contact with remote tools, but by getting used to this, we can provide something like counseling and a sense of interaction with others. Meeting all of you remotely now also gives me a strong sense of connection.

I feel more of a "sense of being connected" than when I used to see Dr. Kamba in Kyushu. To be honest, I had never actually talked while looking at Dr. Mori's and Dr. Kamba's faces so closely (laughs).

I think this is a very big impact. This isn't an era where there were only television and newspapers; being able to provide remote psychological support online means that human interaction has become multi-channeled.

When I was young, I did late-night radio broadcasts and felt I could connect with young people late at night, but now I feel that another different network is opening up online. I feel various possibilities here, like another virtual version of a counseling room.

It's truly wonderful to be able to connect online during this transition period. I used to have a sense of aversion to it, but having jumped over that hurdle, I truly feel that the world expands in this way.

But because of that, there are indeed things I feel we are losing precisely because it is a transition period.

Yes. But I think it's important to be able to talk here including that "emptiness."

That's right. We cover what we've lost while talking about "what we've lost." Loss is a very big theme. Acquiring new things while letting go of and losing things we've been familiar with. But when you unexpectedly reunite with something you thought you had lost, it's very joyful. I feel like I'm experiencing that repeatedly.

It's the same in my online practice. During the state of emergency, it's online, and when things settle down a bit, we can meet. Then, there are both the experience from the online time and the experience of actually meeting. The online part might have been a placeholder, but I can also feel the significance that it served as a very important bridge and maintained the rhythm of being able to meet every week. I can also think of this delicate transition period as something very precious.

As you said, we are in a transition period right now. That's exactly why it's an important time. When victims first encounter a disaster, there is a period of being dazed and lost, followed by a honeymoon period.

This is a time when people's altruistic activities and assistance activities are prominent in the region and community. There are also emergency fiscal measures from the government. After that, if the disaster lasts for a long time or many people cannot be saved, it turns into a period of disillusionment.

Now, some time has probably passed since the honeymoon period, the future is still not visible, and an economic recession is weighing down. It is important to prepare for the period of disillusionment.

That's true. To touch on cultural theory again, what we have to think about during this period heading toward disillusionment is the story of "The Grateful Crane." When everyone intends to be human and only one person becomes a wounded crane, the human community tries to maintain itself by having that person leave. I think this is a typical example of peer pressure.

If Yohyo doesn't just say to Tsu, "You're a crane, you're a crane," but even neighbors like Unzu and Sodo all say, "You're a crane, you're a crane," Tsu can no longer bear to stay and leaves. I think we should all be aware of this psychology of viewing others as a different species or heretics and excluding them.

Because people are enduring through self-restraint, something like frustration builds up inside everyone, and when there is one person who stands out, they vent those unbearable feelings toward them. If the person receiving that is very sensitive, they become convinced that they alone are the problem and that if they disappear, the original peace will return. Such things are likely to appear in this period of disillusionment. In fact, we are all wounded cranes, but if one person stands out, we vent it on them.

I think we could learn about this state of our hearts—this psychology of seeking an outlet—from elementary school. It's not just the people going out to the nighttime districts who are bad; rather, the "nighttime district" within us is the big problem, and I want to think about the fact that there is a hidden crane there.

Medical professionals can also become "wounded cranes." We should be somewhat prepared for the fact that we might be viewed as a different species. Counselors also have to be an outlet. I think accepting those feelings and holding out is an important role for those involved in mental health.

While Japan narrowly managed to prevent the medical collapse seen in other countries, the medical front faced extremely severe conditions. However, even if we say "medical collapse," ordinary people probably don't really understand what that means.

As seen in footage from other countries, at the sites of hospitals where medical systems collapsed, a major discrepancy arose between the number of respirators (ventilators) and the number of patients who needed them, and patients were left on stretchers in hallways. At those sites, the disaster medicine method of triage is being employed. In other words, people judged as unsavable are put on the back burner. That is what medical collapse is.

In normal times, doctors provide the best medical care to every single patient without discrimination. However, on the front lines of a disaster, one faces a situation where the weak must be cut off in order to save the greatest number of people. There, doctors on the scene cannot turn their eyes away from the "Trolley Problem" made famous by Professor Michael Sandel's lectures, and they suffer "moral trauma."

In fact, anticipating a medical collapse, triage guidelines were created early on in Japan as well. While guidelines might protect doctors to some extent from "moral trauma" or lawsuits, I believe we should deepen the discussion on this logic that the sorting of lives is unavoidable in the first place.

Regarding triage, there are probably people who don't even know that such a way of thinking exists.

It means that doctors and medical workers are truly in conflict—wondering what to do if they have to perform triage in an emergency. I think preparation is necessary to act rationally at that moment.

There is the term "mental rehearsal," and I hope that being prepared for it and thinking about it can serve as a mental rehearsal to some extent. This is a very important thing.

To broaden the topic a bit, being forced to make decisions in an emergency is something that not only medical professionals but also the general public experience. I just remembered something from a long time ago: I can't forget an elderly woman in her mid-80s who said, "I can't help but wonder, if my daughter-in-law and I were drowning in the sea at the same time, which one of us would my son reach out to? Just imagining it is painful."

How do we make decisions under extraordinary circumstances? Earlier, a student mentioned the idea of "sifting through / being sifted through," and I think we are being asked once again, in various forms, what we are choosing and what we are losing.

We never know when a situation where we must choose between life and death might come. While taking to heart the fact that there are times when we must make critical decisions instantly, I hope we can build up each small experience one by one.

I really think starting from small issues is important. In this country, where acting with grace and resolve—a psychological sense of cleanliness linked to real-world issues—has become a great aesthetic, it's very difficult for athletes to get flustered or waver, or for them to make political statements, isn't it?

In other words, there is a silent pressure that says, "Don't think about such things given your station." That is exactly what peer pressure is, but I believe it's okay to struggle, to assert oneself, to raise objections, and to express individual feelings.

Doctors worry, and psychologists suffer. I really dislike the idea that one must always behave with graceful resolve. I think it's okay to be a little more unsightly or messy.

I am very grateful for this moment where we can talk about our hesitations, doubts, and conflicts—things we don't live our lives by simply resolving. I believe this is exactly what keeps our mental health well-ventilated.

Suicide during the COVID-19 pandemic has been discussed in various ways. It was reported that numbers decreased in April, right when the state of emergency began and the stay-at-home period started, but they increased in July and August compared to the previous year.

Typically, the peak is in March, and from April onwards, the numbers fluctuate while gradually decreasing. August is usually a time when numbers are lower than in spring, but according to the National Police Agency report, there were over 1,800 cases, an increase of 60 men and 186 women compared to the same month the previous year. I think these are figures worth paying attention to.

This is because suicide is more common among men, but in August specifically, the number of women increased. While the suicides of famous people may have had an influence, it has also been explained that people working in non-regular employment faced layoffs and were confronted with financial hardship.

We can't draw a conclusion yet, but as was the case during the recession of the Heisei era, the number of suicides tends to increase with a delay.

In April, using the model Mr. Kamba presented, I think we were still in the "honeymoon phase." There was still hope. There was expectation that the high temperature and humidity of summer might reduce infections, and there was also the expectation that we would be okay because we are Japanese. However, COVID did not disappear even when summer came; on the contrary, it increased significantly from July.

That's right. In April, support activities were active, and the government sent a message that it would not hesitate to provide fiscal stimulus. I think that the vulnerable people facing psychological and economic problems were barely able to avoid choosing death. To overcome the disillusionment phase, we must strengthen mental health measures.

One more thing: I think we are "thin-skinned." So, when we fall into economic hardship or become socially vulnerable and are pointed at, feelings of self-reproach, shame, and guilt grow—thinking we are a burden to society or causing trouble for others. As is often said in international comparisons, we usually have very low self-esteem and a personality that is easily cornered psychologically.

Even someone like me, who appears in public and sings poorly, might be criticized, but at the same time, I have an anxiety about not knowing what will be said where. It's like stage fright—an unbearable feeling.

We aren't that strong. So, right now, there might be immense pressure on the socially or psychologically vulnerable. People say, "Just go to the government office and apply," but the threshold for that application is high.

It's often called a culture of shame, but I think something that could be called a Japanese mentality is at work.

Because their population is small, measures for the generation from adolescence to young adulthood, the so-called AYA (Adolescent and Young Adult) generation (ages 15 to 39), tend to be neglected. However, in reality, they have to overcome several major life challenges during this period.

They are the generation that goes to school, becomes independent, gets jobs, falls in love, gets married, becomes pregnant, gives birth, and starts families. Many mental illnesses manifest during this AYA generation.

What do you two think about the impact this generation is experiencing?

Interacting with students around the age of 20 on a daily basis, I feel that, as Mr. Kitayama mentioned at the beginning regarding "who you live with," the kind of family a child grows up in is very significant.

During this period of self-restraint, when they feel lonely or isolated, or when they have worries about their families, if they send an SOS to student counseling, we can somehow connect with those students.

However, I am worried about the students who are in a state where they cannot seek help from the outside or voice their current situation.

I don't see many young people in clinical settings right now, but perhaps because their numbers are relatively small compared to the aging baby boomer generation, a situation where they are being forgotten by society might be progressing.

We might not be paying attention to this younger generation because they seem energetic. I want to make sure we don't forget to provide information and reach out to them, including through individual approaches.

I am truly moved by the sensibilities of students around the age of 20. When I meet students who try to talk about their experiences very frankly, like in the group discussion I mentioned earlier, I feel refreshed.

In that sense, I think it's important to provide a place in education where students can freely talk about what they are experiencing and thinking. When we do that, students start to move on their own and influence each other.

In class, I tell them, "Let's cultivate our hearts" so that various sensibilities can start to move. When I do, I can tell that the students respond sensitively to those words and absorb them.

Through mutual interaction with students, I strongly want to cherish the kind of contact that enriches their fresh sensibilities.

Actually, all three of us here had a deep connection with Dr. Keigo Okonogi. I'd like to talk a little about how Dr. Okonogi might feel about the current situation.

Dr. Okonogi taught me many things. Although he told me, "You're not suited to be a psychoanalyst" (laughs), he pushed me to pursue the path of neuroscience for mental illness. He left behind many famous books, but the one that left the strongest impression on me is "Object Loss: The Act of Grieving."

A problem during this COVID-19 pandemic is that at funerals for those who have died, the bodies are treated as sources of infection. For example, that was the case when Ken Shimura passed away. People cannot say their final goodbyes; in other words, they cannot go through the process of object loss, and their grief may be prolonged.

I think the professor would say that even as society moves toward recovery, we must not leave behind the consideration and support for the various forms of object loss that victims and the vulnerable have likely experienced.

When I think of Dr. Okonogi, what comes to mind now is also the matter of object loss.

The fact that we have lost our previous daily lives and things that were taken for granted. It is difficult to admit that we are losing them, and I think we are in a time of struggling right now.

I believe the whole world is going through a very large experience of loss right now. Within that, what exactly are we feeling and experiencing? I hope we can share even a little of that process of the loss experience.

Each person's psychological experience is very different, but commonalities emerge, and unexpected realizations are born by listening to other people's experiences. You might think something belongs to the other person, but then you experience that it was actually something within yourself. I want to cherish such places and spaces.

In this era where we have lost what was "taken for granted," what do we feel, how do we live now, and how will that connect to the future? I want to think about this while imagining Dr. Okonogi's psychoanalytic thinking.

When I think of Dr. Okonogi, there is an episode I always remember.

It was at an academic symposium, and despite the symposium being in progress, I saw Dr. Okonogi watching a baseball game on the radio (laughs). While we were both on stage as panelists, he said to me from the next seat, "The Giants are winning right now."

What I want to say is that Dr. Okonogi was good at creating "horizontal connections." Even at academic conferences, if he was sitting next to you, he would talk to you from the side, saying, "That guy is unbelievable; he's saying something different than usual" (laughs).

He would say all sorts of things. By doing that, he created horizontal connections and unconsciously created what Japanese people call "wa" (harmony).

I think that is the communication we are losing online. Online, you can only communicate with the person in front of you. There is no one next to you. This creates a way of being human that is different from a normal group. So, I think what is being lost now is horizontal connections.

In human communication, we might feel secure by communicating with the person in front of us while simultaneously talking to and being connected with the person next to us. It's not individualism, but a "we-consciousness," and I think Dr. Okonogi used the word "WE."

Today, I feel that I might be horizontally connected with all of you. I think we are enjoying the horizontal connections Dr. Okonogi created. For my own mental hygiene, I think that was the good part of today—being able to feel a horizontal connection with everyone.

Thank you very much for a very fulfilling and pleasant time.