A hug a day keeps the trauma away
A team of Israeli therapists has discovered that a little stuffed puppy named Hibuki can do wonders when it comes to comforting and engaging children who have experienced disasters, such as last year's devastating tsunami in Japan.
In August, a somewhat unusual Israeli delegation landed at Tokyo airport. Three Israelis got off the commercial flight: Dr. Flora Mor, a psychotherapist and head of curriculum development for the Joint Distribution Committee's Ashalim program for at-risk children and youth; psychologist Dr. Shai Hen-Gal, a project director specializing in trauma at Ashalim and the Education Ministry; and Daniella Hadassi, an art therapist who works on behalf of the Foreign Ministry. They brought with them 180 stuffed animals in rustling plastic wrapping. These little plush puppies, with their sad faces, have a proven positive effect on traumatized souls.
The first breath of the chilly Tokyo air was unsettling given the high levels of radiation that had been measured in the city (though the stuffed animals didn't bat an eyelash ), but the team of therapists didn't have time for such worries. They were greeted by their hosts, members of the Japanese Puppet Therapy Association, and by their translator Yishai Hika, and were off to the hotel.
The tsunami that struck Japan's northeastern coast on March 11 took more than 20,000 lives and left nearly a million homeless. The tsunami also damaged the nuclear reactor at Fukushima and radiation that escaped from there threatened Tokyo and parts of northern Japan. Since then the national mood has been in the doldrums. Planned power outages were paralyzing the economy, foreign tourism was wiped out. In the Fukushima area, residents were shutting themselves inside their homes, isolated in their distress.
Japan had begun to slowly recover from the disaster, but while the recycling plants were busy grinding up the rubble for use in new infrastructure projects, in another sensitive area they were struggling to find relief: The Japanese psyche remained trapped between the national code of restraint that requires that one to go one with "business as usual" and avoid public displays of emotion - and the terrible trauma it had undergone.
Many of the worst affected were children in the disaster zone: The world they knew had collapsed, some lost their homes as well as their loved ones. Doctors in the region were reporting symptoms that indicated serious emotional distress. Many children had stopped laughing or crying. Their facial expressions were frozen and they weren't interested in playing.
The authorities have encountered great difficulty in trying to provide such children with psychological assistance. There are hundreds of thousands of affected children, spread over a vast area. Nor is there a very highly developed mental health system as one would expect to see in the West. There are not enough psychologists, psychiatrists and educational counselors to reach all the children and give them the attention they need. And direct mental health assistance from foreign countries isn't available either. Foreigners don't know the language, and Japanese law prohibits anyone who didn't study medicine in Japan from providing medical aid to a local resident. The Israeli delegation was an exception, because of its experience in treating victims of mass trauma.
Five years before the tsunami in Japan, Israel endured a barrage of rockets in the Second Lebanon War. Thousands of residents of the north abandoned their homes and found temporary shelter in the tent city set up by Arcadi Gaydamak in Nitzanim. Thousands of children roamed the camp unsupervised. The psychological counseling service of the Education Ministry eventually sent a delegation there, including Hen-Gal.
"One of the challenges was to quickly diagnose thousands of children and offer them a suitable intervention plan," he recalls. "Some were fine and others had suffered trauma of one degree or another."
Children are just as vulnerable to trauma, caused by catastrophic events or shocking and painful incidents, as adults - perhaps more so. Children who have experienced stress and trauma are liable to direct destructive behavior at others and at themselves, and to suffer learning difficulties, dissociative problems, somatic problems and distortion in self-perception and their perception of others. They can even develop chronic behavior patterns that show minimal involvement in what is going on, plus an excessive preoccupation with the past.
"Traumatic conditions in children entail a terrible sense of loneliness that can include subjective feelings such as 'I don't want to be different than other children,' or 'I don't want to burden everyone with my story,'" explains Hen-Gal, adding that often the adults around an affected child will avoid direct mention of his distress.
Back at Nitzanim, it wasn't possible to offer standard therapy because the families left there after a short stay, so the team had limited time, and thus needed a quick and effective tool. Hen-Gal contacted his professor from Tel Aviv University, clinical psychologist Avi Sadeh.
"He invited me and we met at the camp," Sadeh recounts. "I offered to volunteer but he explained that they had enough volunteers, but needed some sort of strategic solution. I suggested an approach that I use in treating children in a private clinic: I recommend that parents buy a stuffed animal and then I teach them how to use it." And thus Hibuki ("Huggy" ) was born.
Truth be told, Hibuki - a soft, sad-eyed puppy, made in China - began life in Israel as a failure; the importer didn't understand why parents weren't buying it. Sadeh came across it by chance. "I was wandering the toy stores looking for a plush toy and finally I came to one place where I saw this one and knew right away that it was what we needed. I used the research money I had left over to buy the first 70 stuffed animals."
The sad face that kept parents from embracing Hibuki turned out to be just right for Hen-Gal and Sadeh's purposes.
"A traumatized child identifies more with a sad animal because it's easier for him to project his own sadness onto it," Hen-Gal explains. "One of the first questions we asked the children was why Hibuki was sad, and the child would say: 'Because a Qassam fell on his doghouse.' Or, 'He doesn't have any friends.' Another advantage of this stuffed animal was its human expression, plus the long arms with Velcro at the ends that can hug the child and cling to him. The child hugs the puppet and the puppet hugs him. That's where the name comes from."
The two psychologists distributed the stuffed animals in the camp and asked parents and staff to encourage the kids to "take care" of them. The results were astounding. Making the child act like a caretaker prompted him to shift his focus from his own problems to those of the little animal, as it were, and thus indirectly helped the child take care of himself. The parents were also given a very valuable means for reconnecting with the child and understanding how he was doing, via indirect questions about his relationship with Hibuki.
Hen-Gal: "It was clear the parents were afraid to confront reality head-on. They didn't know what to say to the children, and also felt guilty that the kids were paying such a heavy price. As a result, the children were exposed to vast loneliness, accompanied by anxiety. Our intervention made [parents] see that children are affected much worse when they aren't able to speak about their anxiety, and we helped them to get the children talking and to answer their questions."
In the past 15 years, mental health research has found that the healing powers of people who are in the children's natural surroundings - parents, teachers, counselors, etc. - are greater than that of an outsider, no matter how skilled he or she may be. Rather than the magnitude of the disaster, it has been found that it is the ability of such adults to mediate the experience for the child that affects the extent of their psychological damage.
"Even children who are exposed to very severe trauma can heal efficiently if their parents and others around them are able to mediate the distress for them," says Hen-Gal.
Sadeh and Hen-Gal show that treatment with the Hibuki toy is suitable for 95 percent of children exposed to stressful and traumatic events, and that within just a few days, incidents of stress-related behavior such as bedwetting, nightmares, anxiety and violence were reduced by 40 percent. Plus the therapeutic effect was apparently long-lasting.
As the rocket barrages continued, and with funding from the Israeli JDC and from Jewish communities in North America, Hen-Gal returned to the importer with an urgent request that he bring over as many stuffed animals as possible. The importer was able to find 250 in warehouses, but since there were thousands of children in need, other toys were tried, Hen-Gal recalls: "We tried to use a green frog but it didn't work. We asked the kids, 'Why is the frog sad?' But it didn't look sad to them and the kids didn't understand what we wanted from them."
Hibuki does reserve duty
Since then, Hibuki has gained a virtually unprecedented degree of fame. Since 2006, more than 50,000 of the plush toys have been distributed to Israeli communities in the north and south. Whenever children are exposed to trauma, Hibuki gets a "call-up" notice. It was called upon, for example, in Operation Cast Lead; it was summoned to help in the aftermath of the Carmel fire; and it's also being used to treat children who have been in car accidents or have lost a family member. Further research done by Sadeh and Hen-Gal found that Hibuki's intervention is also useful in dealing with more day-to-day stress such as that resulting from divorce, unemployment of a parent or a loved one's chronic illness. The Education Ministry keeps several thousand Hibuki toys in storage for emergencies. The little sad dog has become a star in a crazy era in which children on the home front are often the first to pay the price of war.
Their therapeutic program gained international recognition when Sadeh and Hen-Gal published an article about it in the prestigious Pediatrics journal - which is how the connection with Japan came about. Daniella Hadassi, a therapist who works in disaster zones on behalf of the Foreign Ministry, came across the article and realized that Hibuki could be very helpful in a place like Japan, which has a venerable puppet-related culture. Hadassi also coordinated the arrangements between the Israeli team of psychologists and Prof. Michiko Hara of Japan, a pediatric neurologist who teaches at Saitama University near Tokyo.
Remembering how well the program worked with children affected by the Second Lebanon War, right after the tsunami Hadassi contacted Hara, who specializes in aiding at-risk children and is head of the Japanese Puppet Therapy Association. The JPTA aids young children and teens and has hundreds of members - among them teachers, doctors, nurses and clinical psychologists, some in key government or academic positions. The JPTA was also among the first local groups to issue guidelines on how to deal with children traumatized by the tsunami.
After thoroughly studying the Hibuki therapy concept, Hara sent an official invitation to Hadassi and the other Israeli experts to come to Tokyo to present the method. "She had one condition," recalls Dr. Flora Mor of the Joint Distribution Committee. "Only if we convinced the association's professional staff would we receive approval to go and meet the children and parents who were affected by the tsunami."
The delegation's trip to Japan was funded by the JDC's International Development Program, which provides immediate and long-term aid in cases of natural disasters, extreme poverty, genocide and other circumstances; it was active in New Zealand, Turkey, Haiti, and in Thailand, Sri Lanka, Indonesia, India and the Maldives, following the 2004 Indian Ocean tsunami. After disaster struck Japan in March, a special aid fund was set up by the JDC for inhabitants of the stricken area.
With all due respect to Hibuki, it's just a stuffed animal. The Israeli delegation to Japan, however, was made of human material, which begs the question: How does one proceed in a country threatened by dangerous levels of radiation? The recommendation of doctors in Israel was not to eat local products: no fruit, vegetables, meat or fish. High levels of radiation had been measured in certain areas of Japan, and even in central Tokyo.
When the delegation arrived, their hosts invited them to a pricey restaurant. They sat around a table laden with tempting dishes (Mor, who keeps kosher, stuck mostly to vegetables ), and prayed that the restaurant used imported ingredients, or at least ones that had undergone safety inspection. But in Japan solidarity is solidarity, apparently. "At the end of the excellent meal, the host announced that we'd had the very great privilege of contributing to the rebuilding of the stricken areas. Turns out that he specifically ordered items from the menu based on ingredients from there," relates Hen-Gal, adding, "We realized that there was no way to know anything for sure, and decided that whatever happens, happens. Anyway, no one there understands a word of English and you feel ridiculous trying to find out if the food came from the area with the radiation. Later on, we even drank water from the tap," he laughs.
After the meal the team returned to their rooms on the 10th floor of a Tokyo hotel to plan their presentation to the JPTA the next day.
For her part, Mor had coped with a major trauma herself. In 1960, her mother's family perished in the big earthquake that struck the city of Agadir, Morocco. Her mother miraculously survived, but the fear of earthquakes remained ingrained in the family.
"I pleaded with the reception clerk to get a room on a lower floor so if there were an earthquake I wouldn't feel it so much, but I was told that the low floors were reserved for Japanese guests," she says.
After an earthquake-free night, the team awoke to a challenging morning. The conference began with a presentation by the JPTA and local medical people who'd returned from the stricken areas. The sterile pictures they showed revealed the magnitude of the physical destruction but the human element was missing. A nurse from Fukushima described the situation at the school where she worked: The building was destroyed so the children were being taught in a temporary structure, but not allowed outside because of the radiation.
When their turn came, the people from the Israeli delegation took out Hibuki. The puppet's sad eyes melted the audience. Yishai the interpreter translated their remarks from Hebrew to Japanese, and as soon as their part of the program ended, they were inundated with questions. A teacher from northern Japan wanted to give out the puppets right away and to bring the Hibuki project to all the children in the north who had been affected. Professor Hara, an energetic woman of 69, had been moved to tears.
"It was clear that something was starting to change in the way the issue of trauma in children was being considered after that presentation," says Hen-Gal. "I felt that we succeeded in conveying the message and that there was someone on the other side ready to accept it."
The next day the team of therapists boarded a train for northern Japan.
The 'quiet dragon'
It was very hot in the train station. Electricity was being conserved so the air-conditioning had been turned off. In the subways, volunteers handed out damp cloths so passengers could refresh themselves. As the train traveled further north, from the windows the members of the delegation saw that traces of the destruction were still visible everywhere. Vast areas were laid waste, with perhaps just a single house still standing in the middle. Here and there signs of life were evident among all the rubble; the Japanese had slowly been cleaning everything up.
"In Israel they would remove all of this rubble in a few days with heavy equipment," Mor observed. "In Japan they do it gradually and sort through all the objects. Meanwhile, the children still have to pass by it every morning."
The train passed through Fukushima, where a nuclear reactor exploded. Dangerous radiation levels had been measured in the city and the streets were completely deserted most hours of the day. Amid the houses, however, masses of sunflowers were blooming.
"According to Japanese folklore, sunflowers absorb the radiation," said Hen-Gal, quoting something he was told. For the residents, the sunflower is a source and symbol of hope and comfort in coping with "the quiet dragon" - as the radiation is referred to.
During the long train ride, translator Yishai Hika expounded on how "the quiet dragon" arouses "hidden" trauma in every family, including his. When the atom bomb was dropped on Hiroshima, his grandmother jumped into the river with his mother in her arms, and that's how they survived the radiation. Ever since the disaster in Fukushima, Hika's mother, who lives in a northern city, has been having nightmares every night. Another one of his relatives was in Hiroshima with his baby when the atom bomb fell. A huge tree absorbed a large part of the shockwave near them; the tree disintegrated instantly but their lives were saved.
"Every Japanese has memories or stories from that time that are resurfacing again now, but they don't have anyone to share them with. Only when we ask them explicitly do they share them and they seem glad to share their feelings with foreigners. Among themselves, they hardly talk about it at all," says Hen-Gal.
Prof. Yaakov Raz of Tel Aviv University, who lectures on Japanese culture and was awarded a medal of the Order of the Rising Sun by the emperor of Japan, is not surprised when asked about this. The way the Holocaust is "in our genes," so it is for the Japanese, he explains: "The Holocaust is so big that I don't know if there are any ways to cope with it. It's the same thing for the Japanese with the atomic holocaust. And what happened there is indeed a second atomic holocaust, even if the government won't admit it. It's a national disaster and the government's lies about it are only exacerbating the situation."
Back in Japan, in the coastal city of Ofunato, the delegation was taken to a school that has been absorbing refugees from the area, which was completely devastated. Some of the children are orphans; others "only" lost their homes. Hibuki swings into action. After the team explained the treatment method, Hika translated the instructions and the teachers gave Hibukis to a group of 15 children and encouraged them to care for them; then the children played in the yard and the team observed them.
The children reacted to Hibuki in different ways: One buried it in a pool of plastic balls and tried to crush it. Another went down the slide with it and was careful to keep Hibuki from getting hurt. A third gently pushed the stuffed animal on a swing, but didn't want to touch it.
"Our message to them was that anything the child does with Hibuki is legitimate. Even wrecking it or not touching it. Each choice says a lot. Parents and caretakers are afraid to make mistakes and so they leave the care to the expert, but through playing with Hibuki the parents get involved and then it's also easier for them to express feelings," explains Mor.
At a later meeting, questions were raised that reminded the team of questions they heard from parents in Nitzanim. "The earthquakes never go away," said one Japanese mother. "Every time the earth shakes, my son asks if there's going to be another tsunami. I don't know what to tell him."
"We explained that while she can't promise that there won't be another disaster, she can encourage him by saying that Hibuki gets scared too and that he can try to comfort him," says Hen-Gal. "One mother wanted to know how that would help. We explained that this way the child will continue to feel something. Even if it hurts, at least they'll continue to feel."
Parents asked why the toy is a dog and wanted to know how the Israel team had developed the therapy method, and thus they came to hear about Israeli trauma. One grandmother asked if taking care of the stuffed animal, as it were, wouldn't just place another burden on the shoulders of her granddaughter, who was already caring for her younger brother, after their parents were killed. During the discussion, the Israeli team began to see that in achievement-oriented Japanese society, there are parents who do not like too much of an emphasis on feelings, lest it have a detrimental impact on their children's grades. "We explained that a child in distress is not able to learn and that his academic achievements are also hurt by that," Hen-Gal says.
The encounter with the local parents and mental health professionals was very moving for the visitors. Mor shared with them the story of her mother's family and the Agadir earthquake. The feeling of emotional release in the room was palpable. The deputy chief psychologist of Ofunato - a Mrs. Sato, who is in her thirties - walked over to the side of the room and burst into tears. The other preschool teachers also began crying, and then the Israelis were informed Mrs. Sato had lost her entire family in the disaster.
"During most of the presentation, she listened as a professional, but at the end she discarded her professional cloak and allowed herself to experience the loss in a personal way, after months of restraint," Mor explains.
After four eventful and emotional days in Ofunato, the team returned to Tokyo, to give a presentation on Hibuki therapy at another conference, at the TWMU Hospital.
The director announced his desire to adopt the principles of the project to help children facing major surgery or frightening medical treatment.
On the penultimate night of the trip, the team headed to their 10th-floor hotel rooms. At 3:25 in the morning they awoke as the rooms danced around them: An earthquake was shaking the city. Mor sat down on the bed and clutched her head, she says. "That night connected me to the stories I heard from my mother. In retrospect I understood how important it is to be open to your own personal disaster so that you can cope with someone else's."
The Japanese response actually helped her self-confidence, Mor adds. "Right after the earthquake, rescue crews arrived and checked that there were no cracks in the building. In the morning I saw a large number of rescue forces getting a briefing outside the hotel. We were told that the preparedness level was very high and that there was nothing to worry about. The next night I had no trouble falling asleep ... When you know there is someone in charge and that the system is prepared, it gives you a lot of confidence."
For Mor, the trip concluded with another moving event. On the final evening, the group was joined for dinner by a Jewish businessman of Moroccan descent who lives in Japan. Like Mor's family, he, too, had been through the Agadir earthquake. Moreover, when he recalled how he had escaped from the yeshiva where he'd been studying, while all of his friends there were killed, it turned out that the place he found shelter was in the home of Mor's mother.
"It was an incredible closing of a circle," says Mor.
Ever since the group's return from Japan, positive responses have been flowing in and it is possible that its members will make a return visit early in 2012. The JPTA has conducted therapeutic workshops in the afflicted area for hundreds of parents and children; those who ran the workshops were local people trained by the Israeli team.
But the effects of using Hibuki don't end in Japan, nor with cases of trauma: Psychologist Sadeh reports that Cambodia has also expressed interest in this method, and says that research shows that the little dog is also useful for treating more common problems like nightmares among children. Meanwhile, word of the Israeli project has even reached Tehran: The website Tehran Newsletter published an article describing the principles of Hibuki therapy and called on the Islamic Republic of Iran to adopt them as a means to help the country's children.
And Hibuki himself? He continues to lovingly absorb the kicks and blows and hugs from children, with that same sad puppy face.