Mental illness, medicine, and psychotherapy in Japan

Japan is one of the wealthiest and most advanced countries in the world and this is largely due to its highly motivated, hardworking and committed population. It is not a myth that the Japanese dedicate long hours to their work without showing fatigue. This certainly indicates a strong mental will. However, ironically, Japan is also a country with one of the highest number of citizens with mental problems.

Despite Japan’s culture, which strives towards homogeneity and egalitarianism, the mentally ill patients are greatly ignored. Thus, this paper focuses on the mentally ill to bring about a better awareness of their existence and understanding of the Japanese culture through their plight. To do so, this paper will give a brief description of mental illness in Japan, followed by mental systems and policies, psychotherapy, social institutions, the social issues involved as well as its causes.

Mental illness in Japan

Japan has a unique way of defining the notions of health and sickness. In most countries, the definition of a healthy person is one whose condition of the body and the degree to which it is free from illness. However, in Japan, a healthy person is one who has a clear social role to fulfill. This further emphasizes Japanese strong tendency for group cohesion, where every member in the group knows and fulfills his or her role. Besides the notion of health, Japanese has a clear definition of the sick too.

By Munakata’s 1definition, a sick person experiences illness through the loss of mental self-control (such as neuroses and psychoses), loss of physical homeostasis (such as heart disease and diabetes) and loss of behavioral self-control (such as sexual deviance and drug dependence). Loss of mental self-control is seen as a problem in the determination of the person, where one has to have a sense of self-discipline. Thus loss of mental-self control is not acceptable. This is especially so since Japanese has been brought up to take on this health responsibility and self-control is seen to be responsible for neurosis and depressive state. Psychological causes are usually not accepted by the public, though fatigue or malnutrition is an acceptable cause.

In the present situation, there is an estimated 2 million people in Japan with mental illnesses, of which the numbers of detainees is a much bigger project than that of criminals. Of this number, 350,000 are currently in detention in hospitals, and of these, 170,000 are in closed wards that provide 24-hour confinement. In addition, 305 of them are forcibly hospitalized for about ten to twenty years. This marks the longest stay in a mental hospital by any patients in an industrialized country. Despite this huge number, there are very few adequately trained therapists in Japan and to worsen the situation, there has been a recent increase in neurotic depression.

Causes for this huge number is immensely attributed to stress, fear of competition and insecurity. As standard of living is very high in Japan, there is an essential need for individuals to keep up with their studies or work in order to survive in Japan. There is no room for slacking. Thus, much stress is felt to up keep high standards and to fend off competition, especially since there are only limited vacancies in the universities in Japan. Another area of concern causing mental illness is the sense of insecurity. This is largely due to two opposing concepts, tatemae and honne. According to Sugimoto(1997), tatemae refers to public behavior one has to follow while honne refers to one’s true feelings and desires7. Due to the strength of tatemae, which puts group interest as its top priority, Japanese cannot be openly expressive about their feelings. Consequently, these pent up feelings can lead to mental illness.

The syndromes found in Japan are known collectively as diseases of civilization (Bunmeibyo). They include moving day depression, school refusal syndrome, apartment neurosis, kitchen syndrome and family violence (where children attack parents). Out of these, moving day depression and kitchen syndrome occur only in women. Dr. Katsura Taisaku coined the term “kitchen syndrome”. This ailment stems from a social problem, that Japanese women are still judged first and foremost by their roles as “good wife and wise mother”. Those who are well educated will have no room to develop any sense of independent identity after they are married. Finding gainful employment other than in a factory is socially frowned upon.

As a result, modern Japanese women are bored with their lives. They also have no outlets for complaints due to the strength of tatemae. Thus, they start to use ‘organ language’ to express their frustration. As mentioned by Dr. Katsura, there was a case of a woman suffering from kitchen syndrome who resorted to the use of men’s linguistic forms. Patients with moving day depression also have numerous nonspecific complaints. For example, some feel that the water in their new residence does not agree with them and that their personalities have undergone changes, causing their inability to run their homes as usual8

Mental health system

The Mental Health system in Japan is one that has been borrowed for forty years. As quoted by James M, Mandiberg, who was an associate professor of social welfare at Shikoku Gaku in University, “Like many other things in Japan, the mental health system is a mix of imported models and ideas along with traditional social structures and values. The mix can be confusing for non-Japanese and Japanese alike”. This is because such models should not be imposed without considering social, cultural and economic factors.

It was only in the 1980s when some mental hospital’s scandal led to international investigations of the Japanese mental health system11. This, supported by Japan’s economic success, resulted in an improvement in the mental health system12. Nonetheless, Japan still does not share similar standard as the industrialized Western health, mental health, human and social services, and human rights13. There remains a general lack of direction in government mental health policy which is causing a lot of problems and is in need of reformation.

Mental health policies

The Mental hygiene law of 1950 came up with 3 forms of admission into mental hospitals, all of which was involuntary: “admission by order of prefectural governor, consent admission and provisional compulsory admission”. Nobody could control the admission criteria and patients had absolutely no chance of appealing against the admission. This implied that as of 1988, human rights of the patients were seriously ignored in mental hospitals. This negligence of human rights was also evident in the numerous scandals, which involved mental hospital, reported in the mass media; some examples included “forced labour and deficiency of proper treatment”.

Another aspect of the mental health system that has negative consequences on the family is the Hogo-Gimusha system. This system puts the patient’s guardian (most often the patient’s family member) in charge of the patient, and duties involve taking care of the patient and preventing them from causing harm to others. As a result, many guardians tend to want to institutionalize the patients in hospitals and are not willing to have them discharged. This is to prevent the patients from causing harm to others and in turn getting the guardian into trouble. This actually causes relationships between patients and their families to breakdown.

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Fortunately, there were subsequent changes made to the “mental health legislation, which resulted in the Mental Health Law in July 1988”. This improved legislation entitled patients to better human rights, examples included “voluntary admission and standards to conform to for patients’ treatments”. This new legislation temporarily improved the situation of mental patients. However, there was one area about this new legislation that provided an opportunity for improper treatment of patients.

Psychiatric review boards (PRB) were set up to look at again and reconsider patients’ stay in the hospitals. However, the selection procedure of the PRB was not made transparent, as “PRB members were appointed by the governor of each prefecture”. Rules as to “how the PRB must be constituted” were also problematic. Many psychiatrists from the private mental hospitals, who ended up in the PRB, did not really care about the patients’ needs because their main aim was profit. Also, patients were not discharged “unless they have a place to go with their family’s approval, even if they were clinically suitable for discharge”. PRBs should work actively with organizations to provide support groups and programs to help reintegrate the patients into society. However, the new legislation did “enable founding of social rehabilitation facilities and community mental health services”.
Psychotherapy

In Japan, there are four models of psychotherapy for patients to choose from. They are the Healing Model, Training Model, Interaction Model and Salvation Model. Once a Japanese therapist perceives a client to be operating under assumptions of a model contradictory to the therapist’s own view, there will be some attempt to get the client to redefine assumptions. This helps both of them to operate similarly and congruently. For all the therapies, the patient needs to be specific, detailed and precise in descriptions of self and symptoms in order for the therapy to be successful. Other common features of therapies are the use of authority and initial acceptance of clients as they are (Reynolds, 1987).

Both Naikan therapy and Morita therapy comes under the Training Model. The Naikan therapy, “which was developed by lay practitioner Mr Inobu Yoshimoto from the jodo-shin sect of Buddhism, has been practised in Japan for the past 30 years”. In Naikan therapy, “nai refers to inside or within and kan refers to looking”. In this case, kan has a deeper meaning from Japanese Buddhism: “it means to observe or visualize something during meditation with an intensely integrated mind”. This therapy is “a form of guided introspection directed towards attitude and personality change”.

This therapy’s underlying idea is such that humans are self-centered and at fault, but yet still treated kindly by others. To recognize these kindnesses from others, “individuals must be truthful towards oneself, empathize and sympathize with others and face up to one’s true faults”. After all, for an individual to bring harm to those close to one is a serious infringement of moral values. Patients subsequently “become more meaningfully involved with their past”, and towards the end they accept they have been wrong and want to change for the better.

As for Morita psychotherapy, it works in such a way that patients are required to stay in the hospital for 2 months, and they are prohibited from telling even their doctors about their symptoms. However, they are allowed to write down in their diaries every thought that appears. “The main aim of this treatment is to not resist the symptoms, but to get used to them and even be friendly towards them”. “One must neither search for the root of the illness nor resist it; one just has to come accept it”.

Social institutions

Family

The traditional structure of family relationships is very different in Japan as compared to other countries. The family has profound effects on mental health services. Historically, the ie, which means the family, was very important in Japan42. “The ie had the responsibility in taking care of all the members of the household, and members were bound to respect the will and integrity of the ie”(Nakane, 1970; Rohen,1974; Fukutake,1989)

During the period in Meiji Restoration, patients were locked up in their own homes either under the authority of their parents or consent by the police. Thus, every family member was responsible for public security despite his or her lack of expertise in psychiatry. Currently, traditional ties still exist (especially in the rural and the eastern areas of Japan) despite formal obligations of the ie system being abolished in the post- war constitution. Through a Nationwide Survey on Families’ Welfare Needs, conducted by ZENKAREN in 1985, fathers and mothers represented the main caregiver for 64% of the respondents.

It was found that family relationship determines community role and acceptance and it also affects the length of stay in Japanese psychiatrist hospitals. “In traditional ie relationship, once people leave the supportive relationship of the ie, they become a yosomono, an outsider”. This also means that a yosmono has no chance of re-entering the community. Therefore, strongly embedded family ties result in many patients choosing not to be discharged from the mental hospital to avoid being a burden to the family.

For a Japanese to bring shame to his family is considered the ultimate failure, which far exceeds bringing shame to himself or herself50. Furthermore, the society expects the family to control the mentally ill member and to assist them in their recovery. This family responsibility does not restrict them to seek help from others, which is to say that when family seeks advice from various consultants, the family has not given up its role as the sole provider of the mentally ill patients.

Deviant behaviors such as school refusal or alcohol addiction are seen as problems that are to be controlled and solved by families. If a family abandons this responsibility, they would be criticized and might feel guilty as a result. Hence, due to the high expectations of the society on the family, the problem of deviant behavior worsens as a result. Thus, most often, when the family can no longer provide and take care of the mentally ill member in the family, will they seek treatment for that member. This care for the mentally ill member is then fall onto the mentally ill patients’ families.

Hence, mental illness is commonly seen as a private, family affair whereby other people such as medical professionals should not interfere.

Mental health hospitals

Mental health hospitals are the prevalent institution in Japan mental health system. “Doctors are expected to be parental, wise and to make good decisions for patients”. Japanese patients have a kind of dependency on their doctors similar to how children feel toward their mothers. Thus patients are expected to obey the doctors. As result of such close relationships,
doctors are often motivated by their desire to protect patients and their families as much as possible from loneliness, alienation, powerless and hopelessness that might result from the knowledge of the terminal nature of the illness. Consequently, these blind obligations lead to problems, as doctors often do not tell patients their real diagnosis56. Doctors also tend to avert communication with patients and their families.

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Self-help organizations

Apart from family and hospitals, there are two other social institutions (self- help organizations) in Japan that help the mentally ill and their families. They are Zenkaren and ‘The Village of the Hermit Crab’. The formal, which stands for National Federation of Families with the mentally ill in Japan, was founded in 1965 and has since become a powerful organization in Japan’s mental health field. It is also the sole nationwide self-help organization for families of the mentally ill.

The federation helps the mentally ill in many ways. These include providing assistance to mentally ill people in the community, encouraging community care to establish sheltered workshops, advocating human rights of the mentally ill, carrying out practical and strategic research and social rehabilitation as well as facilitating full participation of mentally ill people in the society.

The Village of the Hermit Crab’ (Yadokari no Sato) is Japan’s very first community-based program61. “Located in Omiya city in Saitama prefecture, it provides community support to the mentally ill” and helps them reintegrate into mainstream society. Everyone who is part of the organization must be a member, including patients and their families and staff, where clients are seen on equal status as compared to other members. All corporate members, including the patients, are in charge of the activities and running of the agency, as well as to let others know about their program.

As part of this program, there is a “care center to support patients living in the community”. This care center “involves a supervised twenty-person long term rehabilitation model residential care home”, where patients reside for an average time of two to three years, and “a twenty-person agency-run business or sheltered workshop” for patients who are currently not institutionalized. This care center has quite a number of functions, including counseling for patients, letting patients have a place to relax and allowing them to interact with others.

Other than this care center, there are also centers for patients to live in and agencies to get jobs for them. There are also “co-operative care and group homes” to provide places for members to live in, “small-scale agency run businesses” to find work for its members. There is also a “life support center” that assists in finding employment for patients, “patients who live alone or with their family, and the group homes”.

The underlying philosophy of ‘The Village of The Hermit Crab’ is the empowerment of the mentally ill; such that they can take on responsibility for themselves and decide the type of life they want to lead. In fact, this program has been conducted with the conviction that the patients are not an ill group, and like anybody else, can and should lead a normal life.

By joining this program, patients have found a network of friends to support them, as “patients might have lost their daily human relationships when they were hospitalized or moved away from their hometown”. This network has also extended to the wider community. Even so, “one key goal for the future would be to create communities where people with mental health problems are able to live harmoniously with other tolerant members from the public”.

Social issues

Over-institutionalization

There are two main social issues involved affecting the mentally ill. They are over-institutionalization and discrimination and marginalization of the mentally ill. In the case of over-institutionalization, “Japan has an average of 2.9 psychiatric beds per 1000 population and according to WTO it accounts for a full 18% of all psychiatric beds in the whole world”. This phenomenon is actually supported by the government segregation policy as well as the high reimbursement policies that the government has crafted. Furthermore, the Japanese themselves are in favor of institutionalizing the mentally ill patients.

They claimed that this institutionalization can prevent and avoid any mental patients getting homeless. Another reason for the large number of mentally ill patients staying in mental institutions is due to personal and social reasons, that is to say that many have no need for medical help in actuality. For example, some patients who may have recovered from the illness but are rejected by their family may continue to stay in the mental institutions.

Another factor aggravating over-institutionalization is the aging population of Japan. Families with aged parents will have problems supporting the mentally ill family member financially, especially in times of poor physical, emotional and economic conditions. As a result, the sole family care responsibility of the mentally ill member is transferred from the aged parents to the sibling generation who are actually less effective and willing in assuming the caretaker role.

This is because most often than not, they find it a chore to look after their mentally ill relatives and will not readily take them in. Thus, families just arrange for hospitalization for their mentally ill family member. Hence, this leads to the mentally ill patients having longer and increased stay in the mental institutions.

Discrimination and marginalization

Discrimination and marginalization of the mentally ill is prominent in Japan through three channels. Firstly, they are discriminated and marginalized by the public and private hospitals. These institutions, despite being a place for treatment of the problem, stigmatize the mentally ill. This is seen in the poor conditions being offered to patients in psychiatric hospitals. For example, special exemption is passed down by the government that limits one-third of doctors in psychiatric wards as compared to other types of wards.

Besides, the numerous abuse cases of mentally ill patients by medical staff show that there is little social concern for the treatment of the mentally ill compared to that of patients with other types of illnesses. Examples are the use of electro convulsive therapy and isolation rooms (with open toilets and no beds) in the punishments of the patients. Furthermore, patients are denied permission to make phone calls or write letters, thus limiting their contact with the outside world. The most outraged treatment of the mentally ill reached a high in 1984 when a patient was killed in Utsunomiya.

Secondly, human rights of the mentally ill are trampled upon. An approximation of 80% of patients is hospitalized involuntarily. In the case of a mentally ill criminal, he or she may be forced into further detainment even after completion of their sentence. In courtrooms, the cross-examination of lawyers is not guaranteed and this may result in an unfair outcome of judgment. Another outright marked treatment of the mentally ill is that they are legally barred from public baths and jobs, such as teaching and truck driving.

Thirdly, the mentally ill are discriminated and marginalized by the society and even their family members. Members of the outside society (soto) actually displayed discriminated acts towards these mentally ill patients. A recent report showed that All Nippon Airways. Co (ANA) actually refused mentally ill passengers on their planes. However, it is fortunate to note that the ministry had instructed the major airlines to revise the rules that prevented mental patients from participating in social activities previously.

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In addition to prejudice from the society, patients may also face prejudice from members within their family group (uchi), who cannot accept the shame and humiliation that they get as a result of their illness. Discrimination from both the society and the family makes it extremely difficult for the mentally ill to cope with their illness, and thus hinders their recovery.

Causes of marginalization and discrimination

The causes of marginalization and discrimination of the mentally ill in Japan can be explained by the socialisation process as well as the role of media. Since young, Japanese are socialized by their parents and through it learns to categorize the world and impose a system of values upon it. “Socialisation is the means by which an essentially biological being is converted into a social one, able to communicate with other members of the particular society to which it belongs”. The significance of socialization in relation to the theory of disease such as the concept of germs can be used to explain marginalization and discrimination of the mentally ill in Japan.

Japanese believes that germs brought in from the “outside” contaminate the “inside”, thus causing illness. In this context, “outside” has a negative connotation of dirt or represents some dangerous powers whereas “inside” denotes the normal healthy body. Besides, Japan has a long history of inventing dualistic structure such as ideation which can be formalized into the following sets of oppositions: inside versus outside, up versus down and pure versus impure.

Therefore, incorporation of “germs” into the “inside” is seen as impure, marginal and dangerous. The mentally ill is regarded as a form of contamination and thus a source of danger to the norm. This deeply embedded structure in the Japanese worldview and culture can significantly affect the way they see or treat the mentally ill in Japan.

Another cause of marginalization and discrimination of the mentally ill is the role of media. In 1964, Edwin Reishauer, an American ambassador to Japan was stabbed by a young schizophrenic person. The murder was sensationalized by the Japanese mass media report by citing the mentally ill as dangerous people. In order to avoid diplomatic reaction on the attack, the government was prompted to mandate reinstitutionalization of patients who had stopped treatment.

Besides, the police department also reacted by increasing the management and control of the mentally ill by insisting on the revision of the Mental Hygiene Law. However, statistics showed that only 2% of the population is regarded as mentally ill. “This meant that their criminal rate is actually lower compared to the general population”.

Another example of sensationalized report is the Ikelda elementary school incident. “In June of 2001, a 37-year-old man walked into a prestigious elementary school in Kyoto, pulled out a knife, and began stabbing the second-graders who were in the room he happened to enter”. The incident had led to the death of 8 children and seriously injured 10 pupils and teachers. This tragic phenomenon challenges the idea that Japan is a “safe society”.

The discovery that the man was under psychiatric disorder attracted a flood of media calls and public sentiment on greater control over the mentally ill104. The widespread and exaggerated media report on the incident stimulated the conservative Liberal Democratic Party and the government it controls to pass a new law to deal with the mentally ill who committed crimes.

The bill, called the “Bill Concerning the Medical Treatment and Observation of Individuals Who Have Committed Grave Acts against Others while in a State of Insanity,” aims as a preventive system to hospitalized mentally ill people who have either avoided condemnation or been acquitted for crimes such as murder, robbery, and rape. Under the system of preventive detention, mentally ill who were found at risk of causing harm to others will be forcibly hospitalized.

Unfortunately, some mentally ill individuals serve longer “sentence” than “regular” criminals as upon release from regular prison, they are sent to a mental hospital for further confinement106. All these exaggerated reports not only stimulate immediate action from the government against the mentally ill but also reinforce prejudice against this marginalized group. Therefore, to associate mental illness with danger makes it extremely difficult for the mentally ill to live ordinary lives.

Conclusion

It is very important that the Japanese government takes necessary steps to improve the welfare of the mentally ill. For example, they should implement more community-based institutions instead of institutional ones. This is because the latter’s solution is more for social control rather than towards solving the problems for the mentally ill and their family. Other Western countries are already moving towards community-based mental health system but Japan is moving towards the opposite direction. Besides, the government should also control the media coverage so as to prevent exaggerated report concerning the mentally ill.

Finally, the authority can generate public awareness to reduce their stigmatization. In addition, the public mental health system should take into account the social and cultural context of Japan and not merely imitate the Western’s public health system. Social customs which plague the mentally ill such as social stigma, tatemae versus honne, aging parents and doctors’ aversion to communication will lead to economic setbacks in advancing mental health care.

Therefore, traditional societal views and economic realities of mental illness in Japan call for a need to change and rethink attitudes, customs and strategies. If no effective action is taken, the mentally ill will remain ignored, stigmatized and isolated.

Bibliography

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About the author

Nadia Petrova

I'm running this blog because I love Japanese culture, especially the art of geisha. When I was a little girl, I used to dream of becoming a geisha myself. In my spare time, I enjoy watching good anime and reading some manga.

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