Mental Illness in Japan: A Need for Change

Keren Lehavot
Japanese Civilization
December 3rd, 2001

 
    On June 8th, 2001, thirty-seven year old Mamoru Takuma, an outpatient receiving treatment for schizophrenia, forced his way into an Osaka elementary school (McCurry 2).  Armed with a blade, he walked in during a morning break between lessons and stabbed his unsuspecting victims in a rampant onslaught, killing eight children and injuring nineteen others (McCurry 1).  Exhibiting a history of violence and anti-social behavior, Takuma later told police that he was “fed up” and wanted to be put to death for the crimes (McCurry 2).  This shocking and atrocious event sparked conversation in Japan about mental illness, which, prior to the introduction of psychiatry in Japan in the late 19th century, was viewed as an incurable curse and a product of supernatural contamination (Boudreau).  Even today, mental illness remains a problem that is often silently shoved into corners of ignorance and oblivion.  In light of the recent school attack, social commentators “pointed to outdated attitudes toward mental illness and the social stigma attached to seeking help for psychological problems” as a possible explanation for the killings (McCurry 3).  The purpose of this essay is to explore communal aspects of Japanese society that maintain stigma against people with psychological illnesses and hinder the advancement mental health care.
One of the main problems confronting Japan’s mentally ill is the stigma attached to them, a long-held custom of Japanese society. Their troubles are not defined by conditions of chemical imbalance or sickness, but by more shameful conditions of weakness (Chorlton).  Karen Riley, a woman who had lived in Kyoto and had a schizophrenic neighbor, claims that the other neighbors were dismissive of mental illness:
 

The subtext of what I listened to them say was like the Japanese prescription, kusai mono ni futa.  Put a lid on anything smelly.  The schizophrenic and her sister, who was stigmatized by association, were solely responsible for their problem: the only sensible solution was to ignore it. (Riley)

    Indeed, some consider mental illness within the family a form of social shame, or haji (Grimes 4).  According to Y. Sakamoto in his “Study of the Attitude of Japanese Families of Schizophrenics Toward their Ill Members,” a Japanese family’s communication is typified by great emphasis on group-interaction and less focus on individual assertiveness (Sakamoto 370).  For a Japanese to bring shame to his family is the ultimate failure, far greater than simply bringing shame to himself.  As Sakamoto points out, this cultural custom was well demonstrated by Kamikaze fighters during World War II: “The Kamikaze fighter could kill himself, not for himself, but for the society and the family, which could not tolerate the shame if he failed” (Sakamoto 372).  A mentally ill member of the familial structure is a cause for disgrace, disturbing balance of this inner group.  For this reason, the psychologically disturbed try to conceal or ignore their problems.  For Japanese men especially, who may suffer from alcoholism or family/occupational pressures, admitting “weakness” and seeking treatment is unimaginable.  In other cases, it can be difficult to persuade parents of the need for mental treatment for their disturbed children (Grimes 4).  Or, if patients actually receive counseling, they may withhold the fact from their families.  Thus, even with successful treatments, patients’ progress may be hindered by a return to an unsympathetic and uninformed community.  They may not only face prejudice from members of the outside society (referred to as soto), but also from members within their family group (referred to as uchi), who cannot bear the dishonor and humiliation reflected upon them (Hendry 43).  This double discrimination from both outsiders and insiders makes coping and management only more problematic for patients.  A positive public attitude towards the mentally ill is a necessary condition for satisfactory care and treatment of these patients.

     While the tradition of stigma prevents people from seeking counseling, the custom of tatemae versus honne makes it harder for people in counseling to open up to the therapist.  Tatemae refers to public behavior, and honne indicates one’s “true feelings and desires which cannot be openly expressed because of the strength of tatemae” (Sugimoto 26).  For instance, tatemae may be used with outsiders in the form of politeness in language.  As Joy Hendry comments, polite language maintains “a certain distance between the conversants, therefore protecting the ‘inner feelings’ from the probings of an outsider” (Hendry 46).  Accordingly, when one seeks counseling for a mental disorder or problem, he may hesitate to express his personal feelings and emotions verbally.  Andrew Grimes, a counselor and group therapist in Tokyo, indicates that even as children, the Japanese have been taught to repress expression of their emotions and beliefs, in public and sometimes even in private, when deviating from the group view in order to preserve the notion of social harmony and agreement, or wa (Grimes 5).  As a matter of fact, containing personal emotion in front of people outside one’s social group is still considered by some a characteristic of a well-bred, mature member of society.  This is a major hurdle for Japanese who try to talk about their problems in therapy sessions, for “in Japanese, the expression of material and emotional desires, of hopes and also of expectations of others are often expressed indirectly using hints or innuendo in speech or by simply depending on others to guess one’s ‘true feeling’ or honne without verbal explanation” (Grimes 5-6).

    Since trying to obliterate or modify this dichotomy of tatemae versus honne is both unlikely and impractical, as it is deeply imbedded in the culture of the Japanese, a more sensible approach to this hurdle is to encourage counseling sessions in English for those comfortable enough to use it.  Many Japanese consider English a more direct language, and it would allow them to express their feelings with greater liberation and less fear, bred from the belief that they are more permitted to do so.  Even patients with varying levels of fluency, if given time to frame what they want to express, could benefit from the shift of language.  Grimes, in “Health Issues and Counselors in Tokyo and Japan,” stated the following:
 

Both in individual counseling and group therapy situations, many people here have said that it is easier for them to freely express their emotions and talk about their worries or problems in English and also, in some cases, that talking in English helped them to become aware of feelings they had never experienced in Japanese. (Grimes 6)

    Thus, speaking English with a therapist may allow patients not only to speak frankly, but also to make new discoveries about their situations.  While this opens up a whole field of issues relating to language that go beyond the scope of this essay, it should be noted that this idea does not suggest that the Japanese need a new language to express emotions. Rather, it addresses the reality that their traditional culture, with its emphasis on politeness and etiquette, constricts the individual in a therapeutic setting, where English may lend itself better for some patients.

    A third tradition challenging the mental health sector is the relegation of care of the elderly, common victims of mental illness, to women.  Takako Sodei indicates that currently “there are about 800,000 bedridden elders and slightly more than 900,000 senile elders in Japan.  If the ratio does not change, the estimates will reach 1,000,000 for each group around the turn of the century” (Sodei 215).  This burden of elder care—which often becomes care for the mentally ill—largely falls on women in the home rather than on institutions that can deal with their problems appropriately, problems such as Alzheimer’s disease and senile dementia.  Women’s role as caregivers is the default, an expectation based on both obligation and love (Sodei 216).  The Twilight Years by Sawako Ariyoshi is a fictional novel that investigates aging in modern Japanese society and problems faced by the elderly and their families, especially when the elderly develop mental illness.  When Akiko’s father-in-law becomes senile, her life dramatically alters.  Not only must she clean, cook, and work full-time, but she must now also attend to a stubborn, aging man.  The conflict portrayed between Akiko’s dedication to her job at a law firm and the need to care for her increasingly dependent and uncontrollable father-in-law is not uncommon.  Currently, many women sacrifice their careers in order to take care of weak elders at home (Sodei 226).  The results can be tragic for both caregiver and caretaker.  To illustrate, Akiko holds pent-up anger at the situation in which she finds herself, overwhelmed by her increased responsibility.  After her father-in-law finally passes away, Akiko realizes no one had shed a tear over his death.  In the last scene, she holds a birdcage in her arms:
 

The bird flapped its wings against her breast and let out a mournful cry.  Tears welled up in Akiko’s eyes and rolled down her cheeks.  It was not until some time later that she realized she was crying.  She hugged the birdcage to her breast and sat there for what seemed an eternity. (Ariyoshi 216)

    The bird trapped within the cage represents Akiko, frustrated and powerless, trapped in a society where she must sacrifice herself for the sake of family, tradition, and expectation.  This realistic sense of burden on female family caregivers may lead them to mistreat the care recipients (or elderly), as reported by a study that examined such incidents (Shibusawa et al. 336).  Daughters-in-law reported the most incidents of hitting the care-receiver (as opposed to daughters and wives), and this ill treatment was often associated with cognitive impairment of the care-recipient (Shibusawa et al. 336).  Such findings illustrate the growing frustrations of women and the desperate need for professional support—not only to reduce women’s responsibility, but also to provide mentally ill elders with the adequate treatment they deserve.

    The traditional concept of women as caregivers ties in with elders’ perception that they should be cared for within the family.  Even though the Ministry of Health and Welfare issued the Ten-Year-Strategy for Promoting Health and Welfare Services for the Elderly in 1989, which included “home help services, visiting nurses, short-term stays at nursing homes, day-care services, and bathing services,” (Sodei 225), a recent national survey by Japan’s large newspaper company found nursing care services to be underused (Saito 302).  The traditional concept of being cared for at home, plus the requirement of paying user’s fees, seems to weaken their use.  The study examined the relationship between “the Japanese elder’s perceptions of nursing care services and their adherence to traditional values” (Saito 302).  Using a sample of 4,391 elders, the study indicated that a statistically significant relationship was found between the elders’ beliefs and their reluctance in using services (Ibid 302).  As exemplified in The Twilight Years, when a doctor is called to provide treatment for Akiko’s father-in-law, he cries, “I don’t want an injection, Akiko.  I hate doctors.  Keep him away from me!” (Ariyoshi 175).  Thus, while availability of services does not seem to be the problem, traditional views associated with care of the elderly not only restrict women, but also prevent the aged from getting proper care for their various mental illnesses.  Like the traditional stigma attached to the mentally ill and the traditional dichotomy of tatemae versus honne discussed earlier, this traditional perception of how the elderly should be cared for is not easy to shatter.  Making the issue one of public awareness may be a valuable attempt to break impeding traditions and move forward towards a time when community services can be utilized to everyone’s benefit.

    Another difficulty based on tradition that confronts mental illness is doctors’ reluctance to share information with patients and their relatives.  To begin with, it cannot be expected that patients and their families achieve insight and understanding to their situation without forming a clear communication with the doctor.  In many cases in Japan, however, this does not seem to be the case.  In one study, participants (consisting of relatives of patients) maintained that doctors did not fully explain the diagnosis to them, or informed them of it in a vague and unclear manner.  One participant said, “The doctor looked away from me, mumbled that my son had schizophrenia, and walked away.  I didn’t understand what the word meant.  Nobody explained what it meant.  Even now I don’t really know what it is” (qtd. in Yamashita 111-12).  This lack of communication from physicians is not unusual, for almost all participants in this study were not made aware of the diagnosis in the doctor’s initial assessment, and most were not told of it until their relative was in need of hospitalization (Yamashita 111).  Receiving no consultation and full explanation from the doctor is a chief problem, for, without it, relatives cannot understand and empathize with the condition of their loved one.

     All of these social customs which plague the mentally ill—stigma, tatemae versus honne, elder care, and doctors’ aversion to communication—lead to  economic setbacks of advancing mental health care.  One such setback is the lack of adequate funding of research in this area (Takei 523).  Generally, the Japanese government does put emphasis on research; in 1994, for example, $9.2 billion was allotted for research—but only $0.55 billion of it was awarded to biomedical research (Takei 523-4).  This amount is far less than that bestowed to Japan’s nuclear energy or to its space industry, and this lower prominence on health research is “in sharp contrast with the USA budget allocation, in which health receives $8.5 billion and the total funds for energy and space are equivalent to the allocation for health research alone” (Takei 524).  Such shortage of funding to mental health has gruesome consequences. Without proper research, new and effective treatments cannot be realized.  This is especially true for complicated disorders such as schizophrenia, where biomedical research makes new discoveries constantly.  Despite this, the main Ministry for health development only provided researchers with $2.8 million in 1993, “which is equivalent to a 36th of the expenditure on schizophrenia research alone in the USA, or about a 500th of that spent on the Japanese space program” (Takei 525).  Economically speaking, this deficiency in financial backing is unwise because the benefits of funding would reduce total cost in the future.  Fuller Torrey, a U.S. psychiatrist and chairperson of the Stanley Foundation, declared, “If research discoveries could reduce the cost of schizophrenia by only 10% by 1998, the savings which would accrue over the following decade would total $180 billion” (qtd. in Takei 525).  Therefore, allocation of funds in Japan should seriously be rethought. The benefits of increasing grants in health research would, after all, not only be economically efficient, but would also lead to new treatments that could decrease the suffering of Japan’s mentally ill population.

While lack of funding has negative consequences for treating mental illnesses, other economic hardships coexist.  Japan’s health system prevents the sale of anti-depressants, drugs that are popular in the West and often found to be successful in treating depression by affecting certain neurotransmitters.  Two of the most popular drugs, Prozac and Zoloft, have not been approved for use, and “Paxil was only recently allowed” (Chorlton).  Ironically, Japan has a national health insurance system that covers most of the treatment for depression, so patients “only pay for 10-30% of all medical expenses” (Yoon).  Despite this low-cost treatment, “local clinics used by most people are staffed by doctors lacking training in, or unwilling to diagnose, depression ” (Chorlton).  Therefore, treatment is often not received.  Similarly, in spite of Japan’s policy for fee-for-service, universal access to health care, both day care facilities, “which provide medical therapy and social activities for several hours during the day,” and non-residential social rehabilitation services are in short supply (Carnahan 16).
 The exploration of these traditional/societal views and economic realities of mental illness in Japan call for a need to change and rethink attitudes, customs, and strategies.  Instead of looking in the other direction and pretending such problems do not exist, it is necessary to acknowledge the realm of abnormal psychology and, rather than neglecting patients, provide them with therapy, support, and hope.  If the mentally ill remain ignored, stigmatized, isolated, and not sufficiently treated, it is likely that tragedies like the harsh deaths and intermixed frustrations of June 8th will not be the last.
 
 

Works Cited

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Boudreau, Chad. “Treatment of Insanity in Japan gets Historical Look.” University of
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Carnahan, William A. Lessons from the Japanese: Collective Choice in Public Policy
Decisions to Care for and Treat the Mentally Ill in Japan. Arlington: Law and
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Chorlton, Jan. “Quiet Desperation.” ABC News.com. 4 Sept. 2001. 14 Nov. 2001.
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Grimes, Andrew. “Counseling, Health Issues and Counselors in Tokyo and Japan.” Pages
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Hendry, Joy. Understanding Japanese Society. London: Routledge, 1995.
 

McCurry, Justin. “Eight Children Die in Osaka School Stabbing.” Guardian Unlimited 9
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Sakatomo, Y. “A Study of the Attitude of Japanese Families of Schizophrenics Toward
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Shibusawa, T, et al. “Elder Mistreatment Among Caregiving Wives, Daughters, and
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Oct. 2001: 336.

Sodei, Takako. “Care of the Elderly: A Women’s Issue.” Japanese Women Ed. Fujimura-
Fanselow, Kumiko and Atsuko Kameda. New York: The Feminist Press, 1995. 213-228.
 

Sugimoto, Yoshio. An Introduction to Japanese Society. Cambridge: Cambridge
University Press, 1997.
 

Takei, Noriyoshi. “Funding of Research in Mental Health Care in Japan.” The Lancet 347
(1996): 523-528.
 

Tsukada, Noriko and Yasuhiko Saito. “Japanese Elderly’s Perceptions of Long-Term
Care Programs and Beliefs.” The Gerontologist 15 Oct. 2001: 302.
 

Yamashita, Mineko. “Newman’s Theory of Health as Expanding Consciousness:
Research on Family Caregiving in Mental Illness in Japan.” Nursing Science Quarterly 11.3 (1998): 110-115.
 

Yoon, Suh-kyung. “Are You Covered?” Far Eastern Economic Review. 9 Aug. 2001. 14
Nov. 2001. <http://www.feer.com/2001/0108_09/p034binnov.html>
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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