The Influence of Culture on
Mental Health and Psychopathology in Japan

Erica Rosen
11/29/01

    Culture, often defined as the enduring behaviors, ideas, attitudes, and traditions shared by a large group of people and transmitted from one generation to the next, is essentially the lens through which a person sees their world.  What is completely healthy and normal in one culture may readily be defined as deviant in another.  The collectivist nature of the culture of mainstream Japan has a profound effect on issues dealing with mental health in Japan.  This includes how psychopathological behavior is defined and manifested within people of Japan, the reaction of society to the mentally ill, as well as the actual treatments and therapies available to the mentally ill population within Japan.

    The Japanese place a high value on uniformity, hierarchy, reciprocity, and harmony.  Japanese children are socialized to recognize the distinction between uchi and soto, as well as honne and tatemae.   The uchi, which basically translates to mean inside or inside group requires different behaviors and expectations than the soto, which is outside or outside group.  Likewise, the Japanese person knows that their honne, true feelings are often in contrast with their tatemae, public face.  Thus, as a result of such cultural and social entities, restraining one’s feelings is very appropriate and often encouraged in a good number of public, daily interactions with people.
Hierarchy and status are additional important aspects of the Japanese culture.  The notion of hierarchy and status are inescapable in Japan; they are even embedded within the Japanese language.  As Joy Hendry points out in her book Understanding Japanese Society, “In the family, older children are addressed by younger ones with a term meaning ‘older sister’ or ‘older brother’, sometimes as a suffix to their names, and adults make use of this form of address when eliciting ‘good’ behaviour, perhaps as a demonstration to a younger child”(p. 48).  Hierarchy, status, and reciprocity are also illustrated by the relationship dynamics of employees within a Japanese company.  There seems to be a strong Confucian element to the way a superior cares for and ultimately benefits from his inferior.

    The education system within Japan clearly illustrates a culmination of the aforementioned elements found within Japanese culture.  Uniformity is manifested mainly by the emphasis that the class and the classroom should be seen as a collective and cohesive environment.  The children are responsible for the physical cleanliness of the room as well as for resolving some forms of conflict amongst their peers.  There is also a lack of tracking children based on abilities.  Thus, the exceptional child is expected to thrive within the same environment as the remedial child.  Restraint amongst the Japanese is illustrated by the fact that very few children will raise their hands or stimulate class discussion.

    There is a prescribed and orderly feel to the Japanese cultural and social norms.  The goal of the Japanese system is the establishment and maintenance of wa, or harmony.  On the surface, this aspiration for harmony is respectable, but it is also possible that the pursuit of harmony may cause problems as well.  The result of such a uniform viewpoint can lead to the stigmatization of even slightest deviance.  Ijime or bullying is one such example that exists within the education system.  The stigmatization of those people diagnosed with a mental illness is another example, and one that will be discussed throughout the remainder of this paper.

     In every culture the defining feature of mental illness or psychopathology is necessarily a deviation from the normal.  Although the existence of psychopathology is universal, the way by which society views and treats those people with a mental illness varies dramatically.  As was mentioned earlier, the culture of Japan seems to look down upon the mentally ill.   Even in the 20th century, 1900 to be exact, the law in Japan required that the mentally ill be isolated and confined to their household.  This Law of Enclosure of the Mentally Disturbed remained in effect until 1919, when the government put the Mental Health Hospital Law into effect.  This law required each district to construct a hospital in which the mentally ill could be housed and cared for.  In 1950, the Mental Health Hygiene Law was enacted and confining patients at home was now considered to be illegal.  Finally, the Mental Health Law of 1988 replaced the Mental Health Hygiene Law of 1950, and the mentally ill were given more rights and an effort was to be made to integrate these patients into the community (Koizuma & Harris, 1992).

    Although there have been changes in the law, the mentally ill are still widely stigmatized within Japanese society.  The mentally ill are seen to bring shame to one’s family name (Munakata, 1989).  This fact holds little significance to the Western reader unless they have some knowledge as to the profound importance that the Japanese ascribe to their family name and ancestors.  From as far back as the beginning of Japan’s recorded history, one’s family could be seen as one’s fate.  In Modern Japan, one must be a part of a koseki, or family registration.  The koseki goes beyond documentation.  “In the hands of organizations the koseki has become a powerful instrument . . . the system works as a powerful deterrent to deviant behavior, as “stains” in koseki negatively affect the life-chances of all family members . . . ”(Sugimoto, 1997, p. 137).

    It is interesting to point out that while mental illness is seen as a stigma in Japan, physical illness is quite acceptable.  Thus, it is often the case that universal psychopathologies such as Depression and Schizophrenia will first manifest as somatic complaints in Japan.  Every culture has its own “idiom of distress,” the pattern of behavior by which people in that culture signify that they are ill (Alloy, Jacobson, & Acocella, 1999).

    Thus, a Japanese patient with utsu-byou, which is Depression, may go to their physician with complaints of weakness, dizziness, and headaches, while an American patient is more likely to go directly to a therapist with complaints of lack of pleasure and gloominess.  The American patient may not even discuss any somatic abnormalities.

    Schizophrenia, or seishin-bunretsu-byou as it is called in Japan, is another universal psychopathology that manifests itself differently in Japan probably as a result of cultural differences.  It has been found that Japanese schizophrenics tend to be more withdrawn and passive than their Euro-American counterparts.  This behavior conforms to the Japanese cultural values (Terrell, 1994).  It has also been found that the label        seishin-bunretsu-byou is so stigmatized in Japan that it is often diagnosed as “neurasthenia,” which is a physical disorder (Sugiura, Sakamoto, Tanaka, Tomoda, & Kitamura, 2001).

    The final disorder to be discussed is Taijin-Kyofu-Sho (TKS).  TKS is what is known as a culture-bound syndrome, meaning that it is unique to or manifested only within a certain culture.  TKS is unique to Japan and Korea.  TKS is characterized by an excessive fear and anxiety that a person will behave in ways that will embarrass or offend other people (e.g., blushing, emitting odors, staring inappropriately, or presenting improper facial expressions) and results in social withdrawal and avoidance.  It is easy to see how TKS connects to the cultural aspects of the Japanese, who expect a person to discriminate with great precision between their honne and tatemae as well as their uchi and soto.

    Now that we have discussed a few of the ways in which the culture of Japan shapes how psychopathologies manifest, it is intuitive to extend the discussion to the actual treatments and therapies unique to Japan.  Treatments of mental disorders tend to be culture-specific.  The way in which the Japanese treat mental illness is akin to other collectivist cultures—the goal is to alleviate suffering and not to better understand one’s self (Draguns, 1990).  Japanese therapies have been termed “quiet therapies,” as they do not emphasize confrontation between therapist and patient like many Western therapies but instead encourage meditation and self-reflection (Alloy et al., 1999).  Two examples of such quiet therapies are Naikan Therapy and Morita Therapy.  (My review of Japanese therapies follows Alloy et al. except where noted.)

    Naikan Therapy, or Introspective Therapy, was developed in Japan in the 1950s.  Naikan Therapy is based on philosophical Buddhist beliefs.  Naikan Therapy sees many problems as being due to self-centeredness.  Patients are therefore expected to engage in extended periods of self-observation, in isolation from other people.  This introspection lasts for approximately one week in a hospital or other monitored facility, and is then continued a few hours a day thereafter.  The job of the therapist is one of minimal involvement; he or she provides sporadic guidance to the patient.

    Morita Therapy, or Personal Experience Therapy, is used particularly for anxiety disorders.  Like Naikan Therapy, the patient is required to spend 1-2 weeks in reflective and meditative isolation.  In Morita Therapy though, patients are then required to stay in the hospital in order to be gradually re-introduced to normal activities.  The goal of Morita Therapy is “ . . . to clear the mind of anxiety-producing perfectionism and to make the patient yearn again for practical activity”(Alloy et al., p. 23).

    The collectivist nature of the culture of mainstream Japan has a profound effect on issues dealing with mental health in Japan.  Unfortunately, because of the high value that Japanese culture places on uniformity, many people suffering from mental illnesses are probably unable to enjoy the same quality of life as their counterparts in other cultures.  Furthermore, it seems as though it would take a significant shift in cultural beliefs in order to remove such stigmatization.  On a positive note however, it does seem that mental health care in Japan is improving as we speak.  According to research conducted by Osamu Tajima, Japanese psychiatry is undergoing a period of transition, with recent changes in the availability of antidepressant drugs, the standardization of diagnostic criteria, and the way in which health care is provided (Tajima, 2001).

Alloy, L. B., Jacobson, N. S.,  & Acocella, J.  (1999).  Abnormal Psychology: Current Perspectives (8th ed.).  Boston: McGraw-Hill.

Draguns, J.G. (1990).  Applications of cross-cultural psychology in the field of mental health.  In R.W. Brislin (Ed.), Applied cross-cultural psychology (pp. 302-324). Newbury Park: Sage.

Hendry, J.  (1995).  Understanding Japanese Society (2nd ed.).  London: Routledge.

Koizuma, K., & Harris, P. (1992).  Mental health care in Japan. Hospital and Community Psychiatry, 43, 1100-1103.

Munakata, T. (1989).  The socio-cultural significance of the diagnostic label "neurasthenia" in Japanese mental health care system.  Culture, Medicine, and Psychiatry, 13, 203-213.

Sugimoto, Y.  (1997).  An Introduction to Japanese Society.  Cambridge: Cambridge University Press.

Sugiura, T., Sakamoto, S., Tanaka, E., Tomoda, A., & Kitamura, T.  (2001).  Labeling effect of seishin-bunretsu-byou, the Japanese translation for schizophrenia: An argument for relabeling.  International Journal of Social Psychology, 47(2), 43-51.

Tajima, O. (2000).  Mental health care in Japan: Recognition and treatment of depression and anxiety disorders.  Journal of Clinical Psychiatry,62 (13), 39-44.

Terrell, D. (1994).  Abnormal psychology. In D. Matsumoto (Ed.), People: Psychology from a cultural perspective.  Pacific Grove, CA: Brooks-Cole.
 

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