Between a rock and a hard place: The mental health system in japan

Like many other things inJapan, the mental health system is a mix of imported models and ideas along with traditional social structures and values. The mix can be confusingfor non-Japanese andJapanese alike.

Between a Rock and a Hard Place: The Mental Health System in Japan James M . Mandiberg

Some have said that Japan’s economic miracle is similar to America’s, except that the economic cycle has happened in a much shorter time. This quicker- cycle description is certainly true of Japan’s mental health system.

Borrowed Models, Borrowed Systems Until the end of World War 11, Japan had no formal or rationalized mental health system. What it has today is largely a postwar phenomenon, influenced by Western ideas of the proper role of the state and its social welfare respon- sibilities. Thus, Japan was building an institutional system, and was encour- aged by America to do so, at just the same time that America was dismantling its own (Mandiberg, 1991). It is not surprising, then, that Japan would be con- fronting community treatment and deinstitutionalization twenty to forty years later than America.

This movement toward building a system, only to find later that the system needs dismantling, was predicted in the late 1960s by D. H. Clark (1968), a British psychiatrist brought to Japan by the World Health Organization to study its mental health system. In a report famous but little heeded in Japan, Clark warned against the large-scale building of institutions as a way of deal- ing with the social problem of mental illness. In a twenty-year follow-up report, Clark (1988) bemoaned that Japan had paid little attention to the experience of the West or to his warnings, and as a consequence faced numerous problems.

In fact, many professionals and others in Japan have paid attention to some aspects of the West’s experience. The American disasters of deinstitu-

N E W DIRECTIONS FOR MENIAL HEALTH SERVICES. no. 60, Winter 1993 0 Josscy-Bass Publishers 3

4 INNOVATIONS IN JAPANESE MENTAL HEALTH SERVICES

tionalization evidenced in the homeless mentally ill (Lamb, 1984), the board- and-care-home mental health ghettos of many cities, and the large-scale incarceration of people with a mental health treatment history in the country’s jail system are all cited as reasons never to contemplate deinstitutionalization and community-based care. But the government has been only too willing to move slowly in this direction. Government policy on mental health often seems to be created only in reaction to perceived international pressure and publicity: Fear of diplomatic reaction to the 1964 attack on American Ambassador Edwin Reischauer (see Chapter Two) prompted the Japanese government to mandate reinstitutionalization of patients who had stopped treatment. The initial visit to Japan by the International Commission of Jurists in 1985, in part prompted by international coverage of a scandal at Utsunomiya Hospital (see Chapters Three and Seven), led to the 1988 revision of the Mental Health Law. United Nations Resolutions on Human Rights, which have no effect on mental health professionals in the United States, are well known to Japanese mental health professionals, who debate about Japan’s compliance.

In the area of programming, the major model promoted in Japan during the past thirty years has been day care. Emphasizing current events groups, arts and crafts, and group discussion, this reflects a model long abandoned by many others as itself leading to the institutionalizing of clients.

This tendency toward conservative models continues today. The 1988 Revised Mental Health Law created three categories of community-based programs: twenty-four-hour supervised residential care hostels (“protective dor- mitories for the mentally disordered”), providing care and skills training; group homes for those not needing twenty-four-hour supervision (“welfare homes for the mentally disordered”); and sheltered workshops. (In Japan, the term sheltered workshop has a somewhat broader meaning than in the United States. It includes the traditional model of contracted work as well as program-owned and program-operated businesses.) Given international pressure, it is surprising that a law that one would expect to reflect the state of the art in 1988 pro- posed only these three models. Even more curious, in addition to proposing cautious models, the 1988 law did not provide adequate funding to act as an incentive to create them. This is in sharp contrast to the attractive fiscal incentives the government has granted people wanting to build psychiatric hospitals. This has made it difficult for anyone, including progressive hospitals, to implement progressive community-based programming.

If there is a villain in all of this, it seems to be the circumstances. A defeated Japan had an alien state role imposed on it, along with an alien social welfare system. This required the government to assume a new care role, while at the same time having to rebuild the economic and infrastructure base. Embracing American ideas of free enterprise, Japan saw that it could both help the economy and take care of a problematic group by assigning it to the private sector. Also, by encouraging a private sector institutional rather than a community-based solution, the country did not need to change basic social relations. That is, on the level of social structure, little difference existed

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between the traditional approach of in-home incarceration of the mentally ill and an institutional approach.

While within Japan there have long been advocates for changes in the mental health system, this has only become an international issue because of Japan’s economic success and world standing. Japan is being held to “international” standards (Harding, Schneider, Visotsky, and Graves, 1985). These, of course, are the imposed standards of the industrialized West. In the areas of health, mental health, human and social services, and human rights, these standards have a long and important historical and cultural base that Japan does not share. Japan is therefore between a rock and a hard place-needing and wanting to be internationally involved but wanting to preserve Japanese tradition, not adopt Western tradition and social structures, all within the context of what are essentially Western-model health and social services.

For example, from the Western perspective of individual rights, Japan’s per- formance with respect to the basic civil rights of mental patients is well below international standards. Hospitalization appears as an arbitrary decision by the family, the prefectural governor’s representatives, or professionals who have a conflict of interest by profiting from the hospitalization decision (see Chapters Three and Seven in this volume). Until 1988, there was no mechanism for patients to appeal this decision, and even today, the appeals process seems to be so poorly designed and implemented that it is not being used (International Commission of Jurists, 1992). In a society that frequently does not disclose diagnoses perceived as negative (McDonald-Scott, Machizawa, and Satoh, 199 11, where medications are in unmarked packages, and where physicians regard ques- tions about treatment as challenges to their competence, the h n d of “informed consent” that does exist in mental health settings appears to be inadequate.

I t is all too easy to compile an even longer list. The point is that Western concepts of civil rights come from a Westem philosophical tradition, legal tradition, state tradition, and process of social evolution. Since Japan does not share these traditions, being judged against them is difficult and at times bewil- dering. Condemning Japan for not measuring up to these standards often seems unfair.

This leads to discussion of what models are appropriate for Japan-a Japan that at the same time wants to have world standing but also to retain its social structures and traditions. In the area of mental health, the question in Japan frequently is what the latest models from America, Britain, or Italy are. By and large, Japanese mental health professionals, families of the mentally ill, and activist consumers are very aware of the newest international models. These models are actively discussed in the various mental health journals and newsletters and among professionals at meetings and conferences.

The effect of ths need to keep up with international models is double edged, however. The type of mental health system Japan currently has is a borrowed model, imposed on Japan without considering cultural, social, and historical conditions. Foreign models continue to be imported and exert influence, if not in government policies, at least with progressive professionals and their


programs. But sometimes the models do not fit. In a visit I paid to a newly built comprehensive mental health center, the director took me around and proudly pointed to his implementation of the newest models from America. He got this model from Boston, this one from California, this one from Wisconsin. How- ever, it reminded me of someone who goes grocery shopping, wheeling a cart through the aisles sayng, “I’ll take this, and one of these, and that looks good, too.” But when the shopper gets all the food home, knowing how to prepare anything with it is another story! This wheeling of a mental health grocery cart through America and Europe has not necessarily resulted in more effective programs, despite the progressive intentions of the people doing this.

I t is similar to the discussion in American circles, initiated by Bachrach (19871, about the transportability and utility of models. Of course, one of the things that discussion hinges on is that whole models cannot and should not ever be lifted out of social, cultural, and economic contexts and imposed some- where else. What can be transported are principles of what works: the kind of community-based long-term support the Stein and Test model (1985) advocates, for example, rather than an exact duplication of how they did it the first time in Madison. The other main issues in the discussion initiated by Bachrach-that models do not necessarily influence systems-is also apropos. In the case of Japan, many models exist, but there is no coherent system out- side the institutional system.

Some Japanese professionals have not simply duplicated American models, however. Many of their programs are featured in this volume. One can see in these programs the creative tension between starting from the real, experi- enced conditions of Japan and the introduction of services that learn from international models but do not try to duplicate them. Hopefully Japanese models like these will lead to a Japanese system-one that is appropriate for the culture and at the same time progressive for the patients.

In this vein, an interesting discussion has been conducted by several members of the Japan Association of Mental Hospitals, T.-Y. Lin from Canada, and two psychiatrists from Taiwan and China (Lin, Asai, and Takahashi, 1991). AS a person who spent seventeen years involved in community support model programs and at the same time tried to be sensitive to culture, I find their discussion provocative. In short, they argue that in Asian cultures in particular, there are several reasons why a hospital is a better base for community mental health programming than newer-model community programs. They cite fac- tors like the community’s trust in tradition-bound institutional structures, a tendency to trust somatic rather than psychological models, and the limited number of community-based professionals.

They argue that while the community might not have confidence in a community support system growing out of a small community-based program, it might trust such a program with an established institution as the base. Though the success of community programs like Yadokari no Sato (described in Chapter Six) belie part of this argument, the successes of hospitals like Ohfuji Hospital (see Chapter Four) and others (Lin, Asai, and Takahashi,

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1991) at the very least present an alternative model to the American tendency to vilify hospitals. To those of us who share that tendency, the argument is all the more intriguing.

History, Culture, and Social Organization

Originally, academic psychiatry in Japan was heavily influenced by formal Ger- man psychiatry and had no real-world application. Several mental health laws were passed in the early twentieth century, but they had little effect. The mentally ill were typically the responsibility of their families, and frequently families resorted to the legally prescribed means of constructing detention cells in their homes. This was common practice throughout Asia and can still be found in some Asian countries (Munakata, 1986). On the other hand, some mentally ill persons were cared for by the Buddhist temples, particularly during World War 11. Descriptions of the first asylum in Japan-Kyoto Tenkyo-in, located on the grounds of a temple-sound similar to Gheel.

In a real sense, however, Japan did not have a Westem-style social welfare system until one was imposed on it during the Allied occupation after World War 11. From a social standpoint, neither a need nor a basis for such a system existed. Japan was still largely a rural and agrarian society with a strong multi- generational and multilineal family system. Families were expected to care for their own. The West’s evolution of the state as responsible had no equivalent in Japan. Simply saying that the family was responsible is not enough. The same can be said of the West at a certain period. But the traditional structure of family relationships is very different in Japan. This has had a profound effect on mental health services, both historically and currently.

Family. Historically, formal family affiliation is all-important in Japan. There is no escaping it. The word usually translated as “family,” ie, is closer to “extended household” in English. The ie had responsibility to care for all the members of the household, and members were bound to respect the will and integrity of the ie (Nakane, 1970; Rohlen, 1974; Fukutake, 1989).

The form of Japanese corporations, for example, becomes more compre- hensible to Westerners when they understand ie. The original businesses in Japan were based on the ie, and so employees were not simply working for an employer but were joining an extended household (Clark, 1979).This has translated into certain corporate practices toward employees in Japan that are hard to understand out of this context. With respect to those considered to be mentally ill, this familylike relationship has been transformed into the con- cept of “vocational parent” (see Chapter Four). These are companies, usually small-scale, that have agreed to hire current and former patients. More than employers, they come to assume a kind of parentlike relationship with the former-patient employee. While in a Western context this may appear to be extreme paternalism, it is entirely appropriate in the context of Japanese culture. As a result, vocational parent employers in Japan seem to be more tolerant and have a greater commitment to the long-term work of their


former-patient employees than do former-patient employers in the United States, even those associated with transitional and supported employment programs.

Originally, this strong ie also meant that there was no question of who was responsible for a mentally ill family member. The state had no role except to enforce that the ie upheld their responsibility (Munakata, 1986). This approach has shaped the way modem mental health legislation has been written.

Further, when one is hospitalized, one enters an ie-like relationship with the hospital and the doctors. Doctors are expected to be parental and wise and to make good decisions for patients. Patients and their families are expxted to do what the doctors say, knowing that they will make wise and correct decisions. Thus doctors frequently do not tell patients their real diagnoses-for cancer, for example-when they believe it is better for the patient not to know (McDonald-Scott, Machizawa, and Satoh, 1992).

Implications for Mental Health. In mental health, this translates several ways. It means that the family is seen as responsible for patients when they are in the community. This responsibility is defined legally. Families are the Hog@ Gimusha (legal gardians) of patients and are responsible for the acts of patients as well as for their care. In hospitalization, this responsibility is transferred in fact, but not necessarily legally, to the hospital and its psychiatrist director. This makes it difficult for the family or patient to question the director’s decisions. Consequently, issues like patients’ rights and the development of a family movement are very different in Japan than in the West. In America, families were historically reluctant to question mental health authorities because they were blamed for the illness and because they were afraid their family member would be denied services if they voiced objections. In Japan, families were also blamed. But far from simply being afraid of being denied the hospital services, when they hospitalized their family member they entered into a culturally defined relationship with powerful stipulations.

Munakata (1986) cites another aspect of ie and its implications for patients and their families. While the formal obligations of the ie system were abolished in the postwar constitution, the traditional ties still exist, especially in rural areas and in the eastern areas of Japan where the tradition was the strongest. In fact, Munakata reports that psychiatric hospital rates were lower in areas with stronger, and higher in areas with weaker, ie traditions.

Munakata believes that ie also affects length of stay in Japanese psychiatric hospitals. In traditional ie relationships, once people leave the supportive relationship of the ie, they become a yosomono, an outsider. To the extent that family relationships determine community role and acceptance, a patient who has become yosomono has no way to reenter the community. In another aspect of this, Munakata asserts that because the family ties are so strongly ingrained in people’s behavior, many patients who could be discharged choose not to be because they do not want to be a burden to their families. He maintains that this is not just a phenomenon in Japan, but is even true when one looks at the comparative length of hospitalization rates by ethnicity in Hawaii. There, he


reports, the hospitalization rate is lower but the length of hospitalization is sig- nificantly longer for Japanese-American patients.

Mental Health Economics

Reading the Journal of the Japanese Association of Mental Hospitals, one sees an obvious defensiveness about private sector mental hospitals in Japan. This is not surprising. The same public-versus-private and profit-versus-nonprofit atti- tudes seem to exist in Japan as in the United States and other countries. But private sector mental health services are not all that different from their coun- terparts in the United States. The American private sector is a mixed bag of religious-affiliated nonprofit agencies, community-based nonprofit organizations, single-facility for-profit organizations, and large corporate multifacility organizations. These private sector organizations range from six-bed board- and-care homes, to counseling centers and social rehabilitation facilities, to skilled nursing facilitiedintensive care facilities, all the way to specialty stand- alone psychiatric hospitals.

The difference is that in Japan, this kind of diversity does not exist. The private sector in Japan consists mostly of hospitals, with a few community- based nonprofit organizations like Yadokari no Sat0 (see Chapter Six). In this category of the private sector, the hospitals include ones that are nonprofit and for-profit and ones that are comparable to the best and worst in other countries.

The limited range of private sector programs in Japan is due to both cultural tradition and government policy In all areas of social welfare, institutions are the rule. Service-dependent populations are served in explicitly non-community-based facilities, typically located at remote sites. The remote-site loca- tion is usually attributed to the high cost of urban land, but a social policy that valued community integration would create ways to deal with this problem. Judging by the effect, policymakers do not intend service-dependent populations to be in the community

As in the United States, insurance reimbursement policy and policies around program subsidies have a profound effect on the kinds of programs available and on the kinds of services they provide. The government-run universal health insurance system and the lack of a voluntary sector in Japan mean that government policy is the major, possibly the only influence on the types of mental health @,grams available. Government policy, in turn, is controlled by an “administrative elite” (Koh, 1989) dominated by the graduates of Tokyo University, who tend to make conservative and self-referential policy decisions. As an example, most legislation in Japan is written by staff in the various min- istries, not by legislators and their staff.

Currently, few community-based program models are eligible for government reimbursement. The program models that are eligible often require staffing patterns that are difficult to maintain given the low level of reimbursement. The predictable result is that there are few community programs,


even in these limited eligible models The hospitals, community agencies, and family groups are simply unwlling or unable to undenvnte the nonreimbursed expenses As in the case of remotely located social welfare programs, the effect is so graphic that one has to assume it reflects the government’s intent

The sluggshness of the government in positively influencing mental health policy, and the nature of the reimbursement system, have forced most of the private sector hospitals to make their margin in numbers: a large number of the least troublesome patients along w t h the smallest number of staff, prefer- ably low paid. Given the government reimbursement policy, hospitals cannot take any other approach, whether their objective is profit, program expansion into rehabilitation areas, or simple survlval

The government does appear to create incentives in mental health when they serve greater policy or social needs One example of this was the Medical Care Facilities Financing Corporation in the 1960s, which was implemented as part of the government’s “income-doubling” economic recovery plan Another example appears to be the new residential program model adopted by the government in 1992 It pays for the residential and rehabilitation expenses of discharged mental patients who are capable of working in competitive jobs This came at a time when Japan was struggling w t h not hawng a large enough workforce to fill all the available jobs, especially the low-paying and unap- pealing ones This seems to be consistent w t h Warner’s (1985) multicountry study, where he found that deinstitutionalization policy was correlated w t h low unemployment rates

While the general lack of a community tradition makes rationalizing a community-based mental health system more difficult, Japan has successfully accomplished rationalization in other areas Education and general health care are two examples, and since the society is rapidly aging, an intense effort to accomplish rationalization w t h community-based semces for the elderly is under way Thus, the explanation that the dominance of hospital programs in Japan and the paucity of community-based alternatives are the result of a lack of community-based tradition is too simplistic The community has a nch tradition of naturally occumng, community-based mutual support actimties These differ from the West’s tradition of organization-based social supports, and so it appears in a Western context that Japan lacks this tradition In reality, the lack seems to be in the effort to find a community model that w11 work for Japan

Additionally, as discussed, the government has focused almost exclusively on the development of hospital-based programming through its reimbursement policy. While the amount of reimbursement for hospital care is low, the amount of capital assistance to begin nonhospital alternatives, and the mechanisms for reimbursement for the use of those alternatives, are vlrtually nonexistent

Where Is the Mental Health System Going? Of course, so as not to restrict our criticism to the Japanese mental health system, the question of where the mental health system is going could be asked


of the United States as well-probably with the same unsatisfactory answer. The main difference is that America has attempted some large-scale mental health systems, while Japan has not. Is there anything to be learned from these American experiments? Without recommending a slavish reproduction of an American model, I think the answer is yes.

Japanese patients are trapped in hospitals in part because of reimbursement policies. Even hospitals that want to try community experiments are often unwilling to do so because they must pay the entire cost themselves. The government, on the other hand, seems not to want higher mental health expenditures and sees community-based programs as leading in that direction. This would seem like the ideal situation in which to look at capitation (Mechanic and Aiken, 1989). While the American experiments with capitation are still equivocal, conditions in Japan would appear to make it more feasible. Japan has universal health insurance, a less diverse health care system, and a family support system with a higher level of defined obligation. Since the rate of hospital reimbursement is so low to begin with (as Chapter Four notes), if the government could be assured that it would be no higher in the community, hospitals and patients would then have the freedom to use the funds for community programming. The alternative for the government is the current policy: the same rate of expenditures spent on permanent institutionalization.

Some in Japan have complained that the government policies emanating from the 1988 Revised Mental Health Law have actually produced a net reduc- tion in the government’s expenditures on mental health. This is caused by a shift in patients from involuntary to voluntary hospitalization categories. The government pays full cost for some of the involuntary categories but does not for the voluntary category. The savings have not been cycled back into mental health programming, despite the obvious need for community-based programming and the paucity of available funds.

A culturally appropriate version of Assertive Community Treatment (Stein and Test, 1985) also appears to have potential for Japan. The development of Assertive Community Treatment from a hospital, using hospital-like staffing patterns and maintaining long-term supportive relationships by staff, is an approach that many in Japan would probably be comfortable with. It would allow for a break with the hospital tradition, but a break that is not totally unfamiliar.

Perhaps because of the lack of a welfare state tradition, sometimes it appears that Japan does not know how to do it. It is a curious phenomenon. I t produces an extreme paternalism in many instances, since that is a traditional function. On the other hand, it produces a real reluctance to embark on certain social policies and a curious reluctance to mandate them. Thus, certain social welfare policies and structures will be recommended with language like should rather than m w . Frequently, the result is slow movement in basic social policies like mental health.

On the other hand, sometimes should is powerful in influencing social change in Japan. Recently, the government suggested that Japanese should


work less and enjoy themselves more. It recommended that people should stop working on Saturday, a traditional work day A short time later, Saturdays were transformed! While Japan is far from a leisure society, the influence of should is strong, once seriously stated..

Japan should change its mental health policy and system in a direction that is both progressive and culturally appropriate. The progressive mental health community can only hope that Japan uses its opportunity to do so.

References

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Clark, R. TheJapanese Company. New Haven, Conn.: Yale University Press, 1979. Fukutake, T. Japanese Social Structure. (2nd ed.) Tokyo: University of Tokyo Press, 1989. Harding, T. W., Schneider, J., Visotsky, H. M., and Graves, C. L. Human kghts and Mental Patients

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Mechanic, D. and Aiken, L. H. (eds.). Paying for Services: Promises and Pltfalls of Capitation. New Directions for Mental Health Services, no. 43. San Francisco: Jossey-Bass, 1989.

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Nakane. C. Japanese Society Berkeley: University of California Press, 1970. Rohlen, T. For Harmony and Strength. Berkeley: University of California Press, 1974. Stein, L. 1.. and Test, M. A. (eds.). The mining in Community Lving Model A Decade of Euperience.

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JAMES M. WNDIBERG was associate professor of social welfare a t Shikoku Gakuin University in Zentsuji, Japan, a t the time of this research. He is former director of Community Support and Community Mental Health services for the Santa Clara County Mental Health Bureau in California.

Between a rock and a hard place: The mental health system in japan

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