In the previous post, I wrote about the historical events that prompted the implementation of the Medical Treatment and Supervision Act of 2005. In this second and last part, we will see what changes the most recent Act on forensic mental health brings about, and what problems it has already met.
THE MEDICAL TREATMENT AND SUPERVISION ACT
The revised Mental Health and Welfare act of 1999 scheduled a reform in 2004, including a new legislation for mentally ill offenders (Kunihiko, 1999). This reform should address the lack of security in mental hospitals. Indeed, no special provisions existed concerning the hospitalization of mentally diseased offenders. Moreover, the concept of “forensic health” originated in Europe and was never discussed before in Japan (Satsumi & Oda, 1995). This issue received public attention after a janitor, suffering from personality disorders, stabbed 8 children to death in the Osaka school massacre in 2001. When it became known that the offender had a criminal record, the public opinion called for a legislation concerning the treatment of the mentally ill and recidivists in particular (Fujii, Fukuda, Ando, Kikuchi, Okada et al., 2014). The Ministry of Justice issued a briefing report, aiming at the integration of forensic inpatient and outpatient services, provided they were strictly controlled. The report also included the necessity of a mentality change towards the mentally ill (Weisstub & Carney, 2005).
In 2002, a new Bill for the Medical Treatment and Supervision Act was introduced to the Diet (Nakayama, 2005). The bill was proposed by the government and supported by the Japanese Association of Psychiatric Hospitals. The emphasis on the prevention of re-offending (再犯の恐れ), however, triggered criticism from the parties involved (Moriya & Ujiie, 2008). The bill stipulated that only those deemed prone to recidivism were suited for hospital treatment. More than 20 organizations objected that future criminal intentions could not be predicted (Nakatani, Kojimoto, Matsubara & Takayanagi, 2010). The Japan Federation of Bar Associations warned that it could “bring about violation of human rights”. The Bill was passed in 2003 and implemented on 15 July 2005 as The Medical Treatment and Supervision Act, short for the Act for the Medical Treatment and Supervision of Persons with Mental Disorders Who Caused Serious Harm. This time, the word for ‘fear for re-offending’, was left out and replaced by euphemisms in the Act, because it echoed the traditional emphasis on maintaining public order (Fujii et al., 2014).
The purpose of the Act is threefold: stimulating rehabilitation, improving accurate treatment and preventing recidivism (Nakatani, 2012). Whether a mentally ill offender will be treated or not, depends on three criteria (Guidelines for Psychiatric Evaluation). Firstly, the nature and severity of the mental disorder and its link with the crime; Secondly, the treatability; thirdly, the existence of factors that could interfere with the rehabilitation. If all three criteria are met, the mentally ill offender is designated a treatment order. The Medical Treatment and Supervision Act, however, only applies to mentally ill offenders who committed a serious crime: homicide, robbery, bodily injury, arson, or a sexual crime (Nakatani & Kuroda, 2013). Other crimes are regulated by the Inmates and Detainees Act or the Mental Health and Welfare Act.
Between 2005 and 2012, there were 2,750 requests for treatment according to the Medical Treatment and Supervision Ac of which 63.1% received an inpatient treatment order (Fujii et al., 2014). Inpatient treatment includes three stages: acute, recovery and rehabilitation (Nakatani et al., 2010). The expected length of stay is 18 months but can be prolonged, which happened in more than 33% of the cases in 2011 (Nakatani & Kuroda, 2013). By December 2007, 14 designated inpatient facilities were attached to public psychiatry hospitals in Japan (Matsubara, 2008), by 2013 there were 30 facilities, or 791 beds available in the whole country (Fujii et al., 2014). Two of the four medical prisons in Japan are specialized in psychiatry (Nomura, 2009). The director of the designated facility confirms the continuity of hospitalization every six months (Ministry of Justice, 2012). He or she also asks permission to the District Court in order to discharge the mentally ill offender (Nakatani, 2012). Through a hearing, the Court decides whether a patient can be released or not.
Outpatient treatment requires a collaboration of various institutions such as designated outpatient facilities and local health and welfare agencies (Nakatani et al., 2010). When the Court orders an outpatient order, the patient is placed under the probation office’s mental health supervision. The director of the probation office defines a plan for every mentally ill offender and assigns rehabilitation coordinators. The expected length of the treatment is three years but can be prolonged with an additional two years. The director of the probation office asks permission to the District Court in order to conclude the outpatient treatment, or to hospitalize the mentally ill offender in case his condition worsens (Nakatani, 2012). The court decides after conducting a hearing (Ministry of Justice, 2012). In March 2008, there were no less than 260 designated outpatient facilities (Matsubara, 2008). By 2014, this number rose to 452 facilities (Fujii et al., 2014).
Although the Medical Treatment and Supervision Act was successfully enacted, the implementation is still in its infancy. In today’s forensic health literature, scholars recognize serious problems that hinder an adequate treatment of mentally ill offenders.
Firstly, it appears that personality disordered offenders are hardly appointed a treatment order. The same applies to offenders whose treatability is doubtful. As a result, the number of treatment orders for insane offenders in Japan is remarkably low compared to other countries (Nakatani, 2012). This number remains stable, although more inmates have been diagnosed with mental disorders (e.g. schizophrenia) in recent years (Nakatani & Kuroda, 2013; Nomura, 2009).
Secondly, human and financial resources for outpatient treatment prove to be insufficient. Next to that, rehabilitation coordinators are not given enough authority in crisis situations (Nakatani, 2012). Furthermore, a regional gap in inpatient as well outpatient designated facilities can be observed (Fujii et al., 2014). Thirdly, the foreseen length of stay for inpatient treatment is too short in most cases, which leads to overpopulation of mental health facilities (ibid.). Fourth, when an offender – suspected to be ill – stands trial according to a jury system, it could be difficult for lay judges to grasp the psychiatric context of the offense (Moriya & Ujiie, 2008).
Fifth, it is observed that thirty percent of mentally ill offenders are addicted to methamphetamines or to other kind of drugs (Imamura, Matsumoto, Kobayashi, Hirabayashi & Wada, 2010). This extends the length of recovery (Nakatani & Kuroda, 2013). Sixth, psychiatric personnel appear to be understaffed. In April 2007, only 26 full-time psychiatrists were employed in Japanese forensic institutions (Nakane, 2007; Kuroda, 2008). As a result, refractory patients, frequent among mentally disordered, are not treated properly. Psychiatric personnel are also rather unwilling and reluctant to work in forensic hospitals (Nakatani & Kuroda, 2013). Seventh, once incarcerated, it remains very difficult for offenders whose mental condition worsens, to be transferred to a specialist institution. Similarly, mentally ill offenders are rarely released on parole, because they have difficulty expressing the motivation necessary for such release (ibid.).
Eighth, not enough attention is paid to death row inmates, who tend to develop mental disorders (ibid.). Ninth, no significant change in attitude towards forensic mental health is noticed (Shiina, Okita, Fujisaki, Igarashi & Iyo, 2013) after the enactment of the Medical Treatment and Supervision Act. Mentally ill offenders appear to be stigmatized twice in society. Tenth, there exists no formal framework for psychiatric practice. Therefore, psychiatrists develop their own way of dealing with mentally ill offenders (Weisstub & Carney, 2005). Eleventh, the treatment of mentally disordered offenders is often cut off when they are released after having served their sentence (Nomura, 2009). When this implies a risk of recidivism, the director of a designated facility notifies the prefectural governor and asks for an involuntary hospitalization order. Local authorities, however, seldom carry out this order (ibid.). Twelfth, offenders of less serious crimes are not covered by the Medical Treatment and Supervision Act and are often incarcerated with minimal psychiatric assistance (Odagaki & Toyoshima, 2010).
Some scholars believe the advantages of the Medical Treatment and Supervision Act do not equal its advantages and call for an abolishment of the act (Nakajima, 2011). Others are less radical but still emphasize the need for a thorough revision of the Act (Odagaki & Toyoshima, 2010). Although the Act was slightly adapted in 2006, the scheduled revision for 2010 did not take place. The fact that the Act is not yet widely known could also be an explanation for the lack of international criticism (ibid.).
The new system is a unique but limited combination of forensic and general psychiatry. This way of dealing with the mentally ill already faces many challenges, and it will not take long before the Medical Treatment and Supervision Act is revised.
END OF PART 2
Thanks for reading!
citation of this article: Van Enis, Ann-Sofie. “The Medical Treatment and Supervision Act (2005): Forensic Mental Health in Japan Today.” Nippaku, January 20, 2015. https://nippaku.wordpress.com/.
 The offender, however, was attributed full responsibility and was sentenced to death.
 Including the Japan Association of Psychiatry and Neurology, the National Federation of Families with Mentally Ill in Japan and the Japan Federation of Bar Associations (Japan Times, 8 June 2002).
「許容しがたい人権侵害をもたらす」said president Kazumasu Kuboi (Asahi Shimbun, 16 March 2002).
心神喪失等の状態で重大な他害行為を行った者の医療及び観察等に関する法律 （略:医療 観察法）in Japanese (Moriya & Ujiie, 2008).
入院処遇 in Japanese (Moriya & Ujiie, 2008).
 The stay of 144 (33.2%) mentally ill offenders was prolonged. In general, forensic patients stay longer than non-forensic patients in mental health facilities.
 Designated by the Minister of Health, Labour and Welfare.
 通院処遇 in Japanese (Moriya & Ujiie, 2008).
 Designated by the Minister of Health, Labour and Welfare.
 Only 1,1% of mentally ill offenders treated according to the Medical Health and Supervision Act is diagnosed with a personality disorder. The reason is that most of them are found guilty and fully responsible, eliminating the possibility of being referred to the Act (cf. supra: Osaka school massacre) (Fujii et al., 2014).
 At the end of 2013, no designated inpatient facility existed in Hokkaidō and Shikoku (Fujii et al., 2014).
 Compare this to Belgium, where 32 full-time psychiatrists and 147 full-time psychologists were employed in June 2006 (Salize, Dreßing & Kief, 2007).