Old Stories of Madness

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Next up in our “Mental Health in Japan” series is a limited selection of stories on “madness” as recorded in Japan’s classic literature of the Heian period (794-1185), with a special focus on terminology. I have already written several posts on Heian literature, partly because it was by reading these books that I became fascinated with Japanese culture. I am a huge fan of Sei Shonagon (I recommend her Pillow Book to everyone who wants to explore court life in Japan around the year 1000) and, of course, I should mention Murasaki Shikibu, creator of Japan’s biggest playboy ever. Both female writers are featured in this post. If you’re interested in the topic of “madness”, you should also check out part one, two and three of my “Mental Health” series.


Story no. 1: The Great Mirror and Mad Emperors

The Great Mirror (Ōkagami大鏡), a historical account written during the latter half of the Heian period, briefly mentions the “madness” of emperor Reizei (950-1011). Ōe Masafusa (1041-1111) describes in his diary (Gōki江記) the eccentric demeanor of the emperor at a young age: One day, he kicked a football for a whole day without minding his bleeding feet; when a fire broke out in the palace, he was singing songs with a loud voice while fleeing; in response to his father’s letter, he once sent a drawing of a phallus and so on[1]. Reizei’s fits of insanity are explained in The Great Mirror as “an affliction attributed to the angry spirits of his half-brother and disappointed rival, Murakami’s oldest son, and of the mother and grandfather of the unsuccessful Prince, all of whom had died when Reizei was about three years old[2]”. His condition is the result of a curse (tatari祟) caused by the revengeful spirits (onryō怨霊) of the relatives he had allegedly robbed from their imperial title, upon which they had died out of despair[3]. Once acceded to the throne, Reizei was forced to abdicate due to his mental instability only two years later. The curse also had repercussions for the mental health of his offspring, among whom Reizei’s son emperor Kazan is discussed in The Great Mirror as well. Another example is Reizei’s daughter Sonshi. It was rumored that she left the palace and became a nun because of a hereditary mental illness. [4].

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Emperor Reizei’s tomb in Kyoto.

Reizei’s mental disorder is referred to as 御物の怪 (o-mono no ke of which o is a honorific prefix) several times throughout The Great Mirror, a term of which the meaning is linked to religion and spirituality. Another term that is used at a certain point in the narrative, is kurui (狂ひ), which has a more negative connotation. Kurui appears in a dialogue between Minamoto no Toshikata, Minister of Popular Affairs, and the priest Fujiwara no Michinaga. Minamoto is sharing some amusing anecdotes about the eccentric behavior of emperor Kazan with Fujiwara, and attributes his mental disorder directly to his “deficient character from birth”. He adds that “Kazan’s craziness (kurui) is even more difficult to handle than his father’s, emperor Reizei”, after which they both burst out in laughter[5].

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Emperor Kazan, Reizei’s son.

Unlike The Story of Splendor (Eiga Monogatari 栄花物語), in which a metaphorical approach is adopted, The Great Mirror criticizes the mental condition of emperor Reizei and his son Kazan directly[6]. Moreover, it is suggested that they bear the responsibility for their disorder themselves, despite the fact that the pathogenesis is otherwise stated as mono no ke throughout the work. Hence, The Great Mirror further comments that Emperor Kazan was said to be “looking great on the outside, but lacking on the inside[7]”, while emphasizing the latter[8]. From the context in which kurui appears, we can deduce that the two terms used to describe a mental disorder here have different connotations. Whereas mono no ke has a spiritual background and a rather positive nuance, kurui appears to be a means to enhance criticism or mockery towards the possessors of such a mental condition.

Another suggestion is that Reizei was only slightly eccentric, and that the abnormality of his behavior was grossly exaggerated by the Fujiwara clan. As a result of these rumors, Reizei as well as Kazan were forced to abdicate at a young age[9]. Even if the assumed mental disorder of both emperors would be part of  a political set-up, the criticism and mockery, or the fact that badmouthing about the opponent’s mental condition was an efficient way to eliminate them, still shows that the ancient society in Japan was, to a certain extent, prone to stigmatization against people afflicted with a mental disorder.

References: [1] Yawata, Kazuo八幡和郎. Biographies of Successive Generations of Emperors: “National History” You Want to Know as a Japanese歴代天皇列伝: 日本人なら知っておきたい「国家の歴史」(Rekidai tennō retsuden: nihonjin nara shitteokitai “kokka no rekishi”). Tokyo: PHP Research Institute, 2008, p. 895. [2] McCullough, Helen Craig, Tamenari Fujiwara, and Yoshinobu Fujiwara. Ōkagami, the Great Mirror: Fujiwara Michinaga (966-1027) and His Times : A Study and Translation, 1980, p. 346. [3] “Emperor Reizei” 冷泉天皇 (Reizei tennō) in Asahi Encyclopedia of Historical Figures in Japan 朝日日本歴史人物事典 (Asahi nihon rekishi jinbutsu jiten) Tokyo: Asahi Shimbun Printing, 1994. [4] Groner, Paul. Ryōgen and Mount Hiei: Japanese Tendai in the Tenth Century. Studies in East Asian Buddhism 15. Honolulu: University of Hawaiʻi Press, 2002, p. 266. [5] For original text and translation in modern Japanese see appendix 3. [6] Satō, Asano佐藤あさの. “Emperor Reizei in The Great Mirror”『大鏡』冷泉天皇 (“Ōkagami” Reizei tennō) summary graduation thesis, Hokkaido university of Education, Association for National language and literature, Sapporo National Language Research, 17 (2012): 103. [7] Original text: その帝をば内劣りの外めでたとぞ、世の人申し. [8] Tsuji, Kazuyoshi辻和良. “The Appearance of Kazan: Narrative in The Great Mirror”花山の姿 : 大鏡の<カタル>方法 (Kazan no sugata: Ōkagami no ‘kataru’ hōhō) Journal of Nagoya Women’s University, Humanities and Social Sciences, 36 (1990): 304–297, p. 303. [9] Hattori, Toshiyoshi服部敏良. Research Tidbits on the History Medicine in Japan日本医学史研究余話 (Nihon igakushi kenkyū yowa) Kagakushoin, 1981, p. 299.

Story no. 2: The Pillow Book and  Mono no Ke

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Writer Sei Shonagon

Mono no ke is a returning concept in Heian literature, represented in The Diary of Lady Murasaki, The Tale of Genji and The Pillow Book, all works written by women. It originated in 8th century China and became a popular term among the Japanese aristocracy during the 9th century. Mono no ke is composed out of the characters物 (mono, meaning “thing”, a substitute out of superstition for writing or saying the word “demon”鬼) and ke 怪, related to気 (spirit) and literally means “the spirit of an evil ghost[10]. It refers to the curse cast either by the ghost of a deceased person or by the vengeful spirit of a living creature. Such a curse took concrete shape in physical or mental illness. Sei Shonagon records in her diary The Pillow Book (Makura no Sōshi枕草子, 1002) under “hateful things” the following item:

Someone has suddenly fallen ill and one summons the exorcist. Since he is not at home, one has to send messengers to look for him. After one has had a long, fretful wait, the exorcist finally arrives, and with a sigh of relief one asks him to start his incantations. But perhaps he has been exorcizing too many evil spirits [=mono no ke] recently; for hardly has he installed himself and begun praying when his voice becomes drowsy. Oh, how hateful![11]

Doctors in the Heian period were called genza 験者, practitioners of esoteric Buddhism or folklore Shintoism, who treated illnesses by exorcizing the evil spirits causing the disease. Shirane explains: “The aim of the exorcist was to transfer the evil spirit from the afflicted person to the medium, usually a young girl or a woman, and to force it to declare itself. The exorcist used various spells and incantations to make the Guardian Demon of Buddhism take possession of the medium. When he was successful, the medium would tremble, scream, have convulsions, faint or behave as if in hypnotic trance. The spirit would then declare itself through her mouth. The final step was to drive the spirit out of the medium[12]“.

Once again, diseases are set against a religious and spiritual background. As the doctor in Sei Shonagon’s story is exhausted from overworking, it appears that sudden attacks of mono no ke were very common at that time. One believed that the most effective way to treat illness was to recite incantations. A failed exorcist session is covered in The Pillow Book as a “depressing thing”.

With a look of complete self-confidence on his face an exorcist prepares to expel an evil spirit [=mono no ke] from his patient. Handing his mace, rosary, and other paraphernalia to the medium who is assisting him, he begins to recite his spells in the special shrill tone that he forces from his throat on such occasions. For all the exorcist’s efforts, the spirit gives no sign of leaving, and the Guardian Demon fails to take possession of the medium. The relations and friends of the patient, who are gathered in the room praying, find this rather unfortunate. After he recited his incantations for the length of an entire watch [= two hours], the exorcist is worn out. (…) “Well, well, it hasn’t worked!” [13]

References[10] Takeguchi, Ryūsuke竹口竜介. “About the Genesis and Social Conditions of Mono no Ke during the Heian Period” 平安時代における物怪発生と社会状況について (Heian jidai ni okeru mono no ke hassei to shakai jōkyō nit tsuite) Journal of Ryūkoku University Graduate School for Literature Research 龍谷大学大学院文学研究科紀要 (Ryūkoku daigakuin bungaku kenkyūka kiyō), 27 (Dec 2005): 328-334, p. 330. [11] Shirane, Haruo, ed. Traditional Japanese Literature: An Anthology, Beginnings to 1600. Abridged ed. Translations from the Asian Classics. New York: Columbia University Press, 2012, p. 151.[12] Original footnote in ibid., p. 149. [13] Ibid., p. 149.

Story no. 3: The Tale of Genji and jealous spirits

In order to nuance our definition of mono no ke, it is necessary to look into its use in The Tale of Genji (Genji Monogatari 源氏物語, early 11th century). The fact that this term appears 51 times indicates its role as a key feature throughout the work. Writer Murasaki Shikibu attributes 18 personae with a spiritual possession, among which the story of Genji’s wife, Aoi, and the spirit of his mistress, the Rokujō lady, is perhaps the most representative.

At Sanjō, Genji’s wife seemed to be in the grip of a malign spirit [mono no ke]. It was no time for nocturnal wanderings. (…) Several malign spirits were transferred to the medium and identified themselves, but there was one which quite refused to move. Though it did not cause great pain, it refused to leave her for so much as an instant. There was something very sinister about a spirit that eluded the powers of the most skilled exorcists. The Sanjō people went over the list of Genji’s ladies one by one. Among them all, it came to be whispered, only the Rokujō lady and the lady at Nijō seemed to have been singled out for special attentions, and no doubt they were jealous. The exorcists were asked about the possibility, but they gave no very informative answers.[14]

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Aoi and Genji, surrounded by anxious court ladies.

Aoi passes away due to an illness caused by the jealous spirit of the Rokujō lady, who is unaware of her own soul’s wanderings. Apart from Aoi’s suffering, Shikibu also emphasizes the mixed feelings of the Rokujō lady, unable to suppress her jealousy and overcome with self-loathing. In this sense, both ladies are victimized by the “madness” mono no ke generates. Other characters described as haunted by an evil spirit, nearly all of them female, are driven mad by love-related conflicts.

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“Aoi no Ue” in Illustrated Book of Monsters (怪物絵本, kaibutsu ehon 1881)

It is clear that the Tale of Genji does not strive to render a realistic image of mental disorders. Shikibu employs mono no ke as a metaphorical tool to liberate women from social restrictions and empower them to express their suppressed feelings. As Bargen argues, “spirit possession and exorcism are understood, on the one hand, as a dramatic, subversive response to social injustice and the psychological repression of women and, on the other, as the attempt of controlling groups to pacify female frustration and rage[15]”. The Tale of Genji already enjoyed great popularity in the Heian period. It should, therefore, not surprise that its influence attributed to the establishment of mono no ke as a dramatic concept in the literature and arts of later periods.

References[14] Murasaki Shikibu and Edward G. Seidensticker, translator. The Tale of Genji. eBooks@Adelaide, chapter 9 “Heartvine”. [15] Bargen, Doris G. “Spirit Possession in The Context of Dramatic Expressions of Gender Conflict: The Aoi Episode of The Genji Monogatari.” Harvard Journal of Asiatic Studies 48, no. 1 (June 1988): 95–130, p. 96.

The Perception of Mental Disorders in Ancient Japan

20160623_193344.jpgAs mentioned before, several parts of my Master’s dissertation (“The Stigmatization of People with a Mental Disorder in Premodern Japan: Research from a Cultural Historical Perspective”) will be posted on Nippaku. Click here to check out the first introductory part! Another history post related to this topic that might be of interest to you is this one about the similarities and differences between the Belgian city of Gheel and the Japanese hamlet of Iwakura. Today, we will go as far back in time as the eighth century to discover how people with a mental disorder were regarded and treated during the Nara and early Heian period.


“Madness” as a Privilege of the Shaman

The oldest notion of “madness” can be traced back to shamanism, a spiritual practice that originated in the Paleolithic period[1]. The Japanese form of shamanism, mikoism, was shaped with the diffusion of shamanism in Central Asia, although there are as many differences as similarities[2]. In the hunter-gatherer society, it was believed that the animals they hunted down for food could reincarnate. A Siberian fortune teller, or shaman, descended into the world of the sacrificed animals to predict by means of their bones whether this was the case or not. The shaman also wore animal hair and skin to adopt animalistic features. In order to psychologically immerse himself in the underworld, the shaman drank extracts of poisonous mushrooms, uttered incantations, danced fanatically until he or she eventually fell down on the ground and entered a state of apparent death. The poisonous substances triggered a state of altered consciousness, interpreted as “madness” and today known as a mental disorder caused by narcotics or alcohol. The fact that the character for “mad” (狂) in Japanese has the radical for dog or animal (犬)[3] can be traced back to this shamanistic practice.

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Picture from an article in National Geographic, depicting a Mongolian shaman. The text says “shaman, the one chosen by the spirits” – http://natgeo.nikkeibp.co.jp/nng/article/20121120/331216/

With the emergence of sedentary agricultural societies, shamans continued to play an important role by predicting successful harvests. The harvest was a matter of life or death, and shamans were often appointed as king or queen of newly-formed states. Although they combined a spiritual responsibility with a political role, shamans still carried a strong link with “madness”. During times of war, the king or queen, “raging with anger” would lead the troops. “Anger” expresses just like “madness” a strong affective change[4]. In the shamanistic society, the privilege of being “mad” inferred a supernatural statute, and was only granted to shamans, or kings and queens.

Footnotes[1] Omata, Waichirō 小俣和一郎. The History of Psychiatry 精神医学の歴史 (Seishin igaku no rekishi). Tokyo: Daisan Bunmeisha, 2005, p. 21ff. [2] Fairchild, William P. “Shamanism in Japan.” Folklore Studies 21 (1962): 1, p. 105. [3] Kamada, Tadashi鎌田正and Toratarō Komeyama米山寅太郎 “狂.” (kyō) in New Kanji Forest新漢語林, Taishūkan Shoten, 2011.

Early Accounts of Mental Disorders

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The oldest extant manuscript (眞福寺本shinpukuji-hon) of the “Kojiki” – Wikimedia Commons

The oldest preserved Japanese law documents that gives an account of the treatment of mentally disordered citizens, is the Taihō Ritsuryō (701). According to this premodern law system, mental disorders were divided into three categories[5] based on the severity of the disorder. Citizens suffering from the two most severe disorders, were registered as fukakō (不課口) or fukuwa (不課), and discharged from corvée. The law also stipulated that people with a mental disorder of the most severe type should receive nursing care[6]. Moreover, the punishment for crimes committed by individuals with a mental disorder was slightly reduced[7]. Although it remains unclear whether these provisions were actually realized, we can see that during the eighth century, the law system did not prescribe the proactive banishment or persecution of individuals with a mental disorder but pursued a policy of social integration.

Records of Ancient Matters (Kojiki古事記, 712), the oldest literary work in Japan, comprises another description of the reaction to “madness”.

Then His-Swift-Impetuous-Male-Augustness said to the Heaven-Shining-Great-August deity: “Owing to the sincerity of my intentions I have, in begetting children, gotten delicate females. Judging from this I have undoubtedly gained the victory.” With these words, and impetuous with victory, he broke down the divisions of the rice-fields laid out by the Heaven-Shining-Great-August deity filled up the ditches, and moreover strewed excrements in the palace where she partook of the great food. So, though he did thus, the Heaven-Shining-Great-August deity upbraided him not, but said: “What looks like excrements must be something that His Augustness mine elder brother has vomited through drunkenness. Again, as to his breaking down the divisions of the rice-fields and filling up the ditches, it must be because be grudges the land they occupy that His Augustness mine elder brother acts thus.” But notwithstanding these apologetic words, he still continued his evil acts, and was more and more violent. As the Heaven-Shining-Great-August deity sat in her awful weaving hall seeing to the weaving of the august garments of the deities, he broke a hole in the top of the weaving-hall, and through it let fall a heavenly piebald horse which he had flayed with a backward flaying, at whose sight the women weaving the heavenly garments were so much alarmed they died of fear.[8]

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Susanoo, here in a sober state, saving a princess from a dragon – Wikimedia Commons

His-Swift-Impetuous-Male Augustness, otherwise called Susanoo, drank too much out of excitement and started to act like a “madman”. His sister the Heaven-Shining-Great-August deity, or Amaterasu, forgave him the first time, attributing his vicious behavior to a mental change caused by alcohol. However, when Susanoo threw a skinned horse through the roof, Amaterasu was terrified and hid herself into a cave.

The “madness” here illustrated can be further explained by the hare and ke dichotomy theorized by Yanagita Kunio in A History of the Meiji and Taisho periods: Social Conditions 明治大正史 世相篇 (Meiji taishō shi  sesō hen, 1930). Hare, “the sacred”, refers to something formal, festive, ritual, public and extraordinary whereas ke, “the secular”, alludes to the profane, mundane, private and everyday life. Based on Yanagita’s thesis, the suggestion here is that people who lost the ability to discern between hare, the sacred and ke, the profane, behaved as was only permitted on hare days, and were, therefore, labeled as a “mad”.

Susanoo, for example, was so proud of his accomplishment that he started drinking alcohol and acting violently, this in contrast with his sister and the other women, who were dealing with their daily activities. His actions were seen as “defilement”, kegare, in a ke context, whereas it would have been perceived as a sign of spirituality in a hare context. Although Susanoo was heavily punished for his vicious acts in the end, it should be noted that Amaterasu first shows some mercy regarding his mental condition.

Footnotes[4] Perhaps best illustrated in the English language, where the word “mad” covers those two connotations. [5] Zenshichi残疾, haishichi癈疾 and tokushichi篤疾.[6] Hashimoto, Akira橋本明. The history of psychiatric care in Japan. Were there rights for “mental patients”? – Gleaners in the history of psychiatric care in Europe.日本の精神医療史. “精神病者”の権利はなかったのか?―ヨーロッパ精神医療史の落穂拾い― (Nihon no seishin iryōshi. “seishin byōsha” no kenri ha nakatta no ka? – yōroppa seishin iryōshi no ochibohiroi), 2002.  [7] Omata, History of Psychiatry, p. 48.[8] Chamberlain, R. H. The Kojiki. Seattle: PublishingOnline, 2001, p. 32-33.

“Mad” People and Religion

One way to discover elements of (non-)stigmatization in a certain period in time, is by looking at the terminology used for individuals with a mental disorder and the positive, neutral or negative connotations these words bear. In Chronicles of Japan (Nihon shoki 日本書紀, 720)[9], Shoku Nihongi続日本紀 (797)[10] and Saimeiki 斎明記[11], the word tabure 狂is used to describe “madness”. Tabure has a double meaning: on the one hand, it is connected with the word tawamure 戯れ, meaning nowadays “jest”, “flirtation” or “joke”, and indicates a deviant social behavior, such as in the story about Susanoo’s ravage. On the other hand, tabure is derived from the phrase tamashii ni fureru 魂に触れる, “to touch the soul”, and refers to spirit possessions, as was practiced in Shintoism[12]. Accordingly, “mad people” were called taburebito狂人. This term appears neutral, even positive in combination with a context based on hare. Notwithstanding, only one word existed to point out “mad people” at that time, so it could in se also express strong disapproval of others’ deviant social conduct.

An example of taburebito used to condemn those not in their right mind, can be found in Veritable Records of Three Reigns in Japan (Nihon sandai jitsuroku日本三代実録, 901). An imperial edict from the year 866 warns that “in the case lunatics would conspire to destroy the state, all deities will quickly resurrect”[13]. This criticism is directed towards the conspirators of the Ōtenmon incident of the same year[14]. Those who would harm the state and therefore also its fundament, the emperor, officially the descendent of the gods, must be crazy. Taburebito is used here to argue that rebellion against the political institution or emperor is pure “madness”[15].

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People running to the burning Otenmon Gate, painted scroll from the 12th century – Wikimedia Commons

Around the Nara period, the Sino-Japanese reading of the character for “mad”, kyō 狂, came into use. Kyō is not as old as the Japanese reading tabure and bears in addition a slightly more negative connotation: it is used to direct social criticism towards people behaving differently from what convention prescribes, especially when the motive or reason for this demeanor is known[16]. In other words, Kyō roughly overlaps with the first meaning of tabure, but has an additional element of criticism.

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Yamabushi – Wikimedia Commons

Another characteristic of “madness” in Ancient Japan lies in the connection between taburebito and the practice of mountain worship (sangaku shinkō山岳信仰). With the development of an agricultural society on the flatland, mountains were held to be the abode of kami and became objects of worship[17]. They were, therefore, forbidden ground for normal villagers. On hare days, kami descended from the mountains to the village, and the “madness” originating at sacred heights was temporarily transferred. People who entered the mountains were thus regarded as “madmen”. Especially on ke days, this kind of deviant behavior represented a breach or escape from everyday interpersonal relations[18].

At the same time, however, mountains were supernatural places where an encounter with the gods became possible, and attracted for that reason people wandering around in search of spiritual enlightenment[19]. Taburebito who used to do so on normal days were regarded as “close to the gods” and gained a special status. Their aberrant conduct was not judged on a personal level but in a religious context, in the sense that their connection with kami was predestined and necessary for a smooth communication with the supernatural world. In the footsteps of shamans and miko, taburebito played an important role in mediating between the two worlds. Considering that “madness” was strongly connected with hare, we can conclude here that an interpretation of non-stigmatization can be applied.

Footnotes: [9] E.g. tabure gokoro no mizo 狂心渠 “the ditch of madness”, an enormous water construction ordered by empress Saimei (chapter 26). [10] E.g. tabure madō 狂迷 “go astray in madness” (16th emperial edict). Frellesvig, Bjarke, Stephen Wright Horn, Kerri L. Russell, and Peter Sells. The Oxford Corpus of Old Japanese. [11] Actually a part of the Nihon Shoki. Saimeiki gives an account of the feigned “madness” (itsuwari tabure) of prince Arima.[12] Oda, Japanese Sources on Madness, p. 15, 17-18. [13] Original text: 若狂人乃國家乎亡止謀留事奈良波。皇神達早顯出給比 (若し狂人の国家を亡さむと謀る事ならば皇神達早く顕出し給ひ).  [14] Although it is unclear who actually conspired against who, the incident started with the main gate of the royal palace (Ōtenmon) burnt down. Several accusations were made, but in the end Fujiwara no Yoshifusa seized the power, executed his political enemies and was promoted as Regent. [15] Dismissing those who rebel against the emperor and imperial family as “madmen” is not only limited to this period, but is a recurring phenomenon throughout Japanese history, also referred to as a side effect of the “chrysanthemum taboo菊タブー(kiku tabū, chrysanthemum refers to the imperial house)”. For an overview of such incidents in modern Japanese history, see Inoue, Shōichi井上章一. Madness and Royal Authority 狂気と王権 (Kyōki to ōken), Tokyo, Kodansha, 2008. [16] Oda, Japanese Sources on Madness, p. 15. [17] Yano, Kazuyuki. “Sacred Mountains Where Being of ‘Kami’ Is Found.” 16th ICOMOS General Assembly and International Symposium: Finding the Spirit of Place – between the Tangible and the Intangible. Quebec, Canada, 2008, p. 1. [18] Oda, Japanese Sources on Madness, p. 27-28. [19] Yanagita, Kunio. Mountain Village Life. Tokyo: Heibonsha, 1961.

“Madness” in Buddhism

During the 6th century, Buddhism was introduced in Japan and later adopted as the official religion. The monk Keikai edited 116 Buddhist stories from the Nara period and earlier in the Nihonkoku (Genhō Zenaku) Ryōiki日本(国現報善悪)霊異記 (822)[20]. In this compilation there are several stories dealing with mental disorders, but remarkable is that this “madness” is often reported as punishment for a crime committed towards Buddhism. For example, it is described how one man harbors ill feeling towards Buddhism and tries to lock up a Buddhist monk begging for money. The monk escapes and recites incantations, upon which the man loses his mind and starts running around like crazy.

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The Nihon Ryōiki – Wikimedia Commons

It is likely that the introduction of Buddhism from mainland China via Korea brought along a change in the perception of “madness” in Ancient Japan. In contrast with the positive connotations attributed to taburebito in Shintoism and folk religion, “madness” here is in nothing related to supernatural beings, but perceived as a punishment on a personal level, a prevalent understanding of “illness” as “evil” in several religions around the world. “Mad” people do not contribute to society or gain a special status in a Buddhist context. They are marked with a mental disorder as proof of their “defiant” behavior and categorized as impure together with criminals, debtors et cetera. In such cases, the Sanskrit word ummatta is used to express “insanity”. Nevertheless, there was legal and social consideration towards people with a mental disorder, for example, monks who developed a mental illness were not accountable for crimes against the Buddhist law[21]. On the other hand, religious experiences such as possessions, illusions or hallucinations are not unusual in Buddhism[22]. These experiences are temporary, caused externally and mystically significant, but unlike Shintoism and folk religion in Japan, Buddhism differentiates between experiences with a spiritual connection and other “madness”, or ummatta. This perception views ummatta as devoid of religiosity (hare) and is more likely to encourage the stigmatization of individuals with a mental disorder, rather than the generalizing notion of “madness” in Shintoism does.

Footnotes: [20] This work is translated by Watson, Burton as Record of Miraculous Events in Japan: The Nihon Ryōiki. Translations from the Asian Classics. New York: Columbia University Press, 2013.[21] Koike, Kiyoyuki. “Mental disorders from a Buddhist View, especially those within the Nikaya, the Vinaya Pitaka and the corresponding Chinese translations” in Indian and Tibetan Studies Research, 7 & 8, p. 178.[22] Oda, Japanese Sources on Madness, p. 55-56.

Mental Health Stigma in Japan: Introduction

20160623_192603.jpgAs promised, excerpts of my master’s dissertation will be published on Nippaku in an adapted version. This post will give an outline of the problem concerning mental health stigma. First, I will discuss the causes and consequences of stigmatization against people with a mental disorder in general and then focus on the specific situation in Japan. Interested in more mental health posts? Check out Iwakura: the Japanese Gheel (Mental Health in Japan Series no. 1) or The Medical Treatment and Supervision Act (2005): Forensic Mental Health in Japan Today – part 1 and part 2.

1. Stigmatization of people with a mental disorder worldwide

d7ce1619515f465aa20331c1db3ff37cFrom various studies, we can conclude that stigma against individuals with a mental disorder is a real and serious problem worldwide[1]. First of all, people with a mental disorder often experience discrimination in housing, education and employment[2]. Not only does stigma influences the negative attitude of others who are otherwise unrelated to the health care industry, it has been proven that mental healthcare workers as well take a stigmatizing stance towards their patients[3]. Moreover, high-quality primary care and non-pharmacological care is often not sufficiently provided, which contributes to a pervasive experience of stigma. Apart from its social consequences, stigma also affects the patient on a personal level. Causing a loss of confidence and a further worsening of the emotional state, stigma has been called “the second illness”, because its effects are sometimes as harmful as the disorder itself[4]. Another critical problem is that stigmatization interferes at every stage of the process towards recovery, i.e. during diagnosis, treatment and rehabilitation[5]. Due to social stigma, mental health patients are much less likely to seek psychological help immediately, agree to treatment or return to society after having spent time at a mental institution. This self-stigmatizing attitude (the internalized type of stigma towards oneself[6]) forms a real barrier to optimal recovery, and is one of the main challenges in the field of mental health care today.

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Mental health stigma in Britain – https://goo.gl/bYqWw0

Stigma is visible in various types of negative attitudes and prejudices. Moreover, the mentally disordered have been stigmatized throughout history. Contrary to people diagnosed with a physical illness, those with a disease of the mind are often regarded as irresponsible, weak and blameworthy, as if they hold responsibility for their own illness[7]. This stigmatizing attitude is reflected in the fact that not even 60 percent of surveyed states by the WHO had a dedicated mental health policy in 2011[8], and only 68 percent provided a mental health plan or legislation in 2014[9]. Additionally, stigma against people with a mental disorder is often promoted by false information in the media and entertainment industry. Not uncommonly, mentally disordered offenders are sensationally reported in the news, and by emphasizing the mental state of the offender, individuals with a mental disorder in general are labeled as inherently dangerous[10]. Stigma takes further concrete shape in derogatory terms and expressions based on such a discriminating attitude like “psycho”, “freak” or “nuts”[11] [12].

Another prevalent prejudice is that “mental health problems are untreatable”. According to a study by Lebowitz and Ahn, who had participants read vignettes emphasizing the treatability of mental disorders, stigma can be reduced by providing correct information on mental disorders[13]. Jorm et al. point out that the increase of public knowledge about depression leads to more recognition of the mental disorder, and in particular stimulates positive beliefs about treatment and the benefits of help-seeking[14]. In other words, it has been demonstrated that in order to deal with stigma, it is necessary to tackle the root problem, ignorance, first, which resulted in a sharp increase of campaigns focusing on “mental health literacy[15]” in the last two decades. For example, Crisp et al. compared the attitudes toward people with different mental disorders before and five year after the Changing Minds campaign in Great Britain. One of the improvements they reported was a reduction in the percentage of stigmatizing opinions[16]. On the other hand, mental health literacy campaigns should be continued on a long-term basis in order to achieve a sustained change[17]. There is, however, the possibility that negative attitudes do no change for the better, even if the public mental health literacy clearly increases[18].

2. The situation in Japan

Ando et al. reviewed nineteen surveys related to mental health stigma in Japan. They reached the conclusion that Japanese people in general have the tendency to regard mental disorders as untreatable diseases, caused by weakness of personality rather than by biological factors[1]. Other studies show that the stigmatization of mental patients in Japan is stronger than in Taiwan[2], Australia[3], Bali[4], but not as strong as in China[5]. Research on stigmatization of schizophrenia shows that the Japanese respondents heavily emphasize the “dangerousness” and “abnormality” of patients, a far more negative attitude than the British respondents[6]. Additionally, these kind of prejudices are not limited to a specific age or environment, as they have been found prevalent among young Japanese people[7] and the rural Japanese population[8] in contrast to other nationalities. We can conclude from the study results described here, that, in general, the tendency to stigmatize people with a mental disorder is relatively strong in Japan.

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Example of a Japanese mental health stigma campaign.

One Japanese study demonstrates the close relationship between correct knowledge or information and social distance from individuals with a mental health problem among young people, in the sense that correctly informed youngsters took a less negative attitude towards the mentally disordered[9]. For that reason, mental health campaigns in Japan as well have been designed to deepen the understanding of the general public, and an increase can be noticed in television soaps and programs featuring people with a mental disorder without stereotyping them[10]. A further indication of efforts to reduce stigma is the decision in 2002 to change the word for “schizophrenia” in Japanese from seishin bunretsu byō 精神分裂病(“mind-split-disease”) to tōgō shicchō shō 統合失調症 (“comprehensive imbalance disorder”), the former expressing a lack of personal autonomy and thus contributing to a stigmatizing attitude[11]. According to a survey on dementia conducted in 2004, older people in Japan hold a slightly more negative opinion compared to younger people. When the same survey was repeated in 2007, the researchers found a reduction in stigmatization by the older age group against people with dementia[12]. Nevertheless, the same survey found that dementia is still strongly regarded as an “untreatable” and “shameful” disorder by Japanese people.

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Illustrating mental health stigma – https://goo.gl/LnWOX

What affects the Japanese attitude even more directly, is the widespread prejudice that “people with a mental disorders are a danger for society[13]”. According to the most recent data from the Ministry of Justice, “the ratio of offenders with a mental disorder is 1.5%, but looking per offense, the ratio for arson (17.4%) and manslaughter (12.8%) is high[14]”. Certainly, we cannot deny the fact that among offenders of serious crimes like arson and manslaughter, the ratio of offenders with a mental disorder is rather high. However, the total ratio of mentally disordered offenders is only 1.5%, which makes a general judgment like “inherently dangerous” far from applicable to all people with a mental disorder[15]. Furthermore, Link et al. state in another study that, although it is correct that mental patients are generally more prone to use violence, the excess risk of violence due to the factor of a mental disorder is rather modest in comparison with other factors[16]. As a result of the prejudice linking mental disorders to violence, people with a mental disorder often experience segregation and isolation. Based on this false assumption, mental health patients themselves and their families generally believe that in case of a mental disorder, it is better to be hospitalized for a long period than being rehabilitated into society. This preconception is clearly reflected in statistics showing that Japan has not only the most hospital beds in general, but also the most beds for psychiatric patients worldwide (fig. 1 and 2).

figure 1fig-1 source: OECD. Health at a Glance 2015 OECD Indicators. Paris: OECD Publishing, 2015, p. 105.

figure 2fig2.png source: OECD. Reviews of Health Care Quality: Japan 2015 ; Raising Standards. OECD Reviews of Health Care Quality. Paris: OECD Publishing,2015, p.172.

Along with a maximum number of psychiatric beds, another indication of the emphasis on inpatient settings in Japan due to a strong stigmatization, is the average length of stay for psychiatric patients of 377 days in 2000 and 298 days in 2011, an extremely long hospitalization period compared to the OECD average of 36 days (fig. 3)[17].
figure 3fig3.png source: OECD. Reviews of Health Care Quality: Japan 2015, p. 172.

Despite the fact that the number of psychiatric beds and the length of hospital stay for psychiatric patients has been decreasing, mental health care in Japan still faces a number of challenges in order to be able to make the step towards “deinstitutionalization” [18]. In Japan, however, “the community-based infrastructure remains underdeveloped with relatively low numbers of staff working in the community, and low numbers of supportive housing facilities, coupled with a strong emphasis on physical treatment rather than psychosocial treatments[19]”. It seems likely that the delay of an out-patient setting such as community-based care in Japan is partly rooted in the strong social stigma towards psychiatric patients because of the difficulties they face regarding reintegration.

Stigma is also believed to play a role in the high suicide rate in Japan (18,7 per 100,000 population in 2013[20]). Despite a decreasing rate from 2000 on, many Japanese struggling with mental health problems still fail to seek medical help due to the mental disorder taboo. Furthermore, the phenomenon “hikikomori”, adolescents and young adults withdrawing from society to extreme extents, has recently called attention to the mental wellbeing of the younger generation in Japan. A study revealed that in 2011, 1.2% of Japanese people aged 20 to 49 identified with hikikomori[21]. This phenomenon can be linked to (self-)stigmatization. Additionally, it has been revealed that many victims of the Great East Japan earthquake in 2011 suffer from mental health problems, which urges the rethinking of an accessible community-based mental health care system[22]. Considering the serious effects of social stigma, it is clear that this problem has to be dealt with in order to improve the challenging situation of individuals with a mental disorder.

Footnotes and references
Since the list of footnotes is really too long to post here, you can check it by clicking on the following link:

Iwakura: the Japanese Gheel?

13553337_10209027881150118_1336223955_nFor two years now, I have been doing research on the history of mental health stigma in Japan. Consequently, I have also written some reports and papers about this topic and the history of psychiatry in general. During my year at Kobe University, I wrote a paper in Japanese about the link between the hamlet Iwakura in Kyoto and the Belgian city of Gheel. Since this is perfectly acceptable Nippaku material, I thought it could be interesting to post a translated version on this blog!


 Introduction

In Flemish, we have a proverb “going to/coming from Gheel” which means being crazy. In Japan there is a similar expression about Iwakura, a hamlet North of Kyoto. Both places appear to be related to mental health patients: Gheel as well as Iwakura have gained fame as “colonies of the mad”. At the end of the 19th century, Gheel attracted worldwide attention because of its unique family care system. Since it was believed that traditionally a similar system existed in Iwakura, it was called “the Japanese Gheel”. We cannot deny that there are many similarities between these two places, but is it really true that family care which emerged from a very specific (religious and economical) context in Gheel is also ingrained in the history of Iwakura? In this post, we will compare the relevant history of both places in chronological order and take on the question whether or not Iwakura can truly be called “the Japanese Gheel”.

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Mental hospital of Gheel (left) and Iwakura (right) – Sources: cultuurgeschiedenis.be/paradijs-der-krankzinnigen/ and kenkyukaiblog.jugem.jp/

1. The history of Gheel

pc4136Gheel (Geel in Dutch) has been an important pilgrimage destination since early times. From the 12th century on, ill people from all corners of Europe came to Gheel because they had heard about the legend of Sint Dymphna (Dimpna in Dutch), the city’s patron saint. It was believed that seeing and touching her relics had curative powers. According to the legend, Dymphna was the daughter of an Irish king ruling in the seventh century. When the queen died, the king started looking desperately for a woman to remarry who looked exactly like his deceased spouse, but could find no one who resembled her more than his own daughter. The king, by then insane from grief, proposed to Dymphna. She refused him and fled together with father confessor Gerebernus and some trusted others to Gheel. They were eventually tracked down and the king beheaded his daughter himself and had Gerebernus killed as well. Both were declared martyrs. The people in Gheel buried their bodies, but later exhumed the bones to function as relics in the Dymphna Church they established in the vicinity of their grave.

Jan_Carel_Vierpeyl_-_Exhumation_of_the_bones_of_St_Dymphna_and_St_Gerebernus

Jan Carel Vierpeyl, “Exhumation of the bones of St Dimpna and St Gerebernus”, beginning 18th century, St. Dymphna church in Gheel – wikimedia commons

In the beginning, Gheel attracted all kinds of diseased people as a place of pilgrimage, but from the 15th century on St. Dymphna became known as the patron saint for the mentally disordered, and the number of visiting “mad people” increased rapidly. The standard procedure was a “novena”, a nine-day ritual that required the diseased to stay during that period in Gheel. For that purpose, sick rooms were set up inside the church. However, space was limited and in high season (i.e. around May, since May 15 was St. Dymphna’s feast day) the number of pilgrims largely surpassed the number of novena participants the church could deal with, and those who arrived sometimes had to wait for weeks before they could receive spiritual healing.

V0048050 Pilgrims receiving the Eucharist in the chapel of St. Dymphn

Pilgrims receiving the Eucharist in the chapel of St. Dymphna – wellcomeimages.org

The inhabitants of Gheel provided a solution in the form of lodging at their own homes. Moreover, not few pilgrims wished to stay for an extended period longer than the nine days in church to maximize the healing effects of St. Dymphna’s relics. From this custom the family care system was born: for an unlimited period, the people of Gheel “adopted” one or two mental patients and in return received a compensation. The patients who could also helped with farming work. In other words, families without any medical knowledge lived together with mental health patients under the same roof, unlike the situation in hospitals or specialized boarding houses.

From 1532 on, the Communal Council of Gheel took care of the accommodation, supervision and novena for mentally ill pilgrims. In the 17th century, however, the patients were placed directly in the host families via a sponsored organization called the “table of the poor” (“De Armentafel” in Dutch). As a result, several pilgrims with a mental disorder stayed in Gheel and lived together with their foster family for the rest of their live. Although Gheel become known as “the merciful city”, the explanation behind this charity was mainly an economic one: for the authorities, family care was simply a cheaper solution to keep “mad” people off the streets than having them treated at mental asylums in surrounding cities.

Geel - De kolonie rond 1900

The mental hospital of Gheel around 1900 – Gemeentearchief Geel

In 1850, Belgium’s National Mental Illness Law legally recognized family care as equal to other forms of psychiatric care. The village was renamed “the Colony of Gheel”. A mental hospital was established in 1862, but the family care system remained, even today. In 1893, there were 1,156 foster families and in 1938, there were 3,736 mental health patients staying at the colony. Nowadays, many families still host one or more patients in exchange for a compensation [interesting video here]. The sight of mentally ill patients on the streets of Gheel is far from unusual. Today, as well as during previous centuries, the “pilgrims” enjoyed a relatively free life style, and there were remarkably few incidents or crimes involving the “mad”, a fact often used as an argument against the assumed strong connection between mental health patients and violence or crime. From the 1860s on, the colony gained fame as the model by excellence for family care and renowned psychiatrists and scientists from all over the world gathered in Gheel. Among them, there were also Japanese visitors. This is the point in history when the comparison with Iwakura began.

2. The history of Iwakura

During the Middle Ages (1185-1603) in Japan, a handful of religious institutions offered services for mental health patients, such as Chinese herbal medicine treatment and moxibustion (burning plant material close to or on the skin) in Buddhist temples, and incantations and exorcism sessions in Shintoist shrines. Because psychiatric treatment avant la lettre was often associated with spiritual healing, those in need undertook pilgrimages to “places of healing” that provided special treatment. Nevertheless, this was still exceptional, and most temples and shrines started to develop facilities for the mentally ill only late in the Edo period or at the beginning of the Meiji period. Hence, from the 17th century on, the number of religious institutions specializing in mental health treatment rose significantly. Shortly before the Meiji revolution, the reading of sutra, incantations, water treatment, moxibustion and Chinese-style herbal medication were available in 28 shrines and temples nationwide. Additionally, 2 mental asylums were established in the first half of the 19th century.

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Water therapy at Fujinuta Falls (date unknown) – Kitsuta Masateru, http://kenkyukaiblog.jugem.jp/?cid=10

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Waterfalls at Daiunji-temple in Iwakura – Kobayashi (1972) http://kenkyukaiblog.jugem.jp/?cid=10

Among these institutions, the Daiunji-temple in Iwakura, north of Kyoto, is a well-known example of a popular destination for mentally disordered pilgrims. Its reputation as a place of healing was based on a legend from 1072. The third daughter of emperor Go-Sanjō who suffered from a mental disorder, recovered by drinking from a well and bathing under a waterfall at the place that was later called Iwakura. From around the year 1765, people started to flock there, which urged the provision of housing, first inside the temple domain and then at inns and local farmers’ houses. The expansion in population called Iwakura as a hamlet into existence. In 1875, a private mental hospital was established, and the people in Iwakura were forbidden to accommodate mental patients any longer because they could not provide adequate treatment. The hospital, however, was closed in 1882 due to financial difficulties. Consequently, many patients returned to the inns and local families’ houses. A second hospital was established in 1884.

During and after the Taishō period (1912-1926) Iwakura experienced a facilities construction boom and at the beginning of the Shōwa period (1926-1989), 10 sanatoria were established there to take care of the mentally ill. Many of the patients stayed for a longer period, some of them for the rest of their life. Those who could, helped with household chores, worked on the land or in the mountains. At the same time in Japan, the custom, and later on legislation of confining “insane” family members at home in zashikirō 座敷牢, cage-like wooden constructions, was widespread.

hidekiueno.net zashikiro

zashikiro – hidekiueno-net.jp

Compared to this way of dealing with mentally disordered people, it is assumed that those staying at Iwakura could enjoy a relatively free lifestyle. Nevertheless, previous research has pointed out that patients who were difficult to handle, were often locked up and physically restrained. In the past as well, the inhabitants of Iwakura who were entrusted the care of these patients and therefore responsible for them, did not want to take any risks. As a result, the “mad” were tied down to prevent them from escaping or causing any harm.

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Patients exercising at Iwakura Mental Hospital –  http://shuchiinfukushi.blog46.fc2.com/blog-entry-524.html

At the end of the year 1935, more than 500 mental health patients were admitted to the Iwakura hospital, and 300 more stayed at the surrounding sanatoria. The Second World War caused severe food shortage, and the mortality rate at mental hospitals nationwide rose sharply. The mental hospital and many of the sanatoria in Iwakura were forced to close their doors. Two new hospitals were established after the war, but the inns and sanatoria played no longer an important role. In the Iwakura of today, mental patients are mainly cared for at the hospital, and inhabitants taking on the task of housing them are hardly seen anymore.

It is believed that the famous Japanese physician Kure Shūzō 呉秀三 (often called the founder of psychiatry in Japan) was the first to draw the attention of specialists on the particular situation in Iwakura. Consequently, the “mad” of Iwakura and its psychiatric history attracted worldwide attention at the beginning of the 20th century. Many western psychiatrists visited Japan and pointed out the resemblance between the existence of sanatoria in Iwakura and the family care system in Gheel. Moreover, the interest in Iwakura was rooted mainly in the comparison with Gheel. We can assume that without the perception of Iwakura as “the Japanese Gheel”, the traditional practice of caring for patients at inns and farmers’ houses would have disappeared much sooner. The attention Iwakura gained during the early years of the 20th century “prolonged”, in a sense, the duration of this tradition. But on what exactly was the comparison with Gheel based?

3. Comparing Gheel and Iwakura

Kure_Shuzo

Kure Shūzō – Wikimedia Commons

In 1906, The Latvian physician Wilhelm Stieda visited Iwakura, and wrote the words “In this village – a Japanese Gheel” (original in German: “In diesem Dorfe – einem japanischen Gheel -” in a specialized journal article. The notion of a resemblance between these two places was widely publicized, and Iwakura gained worldwide recognition. However, if we carefully examine the background against which this comparison was drawn, we learn that Kure Shūzō was the one who pointed out the similarities with Gheel to Stieda. Kure mentioned in his “Essentials of Psychiatry part II” (1895) that in Gheel as well as in Iwakura, there existed a similar system of family care. Before that, no other Japanese physician had mentioned such a thing during study trips to Germany, the place-to-be for psychiatrists at that time and also the country where efforts were made to introduce a family care system based on Gheel’s example.

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Map of the Daiunji temple domain with names of inns and shrines around 1779 – in “Encyclopedia of Famous Places” volume 6, 1968. http://www.kagemarukun.fromc.jp/page003j.html

In contemporary Japan, the traditional treatment in Iwakura was being perceived as “outdated”. After he visited Gheel in 1901, Kure compared the city once again with Iwakura, and this time, he expressed his disapproval of the Japanese situation. This was because Kure actually desired the development of a family care system exactly like in Gheel (which was not the case in Iwakura), but the accommodation of mental health patients at inns and tea houses became prohibited by the Mental Patients’ Custody Act promulgated in 1900. Furthermore, the care for mental patients at the sanatoria that resembled hotels rather than family homes, differed greatly from Gheel’s family care system. In other words, based on the strong desire that “Iwakura should be the Japanese Gheel”, Kure and other Japanese psychiatrists strived towards an introduction of the Gheel system. This failed.

Wilhelm_Christian_Hermann_Stieda

Wilhelm Stieda – Wikimedia Commons

So we can assume that when Stieda met Kure in 1906, he was not really under the impression that Iwakura had a similar family care system like in Gheel. Probably, he referred to the religious background, high population rate of mental health patients and history of lay treatment that both places shared. Nevertheless, Iwakura became mainly known to western psychiatrists for its alleged family care system. As I explained before, this was not the case then, since mental patients stayed at the hospital or sanatoria, and were no longer “adopted” into the farmer’s families. There are examples of family care in Iwakura before 1900, but calling it a “system” would be incorrect. However, the Japanese side did not deny and even supported this erroneous understanding. Hence, Iwakura’s history was recreated as “the Japanese Gheel”. Because Iwakura was already being compared to Gheel, the (re)introduction of a family care system should be possible, Japanese psychiatrists such as Kure thought.

familienpflege iwakura

Translation German: “family care in Iwakura” – http://www.lit.aichi-pu.ac.jp/~aha/doc/Southampton%20congress.pdf

According to specialist Akira Hashimoto, the words “Iwakura is the Japanese Gheel”, written in a time the world of psychiatry was fascinated by the family care system in Gheel, should be understood as an idea created on Japanese soil. I agree that the model of “family care” did not really apply to 20th-century Iwakura, but besides that, there are many resemblances here that should not be overlooked. Moreover, it is clear that in both places, people earned their living by caring for mental health patients. The influx of mentally ill pilgrims resulted in economic profits. The culture of lay psychiatric treatment is also remarkable. By nursing people with a mental disorder on a daily basis, the villagers developed a particular set of skills and became fully experienced, despite their lack of medical knowledge. Furthermore, mental patients enjoyed a relatively free lifestyle and the boundaries between “patient” and “villager” were rather blurry in both places.


I hope this post was able to convince you that Gheel and Iwakura deserve special attention because of their exceptional history of mental health care. More posts on this topic will follow (soon)! In the meantime, those who are interested in psychiatry can read a previous blog post on forensic mental health in Japan here: part 1, part 2.

References

  • 小俣和一郎『精神病院の起源』東京: 太田出版, 1998.
  • 小俣和一郎『精神医学の歴史』東京: 第三文明社, 2005.
  • Official site city of Gheel
  • Nakamura, Osamu. “Family Care of Mentally Ill Patients in Iwakura, Kyoto, Japan.” presented at the International Research Symposium: Therapy and Empowerment – Coercion and Punishment: Historical and Contemporary Perspectives on Labour and Occupational Therapy, lecture at St Anne’s College, Oxford, June 27th, 2013.
  • 中村治「精神医療の流れと洛北岩倉: 第二次世界大戦後」人間科学:『大阪府立大学紀要』 1 (2005): 111–30.
  • 中村治「洛北岩倉における精神病者の処遇」人間科学『大阪府立大学紀要』 2 (2006): 97–114.
  • Hashimoto, Akira. “The Invention of a ‘Japanese Gheel’: Psychiatric Family Care from a Historical and Transnational Perspective.” In Transnational Psychiatries Social and Cultural Histories of Psychiatry in Comparative Perspective, C. 1800-2000, edited by Ernst Waltraud and Thomas Mueller, 142–71. Newcastle upon Tyne: Cambridge Scholars, 2010.
  • 橋本明『京都・岩倉の国際関係論「岩倉は日本のゲールである」という虚構をめぐって』第83回精神科医療史研究会
  • 橋本明「二十世紀前半における京都・岩倉の“国際化”について(その二)」『日本医史学雑誌』48, 3 (2002): 374–75.
  • 橋本明『日本の精神医療史. “精神病者”の権利はなかったのか?―ヨーロッパ精神医療史の落穂拾い―』講演, 2002.
  • 兵頭晶子『精神病の日本近代―憑く心身から病む心身へ』越境する近代 東京: 青弓社, 2008.
  • Mueller, Thomas. “Re-Opening a Closed File of the History of Psychiatry: Open Care and Its Historiography in Belgium, France and Germany, c. 1880-1980.” In Transnational Psychiatries Social and Cultural Histories of Psychiatry in Comparative Perspective, C. 1800-2000, edited by Ernst Waltraud and Thomas Mueller, 172–99. Newcastle upon Tyne: Cambridge Scholars, 2010.
  • 八木剛平, 田辺英『日本精神病治療史』東京: 金原出版, 2002.
  • Wilhelm Stieda. “Über die Psychiatrie in Japan.” Centralblatt für Nervenheilkunde und Psychiatrie 29 (1906): 514-522.
  • full text of “Gheel: the city of the simple” (1869)
  • time line history of Gheel

The Medical Treatment and Supervision Act (2005): Forensic Mental Health in Japan Today – PART 2

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.

banner MTSA 2


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[1], 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).

Osaka School Massacre - matome.naver.jp

Osaka school massacre: offender convicted to death penalty, deemed  criminal responsible despite mentally ill – matome.naver.jp

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[2] 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”[3]. 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[4]. 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).

Q&A manual about the MTSA by the Japanese Federation of Bar Associations.

Q&A manual about the MTSA by the Japanese Federation of Bar Associations.

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[5] 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[6] (Nakatani & Kuroda, 2013). By December 2007, 14 designated[7] 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.

ncnp.go.jp

ncnp.go.jp

Outpatient treatment[8] requires a collaboration of various institutions such as designated[9] 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[10]. 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).

portal.nifty.com

portal.nifty.com

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[11] (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).

moj.go.jp

moj.go.jp

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[12] (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).

MTSA flow chart

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.

namisouthbay.com

namisouthbay.com

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/.


Footnotes

[1] The offender, however, was attributed full responsibility and was sentenced to death.
[2] 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).
[3]「許容しがたい人権侵害をもたらす」said president Kazumasu Kuboi (Asahi Shimbun, 16 March 2002).
[4]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).
[5]入院処遇 in Japanese (Moriya & Ujiie, 2008).
[6] 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.
[7] Designated by the Minister of Health, Labour and Welfare.
[8] 通院処遇 in Japanese (Moriya & Ujiie, 2008).
[9] Designated by the Minister of Health, Labour and Welfare.
[10] 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).
[11] At the end of 2013, no designated inpatient facility existed in Hokkaidō and Shikoku (Fujii et al., 2014).
[12] Compare this to Belgium, where 32 full-time psychiatrists and 147 full-time psychologists were employed in June 2006 (Salize, Dreßing & Kief, 2007).

Bibliography

bibliography MTSA

The Medical Treatment and Supervision Act (2005): Forensic Mental Health in Japan Today – PART 1

For the course “Politics, Law and Society in Japan: A Global Perspective” I wrote a paper about Japanese forensic mental health, focusing on the Medical Treatment and Supervision Act, implemented 10 years ago. I will post this paper in two parts. The first part deals with the historical background and how and why this Act was established. The second part gives a short overview of the functioning of the Act and summarizes the challenges the Act already has been faced with.

banner MTSA 1


INTRODUCTION

How mentally ill offenders are treated has always been a difficult issue to deal with, for the reason that they are situated in a double paradigm: on the one hand they have committed a crime and are therefore offenders; on the other hand they are deemed to be ill and should receive treatment. According to article 39 of the Japanese Penal Code, enacted in 1907, “an act of insanity is not punishable and an act of diminished capacity shall lead to the punishment being reduced” (心神喪失者の行為は、罰しない。心神耗弱者の行為は、その刑を減軽する). The Penal Code, however, does not provide any measurements to treat mentally ill offenders acquitted due to their disorder. Only until recently, forensic mental health was covered by general health treatment. In fact, no special system existed for such offenders, making Japan unique in that way. As a result, mentally ill offenders were treated either in prison when convicted or in general psychiatric hospitals.

In July 2005, the Act for the Medical Treatment and Supervision of Persons with Mental Disorders Who Caused Serious Harm (shortened to “Medical Treatment and Supervision Act”) (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)) was enforced and brought about radical changes. For the first time, the act aimed at the rehabilitation and the right medical treatment of mentally ill offenders. The system established two different types of treatment: inpatient and outpatient treatment. Where previous acts were mostly highlighting the fear of recidivism, the act of 2005 specifically encourages reintegration of mentally ill offenders in society. While the enactment and transition went smoothly, Japan is still struggling with optimizing outpatient treatment.

HISTORICAL OVERVIEW

Traditionally in Japan, a mental disease was not regarded as a medical problem but as the possession of an individual by evil spirits, which could therefore only be treated by exorcist rituals like purification, incantation or shamanist treatment[1] (Mandiberg, 1996; Russell, 1988). The construction of a confined room at the family home to lock up lunatics (zashikirō 座敷牢 (Mandiberg, 1996), nyūkan 入監 (Salzberg, 1991)) was a common tradition until the 20th century.

shinto ritual to heal madness: standing under a waterfall for hours - kenkyukaiblog-jugem-jp

shinto ritual to heal madness: standing under a waterfall for hours – kenkyukaiblog.jugem.jp

The mad could also resort to Buddhist or Shintoist temples and shrines, sometimes resulting in rural communities around these places of refuge for the mentally diseased, and stimulating the reintegration in society. The Iwakura village near Kyoto was one of these pilgrimage and refuge places[2]. Later in 1884, it transformed itself from a community of boarding houses where farm families cared for mentally diseased, into a successful private mental hospital until its closure in 1945 (Nakamura, 2006).

Iwakura Hospital

Iwakura Hospital –  kenkyukaiblog.jugem.jp

During the Edo period (1603-1868), the family head became heavily responsible for the conduct of his family members, and could end up being severely punished for the criminal acts of mentally ill diseased[3]. As a result, mad people were ostracized by removing their name from the family register or confined, whether it was at home, at a temple or in a public prison (nyūrō 入牢) (Russell, 1988). When the proper supervision of mentally ill individuals became impossible, they were often confined with medical care under supervision of eta[4] (tameazuke 溜預) (Yamazaki, 1931). Nevertheless, home confinement was still the primary way of dealing with lunatics.

zashikiro - hidekiueno-net.jp

zashikiro – hidekiueno.net.jp

On the one hand, it should be noted that these provisions were not established for the good of the mentally ill, but rather seen as a necessary measure to maintain social order. On the other hand, the traditional perception of mental diseases altered under the influence of Western medicine and philosophy, brought to the isolated isle by Dutch physicians during the 19th century. Compared to the inhumane imprisonment and traumatizing rituals, they introduced new concepts of psychiatric therapy, which were later put into practice by Japanese students of Western medicine.

influence of rangaku, the studie of the Netherlands, on medicine and mental health - mayanagi-hum-ibaraki-ac-jp

Influence of rangaku, the studie of the Netherlands, on medicine – mayanagi.hum.ibaraki.ac.jp

Both perspectives were developed further during the Meiji Period (1868-1912). Rapid social change compelled the Japanese government to issue laws concerning the attitude towards the insane. A circular in 1878 established certain rules for confinement of the mentally ill: imprisonment at home required a report of a physician and an official request of the family. Those disowned by their family were confined to detention centers (Salzberg, 1991). Because mentally ill individuals were considered as possibly dangerous subjects for society, a series of police orders stipulating the control and punishment of the insane followed (Kuwabara & True, 1976). A law in 1884 stated that mentally ill could only receive treatment if a doctor appointed by the police had examined them. When successfully confined, police authorities checked the patients once in a month. At the same time, however, a critical stance towards confinement and incarceration urged the demand for proper treatment centers. The first mental hospital in Kyoto was established in 1875 (Nakamura, 2006).

A "hospital" for the mentally diseased in Tokyo - kenkyu

A “hospital” for the mentally diseased in Tokyo in 1881- kenkyukaiblog.jugem.jp

One specific case drew particular attention to the necessity of a mental health law.  The daimyō of Sōma prefecture, Sōma Tomotane, at the time involved in a family dispute, was declared to be schizophrenic and thus confined to a zashikirō. Loyal retainers believed this was a conspiracy of the other family members against their lord. They kidnapped the daimyō from the psychiatric hospital he had been transferred to and made the details about his confinement public. This was largely covered in the media, including international newspapers. As it became clear that formal mental health regulations were yet to be established, the Meiji government feared the Sōma affair would undermine their long-fought efforts to develop Japan as a modern state (Russell, 1988). As a result, The Law for the Custody and Care of the Mentally Ill[5] was enacted in 1900. With this law, families were officially permitted to build zashikirō and were kept legally and financially responsible for their supervision and the actions of mad family members. The law was presented as a protection against illegal and arbitrary confinement, but in fact encouraged traditional and outdated practice. Again, the government’s main concern was public safety and order (Mandiberg, 1996).

Loyal retainer Nishigori rescues Soma from the asylum - members.jcom.home.ne.jp

Loyal retainer Nishigori rescues Soma from the asylum – members.jcom.home.ne.jp

Up till now, I have only discussed the attitude towards the mentally ill in general. This is simply because there were no special measurements separating mentally ill offenders from normal offenders. Insane individuals were prevented from committing crimes by incarceration or confinement (‘punitive treatment’) and did not receive medical assistance. Moreover, physicians were rarely involved in mental health treatment. The responsible family members were still forced to rely on shaman rituals, combined with familial care. We can see this as a type of community psychiatry, though very primitive and non-therapeutic (Kuwabara & True, 1976).

A survey, conducted by the government in 1915, indicated that 82% of mentally ill individuals were untreated[6]. Hence, the Law for the Custody and Care of the Mentally Ill was supplemented with the Mental Hospital Act[7] of 1919. This act, again for the sake of public safety, regulated compulsory confinement in a psychiatric hospital, under permission of the state or responsible family members. Nevertheless, most mental patients were still confined at home, taken into account that by World War II, only six public insane asylums had been built in Japan. The government had decided to fund mainly private mental hospitals, whose treatment only rich families could afford (ibid.). The limited number of beds dropped during World War II[8], when the mentally ill were neglected and died of starvation due to the National Eugenics Act[9] of 1940.

In 1950, opposition groups expressed concern for the proactive detention mentally ill people were subjected to. The Mental Hygiene Law[10] was enacted, abolishing home confinement and demanding the establishment of prefectural psychiatric hospitals. Mental diseases were acknowledged as medical problems that required appropriate treatment. However, households remained legally and financially responsible for the acts of mentally ill family members. The law defined three types of hospitalization when a certain degree of danger for the insane himself and his environment could be observed: compulsory or provisional compulsory admission ordered by the prefectural governor, and compulsory admission requested by the legal guardian. Still, the fact that no consent from the patient was needed was seen as a contradiction to the Constitution (Kunihiko, 1991). Once admitted to a mental hospital, there were no provisions to review the decision for another type of hospitalization, and few people were ever discharged. At the same time, options for community placement were very scarce (Mandiberg, 1996). During the 1950s and 1960s, the number of psychiatric beds rose significantly.

Ohio Insane Asylum in the 1950s - gettyimages.co.jp

Ohio Insane Asylum in the 1950s – gettyimages.co.jp

Criminal offenders deemed mentally ill were now often hospitalized instead of incarcerated. Consequently, more facilities were needed. This became clear in 1964 when a schizophrenic young man assaulted Edwin Reischauer, the American ambassador to Japan. On that account, the Japanese police authorities requested more powerful action against the mentally ill (Koizumi & Harris, 1992). This request was turned down, and instead more outpatient and community services were stipulated in the Revised Mental Hygiene Law[11] of 1965 (Nakatani, 2012; Kunihiko, 1991).  It has to be noted, however, that forensic health still did not differ from general mental health. Again, the 1965 law was implemented to maintain social order, and not to effectively help the mentally ill.

Reischauer incident

Reischauer incident

In the 1980s, scandals[12] lead to the establishment of the Mental Health Law[13] (1988) that emphasized the importance of human rights and rehabilitation (Nakatani, 2012). For the first time, the legal rights of the mentally ill were acknowledged and a Psychiatric Review Board reviewed their hospitalization (Cohen, 1995). Although this model was implemented, it appeared impossible to be carried out accordingly[14] (Mandiberg, 1996). The Mental Health and Welfare Act replaced the Mental Health Law[15] in 1995. This law mainly stipulated the increase of outpatient facilities, welfare services and participation in community (Kunihiko, 1999). As these amendments were hardly applicable to mentally ill offenders, only few psychiatrists were inclined to work in forensic health treatment (Nakatani, 2012).

In 1999, a White Paper of the Ministry of Justice pointed out these problems. Public prosecutors, who were more likely to file a report to the prefectural governor in case they assumed criminal responsibility, only indicted a small number of mentally ill offenders. A medical examination was subsequently carried out. If the assumption was verified, the prefectural governor commanded an involuntary admission. Although this procedure assured quick treatment for acquitted mentally ill offenders, the chance to stand trial was minimalized. Furthermore, general mental health hospitals often did not have the required security to receive criminals. In addition, psychiatrists carried a heavy responsibility, as they had to decide about the discharge or continued confinement of the patient, considering the possibility of recidivism (Nakatani, 2000).

protest against psychiatric hospital Utsunomiya - kaihou-sekisaisya.jp

protest against psychiatric hospital Utsunomiya – kaihou-sekisaisya.jp

END OF PART ONE

The second part will give a short overview of the functioning of the Act and will summarize the challenges the Act already has been faced with.

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/.


Footnotes

[1] The treatment by shamans or monks was often very expensive. Hence, rejection of the mad family member became a common practice (Official Order of the Kyoto local government, No. 325, July 25, p. 187, cited in Kuwabara & True, 1976).
[2] Mandiberg (1996) compares this to the city of Gheel in Belgium, whose concept of ‘family care’ inspired the Iwakura hospital, an ambition that never came true (Hashimoto, 2014).
[3] Because of the institutional gonin-gumi system (五人組), a group of five households shared collective responsibility.
[4] The eta穢多, burakumin部落民 or hinin非人 was an outcast group because of their impure or death-associated occupation. Together with the mad, underage and extremely ill offenders were supervised as well in these special detention centers (Salzberg, 1991).
[5] 精神病者監護法 in Japanese (Moriya & Ujiie, 2008).
[6] Department of Welfare, Bureau of Medical Administration (1955), cited in Kuwabara & True, 1976.
[7] 及び精神病院法 in Japanese (Moriya & Ujiie, 2008).
[8] In 1941 there was place for 24,000 mental patients all over Japan. By 1945, only 4,000 beds were left (Russell, 1988). The Iwakura Mental Hospital was forced by the Japanese army to close his doors (Nakamura, 2006).
[9]国民優生法In Japanese. Available at http://www.res.otemon.ac.jp/~yamamoto/be/BE_law_04.htm, accessed on 29 November 2014.
[10] 精神衛生法 in Japanese (Encyclopedia Nipponica online, accessed on 29 November 2014).
[11] 精神衛生法改正 in Japanese (Moriya & Ujiie, 2008).
[12] In 1984, two patients died by abuse in The Mental Hospital of Utsunomiya. Further research disclosed that over three years, 222 of the 1,000 patients hospitalized there had died in suspicious conditions (Jakopac & Patel, 2009). The United Nations Commission on Human Rights criticized Japan’s mental health system (Gostin & Gable, 2004).
[13] 精神保健法 in Japanese (Moriya & Ujiie, 2008).
[14] “Few patient-initiated PRB review applications are filed, and the few of those that are filed result in recommendations for discharge or change in treatment” (Mandiberg, 1996).
[15] 精神保健福祉法精神保健および精神障害者福祉に関する法 in Japanese (Moriya & Ujiie, 2008).

Bibliography

bibliography MTSA