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”.

gheel iwakura.png

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 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