Over the past couple decades, mental illness, a topic once considered taboo, has slowly made its way to the forefront of health and lifestyle discussions in the US. While the stigma is still very prevalent, a rising number of people are successfully combating the shame surrounding mental illness. There’s a plethora of companies popping up all founded on the concept of “self-care” and learning to take control of your mental health. Hashtags like #SickNotWeak allow people to share their own struggles and triumphs with mental illness online. Blogs and websites like The Mighty publish stories and advice on combating the stereotypes surrounding mental illness and disability. Even celebrities are starting to open up about their mental illnesses and using their platforms to help spread awareness.
It’s a different story in Japan.
Despite having a fairly efficient health care system, Japan lags behind in providing both awareness and support for mentally ill people. Thanks to international coverage, pretty much everyone is cognizant of Japan’s high suicide rate, the increase in deaths from overwork (過労死; karoushi), social recluses known as hikikomori, and the harsh bullying and abuse children face in school and the home. Non-Japanese residents often hesitate to seek psychiatric help due to language barriers.
Some recent shocking cases hint at the cracks of a flawed and outdated system, not to mention severely misinformed perceptions regarding mentally ill people. Now known as the Sagamihara stabbings, in 2016 a former employee at a care center for physically and mentally disabled people killed 19 patients and severely injured numerous others in the belief that disabled people should be "euthanized."
In 2017 police arrested a couple in Osaka after discovering the frozen, malnourished body of their 33-year-old daughter in a cramped room; she had a mental illness, the couple claimed, and needed to be confined. They fed her one meal a day and set up a dozen or so cameras for monitoring. They also tried to dispose of her body in a manner that indicated they didn’t want anyone knowing about her.
In 2018, a 27-year-old English teacher from New Zealand died after being physically restrained in a psychiatric facility for ten days. He’d been having a manic episode, according to his brother, yet he was calm by the time restraints were used. Even after his manic episode passed, he remained restrained until a nurse found him in cardiac arrest. Autopsy results purportedly indicated the restraints led to blood clots causing his heart to fail.
Misperceptions, fear of being stigmatized, and outdated medical practices only serve to harshen the climate for people suffering from a mental illness, making them less likely to seek help. This isn’t to say there’s no discourse on mental health in Japan. Rather, it’s the manner of presentation and roundabout discussions that tend to fail in conducing actual change.
The Development of Japan’s Mental Health Services
The first law of any kind regarding the mentally ill came about in 1900 in the form of the Law of Confinement and Protection of the Mentally Ill. This legalized home confinement, which had actually been in practice since the Edo era. Basically, families could confine a mentally ill relative in any kind of enclosure or space, no matter how hazardous or inhumane. All that changed with this law was that families had to send petitions to the local government to confine a mentally ill relative. No provisions were listed as to how home confinement should be practiced, leaving many mentally ill people suffering in squalid and miserable conditions.
Legal home confinement came to an end in 1950 with the passage of the Mental Hygiene Law, which moved the responsibility of care from families to hospitals and psychiatrists. Soon hospitalization became the new go-to solution. Dropping their "abnormal" relatives off at the hospital was an easy way for families to assuage their fears of social stigma. Yet long-term hospitalization leads to still more problems. Patients are less likely to leave or be discharged the longer they stay. They tend to "have fewer social skills, and there are few places other than hospitals where they can go. Hence, they continue to stay in hospitals" (Ito & Sederer 210). It was only in 1995 with the Mental Health Act that mentally ill people were considered disabled, leading to stricter laws regarding hospitalization.
Governments have a sordid history of making promises they can’t keep. In 2017, plans to revise the Mental Health Act entered the Diet, with a focus on strengthening follow-ups after hospital discharges. Many, however, suspected that the Diet only wanted to add measures to prevent an incident like the Sagamihara stabbings from happening again.
A writer for Yomiuri Shinbun disparaged over the government’s half-assed efforts to implement reforms with the mentally ill in mind:
...How much has the government done to support psychiatric inpatients and mentally disabled people living in the community? Is there a structure in place to protect the human rights of inpatients? Have they seriously promoted support for hospital discharge? Have they focused on the welfare that supports reintegration into the community? I think these are the primary causes of failure in that unbalance.
(JP) Link: Why Is the Amendment of the Mental Health Act Failing?
精神保健福祉法の改正案はなぜ、つまずいているか : Page 2 : yomiDr. / ヨミドクター（読売新聞）
So if the government is slow to step up, who else will call for change? It’s been organizations not directly under government control that have made the most impact in reducing stigma.
What’s In a Name?
It’s common for psychiatric terms to be misappropriated and used as insults or labels. This was a problem for Japanese doctors and psychiatrists when attempting to explain schizophrenia to diagnosed patients. For a long time, schizophrenia was known as seishin bunretsu jou (精神分裂症), or "mind-split disease." This term evoked unflattering, often violent images, so stigma against schizophrenic people was especially severe. It also led people to believe the disease was incurable.
In the 1990s, a group made up of patient families and professionals came together and offered a unique solution: why not just change the name of the disorder itself? Believe it or not, that’s what ended up happening. Schizophrenia now became known as tougou shitchou shou (統合失調症), or "integration disorder." This new name gradually gained traction in medical and public circles, and patients were able to better comprehend their diagnoses.
Link: Here’s What Happened When Japan Renamed Schizophrenia
Here's What Happened When Japan Renamed Schizophrenia | AllPsych Blog
This is a terrific example of change for the better — but it isn’t common. Sometimes the fear runs too deep to combat with a simple name change.
Shame and Stigma
The word most often used to mean "mental illness" in Japanese is kokoro no byouki (こころの病気). In Japan, people with mental illnesses are considered deviant, weak, outside the norm; their existence itself is a barrier preventing them from becoming a full member of society. Families with members suffering from a mental illness are looked down upon, as if there’s something wrong with their bloodline, and their social reputation is often scrutinized. This mindset has reigned for hundreds of years, due in part to a lack of understanding about what mental illness is.
What kind of image do you have of mental illness? Unfortunately, in the current situation, prejudiced thinking like “I don’t care about mental problems” and “It makes them weak people” exists. However, if people don’t have a proper understanding regarding mental illness, they might do something unreasonable, hurt someone’s feelings, or exacerbate the person’s condition without realizing it.
(JP) Link: 1 in 5 People Have a Mental Illness! A Workplace Doctor Thinks About Society and Mental Health
Certainly the media isn’t helping. One video produced by NHKハートネット on borderline personality disorder depicts a scene with a young woman self-harming. The camera angles, jump cuts, and incongruous peppy music only seem to glorify the act. That scene is repeated a number of times throughout the video. Quite frankly, it was disturbing, so much so I won’t even link to it. If self-harm is presented in such a way, how will people ever take it seriously?
There is some progress being made, however small. Just last month former AKB48 member Nishino Miki talked about how her fellow idols struggle with mental health issues. Websites like Kokoro No Mi, which offer advice on how to maintain your mental health, are flourishing.
Yet Japan still has a lot of ground to cover. The Japanese government placed restrictions on overtime labor last year, but with such a deep-set overwork culture, some experts think this won’t do much to combat karoushi. (Indeed, as we documented elsewhere, some married Japanese men choose to use this newfound time by simply not going home to their families.) Preventative measures both in the workplace and school are in short supply. With a rising population of elderly people, Japan also needs to start rethinking their health care services if they hope to fully assist the rising population of elderly people showing signs of dementia or Alzheimer’s.
It’s unfortunate that many Japanese have a negative outlook on the mentally ill. Public education is the best way to start dismantling stereotypes, but in a largely conformist society, putting your own mental health needs first isn’t instinctive like it is for most Westerners. The bottom line is Japan has a mental health crisis on its hands, and it will only get worse before it gets better. And will it get better? With the above high-profile cases highlighting a dire need for some kind of reform or education regarding mental illness, the government can’t keep ignoring the issues. But I have a feeling grassroots-organized efforts - and sufferers themselves - will ultimately make the most lasting impact.
Ito, Hiroto & I Sederer, Lloyd. (1999). Mental Health Services Reform in Japan. Harvard review of psychiatry. 7. 208-15. 10.3109/hrp.7.4.208.
Alyssa Pearl Fusek is a freelance Japan and mental health content writer living in Chico, California with her partner and one cat. She graduated in 2015 from Willamette University with a B.A. in Japanese Studies and continues to improve her Japanese language skills. She is also a published poet and fiction writer. You can check out her freelance writing work at The Japanese Pearl.
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