Mental Health Care in Japan 9780203098349, 9780415629843, 9780415690683

Table of contents :
Front Cover......Page 1
Mental Health Care in Japan......Page 6
Copyright Page......Page 7
Contents......Page 8
List of illustrations......Page 9
Notes on contributors......Page 11
Foreword by Graham Thornicroft......Page 15
List of abbreviations......Page 18
Acknowledgements......Page 17
1. Mental health care in Japan: an introduction: Ruth Taplin......Page 19
2. Mental health policy and services: where we stand: Hiroto Ito......Page 54
3. Reintegrating the mentally ill into society and work: Satoru Hashimoto......Page 75
4. How mental hospitals treat their patients, and programmes for rehabilitation into the community: Yayoi Imamura......Page 91
5. National Federation of Families for the Mentally Ill in Japan: historical and future perspectives: Hajime Oketani and Hiromi Akiyama......Page 101
6. An overview of the user movement in Britain and Japan: Sandra J. Lawman......Page 116
7. Attitudes to mental illness in Japan and Britain: Shuntaro Ando and Graham Thornicroft......Page 131
Postscript: a personal perspective: sandra J. Lawman
......Page 160
Index......Page 161

Citation preview

Mental Health Care in Japan

Mental health, including widespread depression, a high suicide rate and institutionalisation, is a major problem in Japan. At the same time, the mental health care system in Japan has historically been more restrictive than elsewhere in the world. This book looks at the challenges of mental health care in Japan, including problems such as the institutionalisation of long-term patients in mental hospitals. The book discusses the latest legislation to deal with mental health care, and explores the various ideas and practices concerning rehabilitation into the workforce, the community and service user groups that empower the mentally ill. It goes on to look at the social stigma attached to the mentally ill in Japan and Britain, which touches upon the issue of counselling those with post traumatic stress after the recent earthquake. Ruth Taplin is Director of the Centre for Japanese and East Asian Studies, London, and is Editor of the Interdisciplinary Journal of Economics and Business Law (www.ijebl.co.uk). Sandra J. Lawman is an Associate for the Shaftesbury Partnership.

Routledge Contemporary Japan Series

1

A Japanese Company in Crisis Ideology, Strategy, and Narrative Fiona Graham

2

Japan’s Foreign Aid Old Continuities and New Directions Edited by David Arase

3

Japanese Apologies for World War II A Rhetorical Study Jane W. Yamazaki

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Linguistic Stereotyping and Minority Groups in Japan Nanette Gottlieb

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Shinkansen From Bullet Train to Symbol of Modern Japan Christopher P. Hood

6

Small Firms and Innovation Policy in Japan Edited by Cornelia Storz

7

Cities, Autonomy and Decentralization in Japan Edited by Carola Hein and Philippe Pelletier

8

The Changing Japanese Family Edited by Marcus Rebick and Ayumi Takenaka

9 Adoption in Japan Comparing Policies for Children in Need Peter Hayes and Toshie Habu 10

The Ethics of Aesthetics in Japanese Cinema and Literature Polygraphic Desire Nina Cornyetz

11

Institutional and Technological Change in Japan’s Economy Past and Present Edited by Janet Hunter and Cornelia Storz

12

Political Reform in Japan Leadership Looming Large Alisa Gaunder

13

Civil Society and the Internet in Japan Isa Ducke

14

Japan’s Contested War Memories The ‘Memory Rifts’ in Historical Consciousness of World War II Philip A. Seaton

15

Japanese Love Hotels A Cultural History Sarah Chaplin

16

Population Decline and Ageing in Japan The Social Consequences Florian Coulmas

17 Zainichi Korean Identity and Ethnicity David Chapman 18 A Japanese Joint Venture in the Pacific Foreign Bodies in Tinned Tuna Kate Barclay 19 Japanese-Russian Relations, 1907–2007 Joseph P. Ferguson 20 War Memory, Nationalism and Education in Post-War Japan, 1945–2007 The Japanese History Textbook Controversy and Ienaga Saburo’s Court Challenges Yoshiko Nozaki 21 A New Japan for the Twenty-First Century An Inside Overview of Current Fundamental Changes and Problems Edited by Rien T. Segers 22 A Life Adrift Soeda Azembo, Popular Song and Modern Mass Culture in Japan Translated by Michael Lewis 23 The Novels of Oe Kenzaburo Yasuko Claremont 24 Perversion in Modern Japan Psychoanalysis, Literature, Culture Edited by Nina Cornyetz and J. Keith Vincent

27

Japanese Aid and the Construction of Global Development Inescapable Solutions Edited by David Leheny and Carol Warren

28

The Rise of Japanese NGOs Activism from Above Kim D. Reimann

29

Postwar History Education in Japan and the Germanys Guilty Lessons Julian Dierkes

30

Japan-Bashing Anti-Japanism since the 1980s Narelle Morris

31

Legacies of the Asia-Pacific War The Yakeato Generation Edited by Roman Rosenbaum and Yasuko Claremont

32

Challenges of Human Resource Management in Japan Edited by Ralf Bebenroth and Toshihiro Kanai

33

Translation in Modern Japan Edited by Indra Levy

34

Language Life in Japan Transformations and Prospects Edited by Patrick Heinrich and Christian Galan

35

The Quest for Japan’s New Constitution An Analysis of Visions and Constitutional Reform Proposals 1980–2009 Christian G. Winkler

36

Japan in the Age of Globalization Edited by Carin Holroyd and Ken Coates

25 Homosexuality and Manliness in Postwar Japan Jonathan D. Mackintosh 26 Marriage in Contemporary Japan Yoko Tokuhiro

37

Social Networks and Japanese Democracy The Beneficial Impact of Interpersonal Communication in East Asia Ken’ichi Ikeda and Sean Richey

38

Dealing with Disaster in Japan Responses to the Flight JL123 Crash Christopher P. Hood

39

The Ethics of Japan’s Global Environmental Policy The Conflict between Principles and Practice Midori Kagawa-Fox

40

Superhuman Japan Knowledge, Nation and Culture in US–Japan Relations Marie Thorsten

41

Nationalism, Realism and Democracy in Japan The Thought of Masao Maruyama Fumiko Sasaki

42

Japan’s Local Newspapers Chiho¯shi and Revitalization Journalism Anthony S. Rausch

43

Mental Health Care in Japan Edited by Ruth Taplin and Sandra J. Lawman

Mental Health Care in Japan

Edited by Ruth Taplin and Sandra J. Lawman

First published 2012 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Simultaneously published in the USA and Canada by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2012 selection and editorial material, Ruth Taplin and Sandra J. Lawman; individual chapters, the contributors The right of Ruth Taplin and Sandra J. Lawman to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Mental health care in Japan / edited by Ruth Taplin and Sandra J. Lawman. p. ; cm. – (Routledge contemporary Japan series ; 43) Includes bibliographical references and index. I. Taplin, Ruth. II. Lawman, Sandra J. III. Series: Routledge contemporary Japan series ; 43. [DNLM: 1. Mental Health Services–Japan. 2. Mental Disorders– ethnology–Japan. WM 30 JJ3] LCclassification not assigned 362.20952—dc23 2012008337 ISBN: 978–0–415–69068–3 (hbk) ISBN: 978–0–415–62984–3 (pbk) ISBN: 978–0–203–09834–9 (ebk) Typeset in Times New Roman by Swales & Willis Ltd, Exeter, Devon

Contents

List of illustrations Notes on contributors Foreword by Graham Thornicroft Acknowledgements List of abbreviations 1

Mental health care in Japan: an introduction

ix xi xv xvii xix 1

RUTH TAPLIN

2

Mental health policy and services: where we stand

36

HIROTO ITO

3

Reintegrating the mentally ill into society and work

57

SATORU HASHIMOTO

4

How mental hospitals treat their patients, and programmes for rehabilitation into the community

73

YAYOI IMAMURA

5

National Federation of Families for the Mentally Ill in Japan: historical and future perspectives

83

HAJIME OKETANI AND HIROMI AKIYAMA

6

An overview of the user movement in Britain and Japan

98

SANDRA J. LAWMAN

7

Attitudes to mental illness in Japan and Britain

113

SHUNTARO ANDO AND GRAHAM THORNICROFT

Postscript: a personal perspective

142

SANDRA J. LAWMAN

Index

143

Illustrations

Figures 2.1 2.2 2.3 2.4 3.1 4.1

Number of patients Number of inpatients by age group Mental health services in Japan Direction for optimal services The scheme of job support for people with disabilities Prescription pattern of antipsychotics drugs for schizophrenic inpatients in Japan 4.2 Transition of mental health rehabilitation in Japan 4.3 Map of Urakawa 4.4 Psychosocial model of Urakawa 5.1 Number of beds in psychiatric hospitals: international comparison 5.2a Antipsychotic drug dosage for patients with schizophrenia: international comparison 5.2b Amount of antipsychotic drug dosage for inpatients with schizophrenia: international comparison

37 43 47 54 63 76 78 80 82 84 85 85

Tables 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.1 2.2 3.1

Problematic experiences of the family Whether the families have been asked about difficulties they face Working together to provide support Support by visit Results of hospital discharge support services Positive attitudes of the public towards mental health Negative attitudes of the public towards mental health Discrimination experienced by sufferers Experiences of restricting own behaviour Psychiatric beds in Asia Changes to the law on protection of human rights of persons with mental illness System of self-sufficiency benefits etc. for welfare service

10 11 11 11 14 25 25 26 26 43 44 62

x Illustrations 3.2 3.3 3.4 3.5 3.6

The number of welfare service business operators for persons with disabilities The estimated number of workers with mental disorders by degree of disorders The estimated number of workers with mental disorders by age group The number of new applications for employment for people with disabilities through public employment security offices The number of people with disabilities who obtain jobs through public employment security offices

64 65 66 66 67

Contributors

Hiromi Akiyama has been the public relations coordinator for the Community Mental Health and Welfare Bonding Organization (COMHBO) since 2008. She was a project manager and research assistant at the Department of Psychiatry, Center for Mental Health Policy and Services Research, University of Pennsylvania, from 2004–8. Akiyama has been an independent intercultural communication consultant – and an independent translator/interpreter – since 2008. She has published ‘A letter from Philadelphia’, Doosoo Tsuushin 17, Shikoo-kai. Tokyo: Japan (1992). Shuntaro Ando is currently at the Graduate School of Medicine, the University of Tokyo. He holds a PhD in Medicine (2009–10) from the London School of Hygiene and Tropical Medicine and an MSc in Public Health (Health Services Research stream). In 2011 Ando was a researcher in the Department of Psychiatry and Behavioral Science, Tokyo Metropolitan Institute of Medical Science. While a part-time doctor at the University of Tokyo Hospital, Ando was responsible for the treatment of inpatients who suffered from general psychiatric diseases such as schizophrenia, depression, neurosis and personality disorders. His latest publications include: Ando, S. and Kawakami, N. ‘World Mental Health Japan Survey Group: utility of self-reported sleep disturbances as a marker for major depressive disorder (MDD): findings from the World Mental Health Japan Survey 2002–2006’, Psychiatry Research (in press); Ando, S., Clement, S., Barley, E.A. and Thornicroft, G. ‘The simulation of hallucinations to reduce the stigma of schizophrenia: a systematic review’, Schizophrenia Research (in press). Satoru Hashimoto is Associate Professor of Kansai University Faculty of Law. He specialises in the theory of the structure of the firm and non-profit organisations, and teaches ‘theory of industrial systems’, ‘theory of the corporate system’ and related subjects at his university. His recent interest is in change in corporate structure within the context of change occurring in the welfare state and he is currently engaged in theoretical and substantive research in this area. Recent research has also focused on third-sector organisations and social enterprise. Commissioned by the Ministry of Health, Labour and Welfare in Japan, he is now conducting research on disabled people within the Japanese

xii Contributors firm, which will result in policy recommendations for the disabled, both physically and mentally, and their incorporation into the world of work. Yayoi Imamura (MD) graduated from Sapporo Medical University in April 2002. She has since worked in a number of neuropsychiatry divisions in different hospitals in Japan, with the most recent being a post from April 2010 until present in the Division of Social Reintegration Support Services, Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, which is currently regarded as the best and most modern in Japan. She lectures at various venues including Sapporo Medical University, and is a regular speaker at study meetings and seminars related to alternative approaches towards mental illness. Some of her interviews are available over the Internet. She is currently writing a book on an advanced method that could be applied to people with mental illness. Her major publications include the following co-authored articles: ‘Possibility of regional mental treatment – perspective from Tohoku and Hokkaido regions’, Psychiatria et neurologia Japonica 108: 957 (2006); ‘Attempted suicide at an emergency centre’, Psychiatria et neurologia Japonica 105: 804 (2003). Hiroto Ito was appointed by the government of Japan in December 2011 as one of the members to prepare to include mental illness as one of the five major diseases in Japan (along with acute myocardial infarction, cancer, diabetes and stroke). He is also starting a nationwide collaborative project on screening and treatment of co-morbidities of persons with mental disorders and physical illness. From 2006 to present he is also Director, Department of Social Psychiatry at the National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan. His recent publications include: Ito, H., Setoya, Y. and Suzuki, Y. ‘Lessons learned in developing community mental health care in East and South East Asia’, World Psychiatry (in press); Miyamoto, Y., Tachimori, H. and Ito, H. ‘Formal caregiver burden in dementia: impact of behavioral and psychological symptoms of dementia and activities of daily living’, Geriatric Nursing (in press); Kobayashi, M., Ito, H., Okumura, Y., Mayahara, K., Matsumoto, Y. and Hirakawa, J. ‘Hospital readmission in firsttime admitted patients with schizophrenia: smoking patients had higher hospital readmission rate than non-smoking patients’, International Journal of Psychiatry in Medicine 40: 247–57 (2010). Sandra J. Lawman is a health consultant for the Shaftesbury Partnership, currently a member of Rethink London Committee and National Audit Committee, and Vice Chair of CASA Housing Support; she is a former Lambeth local councillor and Chair of Social Services, a former Board Member of Mosaic Clubhouse and former Secretary to the Trustees of the South London and Maudsley Mental Health NHS Foundation Trust Charitable Funds. Hajime Oketani is Director-General and a board member of COMHBO since 2007. He has been working for mentally disabled people and their families with the most influential association representing their interests at this time in Japan, namely the National Federation of Families for the Mentally Ill in Japan. After

Contributors xiii working with that organization since 1984, being the Director-General (2000–3), he has been regularly issuing articles and editing journals in relevant areas. He was an active editor of the monthly journals Zenkaren (1986–2004) and Review on Local Community Mental Health and Welfare (1991–2004); and published two books as editor Mentally Ill – 100’s Experiences (Chuohoki Publishing, 1993) and Mentally Ill – Experience of the Family (Chuohoki Publishing, 1995). He was a member of the editorial board of the Japanese Federation of Mental Health and Welfare (2000–3) and is now working on the White Paper on Mental Health and Welfare (2004–present). Major committees he has been involved with include one relating to schizophrenia, organised by, for example, the Japanese Society of Psychiatry and Neurology and study and steering committees on vocational ability for disabled people (Ministry of Health, Labour and Welfare, 2003–5). Ruth Taplin is Director of the Centre for Japanese and East Asian Studies, which won Exporter of the Year in Partnership in Trading/Pathfinder for the UK in the year 2000. She received her doctorate from the London School of Economics and is the author/editor of 15 books and over 200 articles. She wrote freelance for The Times newspaper for nine years on Japan, Taiwan and Korea. Taplin studied Japanese at Durham University over 20 years ago as part of a special course for future leaders in the Japanese field in the UK. Her most recent books include: Decision-making and Japan: A Study of Japanese Decision-making and its Relevance to Western Companies (reprinted by Routledge in 2003, first published by The Japan Library in 1995); Exploiting Patent Rights and a New Climate for Innovation in Japan (Intellectual Property Institute, 2003); Valuing Intellectual Property in Japan, Britain and the United States (Routledge, 2004); Risk Management and Innovation in Japan Britain and the United States and (with Masako Wakui) Japanese Telecommunications Market and Policy in Transition (both published by Routledge, 2005); Innovation and Business Partnering in Japan, Britain and the United States (Routledge, 2006); Outsourcing and Human Resource Management: An International Survey (Routledge, 2008); Intellectual Property and the New Global Japanese Economy (Routledge, 2009); and (co-edited with Alojzy Z. Nowak) Intellectual Property, Innovation and Management in Emerging Economies (Routledge, 2010). Professor Taplin is a featured author of Routledge. She is editor of the Interdisciplinary Journal of Economics and Business Law (www.ijebl.co.uk). Graham Thornicroft is Professor of Community Psychiatry, Institute of Psychiatry, King’s College London; Head, Health Service and Population Research Department, Institute of Psychiatry; Consultant Psychiatrist, South London and Maudsley NHS Foundation Trust; and Director, Health and Policy and Evaluation Institute, King’s Health Partners. Professor Thornicroft has authored and edited 23 books and over 230 peer-reviewed papers in Pubmed. Some recent papers include: Howard, L., de Salis, I., Tomlin, Z., Thornicroft, G. and Donovan, J. ‘Why is recruitment to trials difficult? An investigation into recruitment difficulties in an RCT of supported employment in patients with

xiv Contributors severe mental illness’, Contemporary Clinical Trials 30(1): 40–6 (January 2009); Thornicroft, G., Brohan, E., Rose, D., Sartorius, N. and Leese, M. ‘Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey’, Lancet 20(373): 408–15 (January 2009); Tansella, M. and Thornicroft, G. ‘Implementation science: understanding the translation of evidence into practice’, British Journal of Psychiatry 195(4): 283–5 (October 2009).

Foreword Neutralising the toxic effects of stigma

A few days ago, as a psychiatrist, I was asked to make a home visit to assess a woman who was unwell. She had the belief that her bed shook and vibrated at night and that a neighbour upstairs was using some kind of witchcraft to disturb her in this way. She was so upset that she had moved her bed into a different room, to no avail, and then started to try sleeping on the floor on a blanket, but still she could not sleep properly. She was so distraught that she was considering pouring bleach through the neighbour’s letter box to decontaminate this threat. Although where I work in London we have home treatment teams to help people in mental health crises, she wanted to leave her apartment for a while to escape this torment. I offered her a voluntary admission to hospital. She thought about it and said that if she accepted, and if her family found out about this, it would bring great disgrace upon her and upon her whole family. So she declined the offer. I and my colleagues were left to consider whether, for her best interests and for the safety of her neighbour, we should arrange for a compulsory admission to hospital, and if this would be the least restrictive option to try to help her. This story illustrates the fact that stigma and discrimination are common, often severe, and can profoundly jeopardise the social inclusion of people with mental health problems.1 In this case, for example, the expectation of disgrace, dishonour and reputational damage led her, not unreasonably, to refuse the offer of treatment on a voluntary basis in hospital. Ironically though, in the longer term, if she were treated on a compulsory basis in hospital, then the stigmatising consequences may be even more severe for her. Such ‘Catch 22’ situations are indeed common and, for a service user, the offer of psychiatric help can be seen as a mixed blessing, where the harm may outweigh the benefits. Recent research, carried out by interviewing people with a diagnosis of schizophrenia in 27 countries worldwide, has shown that 95 per cent reported experiences of negative discrimination, for example in applying for a job. Stigma was present and damaging in all the countries assessed.2 One toxic aspect of stigmatisation is that over half the people interviewed said that they had not applied for a job, or had not tried to initiate a close personal relationship, because they expected to encounter a stigmatising reaction – because they expected to fail. The promotion of greater public understanding of mental disorders, therefore, is one of the most important and pressing issues leading to better mental health

xvi Foreword care. This is why Mental Health Care in Japan addresses key gaps in understanding the Japanese approach to mental illness and mental health care. It is a vitally informative source for psychiatric and allied professional staff in Japan, and for everyone interested in these issues. A particular strength of the book is its clear emphasis upon putting the insights of service users centre stage, and using these priorities and preferences as the best indicator for the future direction of travel of mental health care in Japan. The book places mental health care issues in Japan within the mainstream of society – not leaving them hidden away. It is also timely as there is now an increasing awareness of the toll that mental disorders take across Japanese society, especially in relation to suicide, and the consequences of disasters. This book will therefore add to the momentum towards the greater social inclusion of people with mental health problems, a movement that is now accelerating worldwide. Graham Thornicroft Professor of Community Psychiatry King’s College London, Institute of Psychiatry January 2012

Notes 1 2

Thornicroft, G. Shunned: Discrimination against People with Mental Illness. Oxford: Oxford University Press (2006). Thornicroft, G., Brohan, E., Rose, D., Sartorius, N. and Leese, M. ‘Global pattern of experienced and anticipated discrimination against people with schizophrenia: a crosssectional survey’, Lancet 20(373): 408–15 (2009).

Acknowledgements

The editors would like to thank the sponsors of this book that made it possible: the South London and Maudsley NHS Foundation Trust Charitable Funds (SlaM), Maudsley International and Great Britain Sasakawa Foundation, especially Sir John Boyd. Great thanks is due to Mr Peter Sowden for his continued support and words of wisdom in writing this book. The book would not have been possible without the considerable efforts of the contributors and colleagues including (in no particular order): Mr Kazuo Kodama, Mr Reiji Watanabe, Mrs Nobuko Kobayashi and Mrs Nobuko Nishida. Organisations that have also lent their support are the International Centre for Clubhouse Development and Japanese Clubhouses, particularly Habataki Clubhouse, Mosaic Clubhouse, Rethink and Mind. We would also like to thank South London and Maudsley Charitable Funds (SlaM) and the Institute of Psychiatry for their assistance with the seminar/book launches that took place in the last week of June 2012.

Abbreviations

AA ACT ADL COMHBO DH

Alcoholics Anonymous assertive community treatment activities of daily living Community Mental Health and Welfare Bonding Organization Day Hospital, Neuropsychiatry Department of Tokyo University Hospital DPC/PDPS Diagnosis Procedure Combination/Per-Diem Payment System DSM-IV Diagnostic and Statistical Manual of Mental Disorders-IV ECT electro-convulsive therapy FY fiscal year ICCD International Centre for Clubhouse Development ICD-10 International Classification of Diseases 10 ICPTD International Committee for Prevention and Treatment of Depression JCPTD Japan Committee of Prevention and Treatment of Depression JEED Japan Organization for Employment of the Elderly, Persons with Disabilities and Job Seekers JSPN Japanese Society of Psychiatry and Neurology MHLW Ministry of Health, Labour and Welfare MOL Ministry of Labour MOW Ministry of Welfare MSW medical social worker NPO non-profit organisation NSF National Schizophrenia Fellowship PSW psychiatric social worker PTD Prevention and Treatment of Depression SHG self-help group SlaM South London and Maudsley NHS Foundation Trust Charitable Funds WHO World Health Organization WPA World Psychiatric Association

1

Mental health care in Japan An introduction Ruth Taplin

Introduction and overview Mental health care in Japan has been much misunderstood with little attention given to the role of service providers and the fact that Japan still has the highest number of suicides of any country in the world underplayed. In this book the contributors, who are both psychiatric professionals of the highest calibre and practitioners and service users, add their perspectives to the current state of mental health care in Japan. A great deal of this material has not been available before in the English language. To do this, a number of key areas of enquiry are explored and analysed: the role of culture such as tatemae and honne; the role of the family in causing mental illness; whether the best care is in the community or still in hospitalisation; the need for the mentally ill to be integrated into mainstream work; social stigma; and the development of the service users group as an essential part of mental health care in Japan. It has only been recently in Japan that mental illness has become an issue of concern and action. This has been seen in the reforms to a number of statutory acts passing into law concerning the mentally ill and disabled. A White Paper, which will be reviewed further, has given the issue more prominence. Towards the end of December 2011 Dr Hiroto Ito, one of the expert contributors to the book, was appointed by the Japanese government as one of the members to make preparations to include mental illness as one of the five major diseases in Japan in addition to acute myocardial infarction, cancer, diabetes and stroke. He is also starting a nationwide collaborative project on screening and treatment of co-morbidities of persons with mental disorders and physical illness. This is a major step forward for placing issues of mental health care in Japan in the mainstream, which has been much needed. Depression and suicide in Japan has been a much hidden problem and it was only in September 2010 (based on 2009 figures) that the Japanese government released figures noting the financial cost, to say nothing of the social and emotional costs. Such problems cost the Japanese economy nearly 2.7 trillion yen including among other factors, medical costs, loss of income and spending on social security. The Japan Times1 reported the suicide rates for 2009, which were announced at a meeting concerning resolving issues of suicide and depression by Health Minister

2 Ruth Taplin Akira Nagatsuma. More than 32,000 took their lives with the majority of individuals between 15 and 69 years of age. Hiroto Ito notes in Chapter 2 that the suicide rate in Japan rose from 18.8 suicides per 100,000 population in 1997 to 24.9 per 100,000 in 2010.2 He argues that the prolonged recession seems to affect this trend and that the National Police Agency suggested common reasons including health concerns, unemployment and financial difficulties. As suicide has been now acknowledged as a major issue in Japan, the Basic Act on Suicide Prevention was enacted in 2006. Multidimensional countermeasures are being implemented through both the high-risk group approach and population approach, but unfortunately the suicide rate does not appear to be declining as expected. So if the suicide rate is not declining despite much effort being put into its reduction, there must be other factors that will be explored in this book and below in relation to the Japanese family and other variables of causation. The cost to the Japanese economy of depression and mental illness is great with an estimated 45.6 billion yen being lost on worker compensation benefits for those who had to take time off work because of depression. Former Prime Minister Naoto Kan connected the high numbers of suicide and depression with both economic and emotional downturn and launched a video campaign to try and combat the problem.3 Tatemae and honne Tatemae and honne are concepts essential to understanding the Japanese psyche as the former refers to how things should be and the latter refers to the reality and how things are in actuality. In all cultures there is a tension between such states of mind. In Japan, the very attempt to separate the two states of mind so they do not come into conflict can cause other tensions, especially within the context of the family where it is more difficult to hide true feelings. Within Japanese society, strict rituals, which are exercised day in and day out, serve to keep the two separate at work, in business communication and in institutions. However, within the family where one lives emotionally and closely with kin, the two concepts often come into conflict causing mental distress from lack of communication. The family is the one place in which individuals have the chance to air their genuine feelings. When individualism is stifled and all relations become one of society through ritual, human safety nets for expression can turn inward with anger becoming internalised and depression ensuing. There are some safety mechanisms for genuine emotions in Japanese society such as karaoke evenings when all become drunk, rank is supposedly forgotten and workers are allowed to become open with their bosses with the content of drunken outbursts forgotten the next day. This does work in some contexts but for the family and in society as a whole such tensions can become unbearable. Often children must adhere to ritualised lives set out for them by their families and if they do not fulfil their duties are treated very harshly emotionally and mentally. This is why many psychiatric social workers find communication within the family the first port of call when trying to deal with those who suffer from mental illness. Yayoi Imamura, a psychiatrist who contributes a chapter to

Mental health care in Japan 3 this book (Chapter 4), notes that for centuries in Japan it was the family that had to hide away mental illness with private isolation rooms permitted, as the behaviour of the mentally ill had to be hidden and any aberrant behaviour could not be tolerated. Below examples are given of how mental health care is changing for the better at the level of the family, local authorities and the wider communities, with service user groups an important part of this process.

The family, communication and mental illness Shouzou Imai,4 a psychiatric social worker, has so far been involved in supporting sufferers and families who suffer from various illnesses and are facing a range of issues, such as issues associated with the period of adolescence, personality disorders, addiction and growth disorder as well as mental disorders, a main cause of such problems. He found himself seeing ‘something’ that exists as a common issue between ‘a sufferer and family’ as well as between ‘families’, although the symptoms, issues, treatments and measures they have been seeing are different. Recently, he started paying more attention to the ‘something’. Putting aside illness, issues associated with people’s state of mind and other issues, he felt strongly that re-establishment and facilitation of communication was a far more important issue as a first step to resolve and reduce the issues. Although Imai understands that it can be said that in hindsight, communications have failed to be delivered smoothly as a result of challenges and pain, caused by illness and problems, he felt from his experience that verbal communications were delivered unilaterally or there were many families who communicated less in quantity or poorly in quality, issues that were at the root of the problem. To analyse further how the family and communication are linked to mental illness Imai began to define what is meant by communication. What is communication? Communication: Human beings deliver their will, emotion and thoughts to each other and it is delivered through means such as language, letters, gestures, expression and voice which appeal to both a visual and acoustic sense.5 Communication is to be carried out by utilising various means and methods not only verbally. Silence/timing, gesture, the way of speaking and looks are used. Meaning and purpose of communication Human beings have different personalities and senses of values even though they may be connected as parent and child, husband and wife and siblings. Even though we say that we ‘are fellow human beings who share the food out of the same pan’ or ‘a family shares the same destiny’, it does not necessarily mean that our views and interests are exactly the same. Therefore, it is absolutely imperative that we establish meaningful communication, either in quality or quantity, to establish and maintain a harmonious relationship.

4 Ruth Taplin In the event that important issues need to be solved or improved urgently, much closer communication will be required. In having a meaningful communication, people can have a feeling of togetherness and deal with the common issues they face. Understanding the ‘definition of communication’ more widely and deeply When we talk about communication, we tend to regard it as ‘a relationship through conversation’ in most cases. In other words, the definition of communication is interpreted very narrowly. Although greetings such as ‘Good Morning’ are an important element for establishing a relationship, it is not sufficient to establish communication. Other elements, such as correspondence for something, exchange of information and chatting are a necessary and a refreshing element in our daily lives and are naturally considered as part of communication. However, communication can have much wider meaning, such as delivering deepest thoughts, from one person to another, views and opinions and, in some cases, delivering thoughts to each other sufficiently, even if such thoughts concern very serious issues. Additionally, forming a relationship and working to bring certain issues that remain vague in people’s minds to their attention through dialogue also forms an important part of communication. Preconditions required to establish communication Communication takes place through human relationships. Establishing and maintaining human relationships backed by affection is the basis for achieving smooth communication. It is natural that people have different tastes, interests, sense of values and lifestyles. However, people are required to have an attitude to show understanding towards such differences in order to establish communication between each other. While people may grow to like someone, they may also grow to hate someone. It is natural that a couple may eventually not wish to see one another. However, in case of having a child, it may be difficult for his/her parents to behave according to their feelings or emotions, as the child lives in the environment that has been created by his/her parents. In this case, parents have to maintain their relationship by controlling their emotions but they may be put in very difficult circumstances sooner or later. However, a child has nothing to do with it and parents are required to separate their own issues from issues associated with childcare and to form a system of cooperation only for childcare. Communication methods A verbal method is commonly used for communication. We deliver our thought to others by means of words.

Mental health care in Japan 5 Non-verbal methods can also be used, which include body movements, facial expression, gestures, tone of the voice, looks, silence/timing, atmosphere, signs and manners. We communicate with each other through sending out various signals as our five senses guide us. Non-verbal communication allows for far more relevant communication than verbal communication because the former delivers much wider and deeper meanings through expression. For example, when what has been delivered by word does not correspond to what the expression or atmosphere actually delivers, the latter becomes more important. What is required to carry out meaningful communication Imai notes that from his experiences of being involved in family groups that there are many people who are not good at expressing their own thoughts, feelings and opinions, such as ‘tough’, ‘sad’, ‘angry’, ‘worried’, ‘happy’ as well as ‘I think this . . .’ or ‘I think that is an issue’. This is what happened when he gave some of the families a theme such as: ‘Talk about yourself (Talk about your own feelings or thoughts to someone close).’ It was unclear whether they could not understand the meaning of ‘Talk about yourself’ or if they had never talked about themselves before in their lives. There are many people, however, who can talk eloquently about others, not themselves, such as ‘lifestyle or episode of a son and daughter’ or ‘complaints and moaning about the uncooperative husband’. It seems that they lack sensitivity to the fact that they are the ones concerned (or are sufferers?) and they have left their ‘selves’ somewhere else. They appear to be like invisible persons. They cannot help but think that the majority of the group consists of those who ‘are used to suppressing themselves’ and those who ‘try to keep calmness or harmony in their family by putting up with events’ unconsciously and not speaking much about themselves in relation to verbal communications within their families. This led Imai to believe that problems in relationships with their grandparents as well as problems related to the circumstances in which they have grown up, such as traditional views of values, customs and strict rules in their family, lie behind the above issues. He assumes that the non-verbal communication of a person may not be delivered well to others, despite its delivering a large amount of messages, because the human relationship itself has become tenuous recently. It is important for people who have the above tendency to form the habit of ‘speaking about themselves’ through using verbal means. Aiming to form ‘a relationship with dialogue’ The origin of ‘a relationship with dialogue’ is a relationship between a mother and baby. What a baby can do is to cry to express hunger, being uncomfortable in a nappy, wanting to be hugged or being worried. A baby expresses his or her ‘comfort’ by smiling or sleeping. A mother needs to have an awareness of others/understand

6 Ruth Taplin others so that she can judge what her baby is trying to communicate. It is an important element for us to maintain this mind set to a certain degree so that we can have smooth communications. When a father declares unilaterally that childcare is left to the mother, she becomes responsible for any issues that will arise and execution of necessary roles, as long as the father’s action is interpreted as entrusting her with such a role. However, the mother can regard such a declaration from him as a declaration to abandon childcare. It is ideal that both parents are engaged in childcare and it is not a fundamental role allotment as long as the mother is not convinced with her own role. Even though the father is not at home during the day time or is busy at work, it is his role to give his psychological support or being a partner to discuss issues with the mother by creating time to do so when she needs to communicate. Communication never takes place in a relationship between the ‘ruler and ruled’. In other words, it is an important issue to have a mutual, not a unilateral, relationship in a daily life in order to maintain meaningful communication.

Psychological education for the family Psychological education for a family with a mentally ill member suffering from illness such as integration disorder syndrome has been proved effective scientifically, reducing burdens on the family or lowering the recurrent rates of the illness. In recent years, promoting family’s recovery has also been gaining attention, through the psycho-educational approach to a family.6 In Japan, medical institutions have mainly been carrying out discussions concerning the development of an effective model for psychological education of families as well as an appropriate system to carry out such education. Offices and public health centres at the local administrative level have been providing various types of support to families. From the point of view of providing community-centred support and shortening hospitalisation, it is now required that medical institutions, local business entities and local authorities all work together to provide family support that is effective to promote the recovery of the whole family. The Recovery Forum discusses in many sessions how to develop effective models of family support that can promote the recovery of the family, by referring to case studies of family support provided at local business entities, level of the local authority and also effective models used in the local community. In session 3 there is the introduction of an actual system being implemented in a local community, followed by discussion of the reality, prospects and challenges in family support at the local level. There is discussion of an effective model for family support and a system to implement it for the purposes of promoting the recovery of the family in the local community based on the book and ideas of Mr Toru Tsuchiya.7

Mental health care in Japan 7

Assertive community treatment One of the most active ways in treating the family as a whole to deal with a family member’s mental illness and mentioned in the practitioner’s chapters of this book is the assertive community treatment (ACT).8 Family support is one of the most important elements in ACT. As support in ACT is provided comprehensively, mainly through a home visit, supporters have more opportunities to meet the family of the sufferer and can deliver their support not only to the sufferer but also to their family. Providing fruitful support to the sufferer also allows their family to have the time to think about their own recovery, which is supported through ACT. This is an important opportunity. The best way to understand how ACT works within the family is through an example.9 In this case study below family support in ACT is focused on strength through the peer clinic. A peer clinic is a mental health clinic that was established on 1 February 2007, with the aim to provide considerable support to people who suffer from mental health disorders, regardless of the severity, so that they can live freely and comfortably in their local community. The clinic is unique in that it offers outpatient treatment and an out-reach service such as ACT and a socialising space for suffers called Niji-no-Ie (Rainbow House). Case study This is a case study of a female in her forties who is suffering from integration disorder syndrome and is in need of out-reach services such as ACT. The woman lives with her husband and two children. She has suffered from mental illness since giving birth. Several visits to the hospital were made but were discontinued. She had no treatment for about 10 years. This was a severe negative case as she did not have any meals with her family and there was no communication. She just passed a memo if something was needed to be delivered, and did not go out, even to her children’s school entry ceremonies. She undertook no domestic duties. Her husband visited a hospital to request a home visit. She refused to pay a visit to the hospital. A chronic integration disorder syndrome was diagnosed and, as she refused home visits, visits were made when her husband was off work every Thursday. Home visits started with forming a relationship and assessment. She kept refusing, saying that she did not have time as she was busy with the children or that neighbours would become suspicious (a fear of social stigma that is described further on and in this book by Ando and Thornicroft in Chapter 7). She disappeared into the kitchen after serving tea. Her husband told a case worker about her history of mental illness and her recent condition. The assessment consisted of evaluating the strengths of family members and the type of issues they are facing. No assessment sheet was used, focusing on listening to their stories to understand the situation. The intervention included working to leverage the good state of health of her husband, who indirectly sought assistance for his wife. Her son was absent from junior high school and was waiting for a decision by the domestic court. Her

8 Ruth Taplin daughter was in her early teens and tended to be late for school. It was assessed that intervention was needed before they grew up and the issues became more complicated. It was suggested to her that counselling for her son was needed as she was at least concerned with her son’s future, although she was not doing enough as a mother. Subsequently, she attended the peer clinic with her son. Counselling consisted of individual and separate counselling with mother, husband and son, counselling with wife and husband, counselling with husband and son and counselling with them all. Home visits were rejected, therefore a worker talked mainly to her husband. However, the relationship among family members did gradually show signs of change, in the form of an increase of communications between the wife/mother and others. Request for medication The woman requested medication, saying that she would not be able to sleep, thinking about her son’s examination for high school, and if she was in such state of health, he would not succeed. She also asked for information about high school examinations from one of the case workers who has a son of the same age as hers. Her son failed to enter the high school of his first choice but passed with the second choice. She and her husband attended an entry ceremony. As she did not attend her son’s entry ceremony to junior high school three years before, recovery of the family was impressive.

Reality of family support Several issues arose from the case study discussed above: 1

2

3

4

ACT staff members listened to the parents’ story such as their son’s bad behaviour, including smoking. For the husband, who held a responsible position, his son’s behaviour was shameful, but the staff tried to accept such issues as what they could expect in everyone’s life. The husband was a hard worker and supported his family and started to recount his real inner feelings such as his wish to run away from his family. The husband thought his wife was just lazy as he did not have knowledge about the mental illness. Psychological education texts from the Community Mental Health and Welfare Bonding Organization (COMHBO) were used to educate him about the illness, which can be cured. The text helps people understand that other families have similar issues. The biggest issue was the son’s behaviour and high school examinations. The wife, husband and son were able to have effective counselling, allowing for adjustments in the family relationship. During weekly home visits, it was explained that her strange or seemingly lazy behaviours, which made her husband feel strange or frustrated, corresponded to certain symptoms of the illness and it was also explained about the meaning

Mental health care in Japan 9 of such symptoms in terms of recovery. A cycle of assessment, review of what has happened and understanding the meaning of the symptoms in terms of recovery was continued during home visits, which allowed ACT staff members to understand the viewpoint of her husband. Support that can be provided through ACT only (home visits) In case the sufferer refuses to visit the clinic, the case workers cannot communicate with him/her without an out-reach service. Even though the sufferer may not want to see a visiting staff member, it is necessary to pay a visit to his/her home, which he/she regards as their own living space, and to continue to pay a visit and communicate with the sufferer, even though it is for a very short time. Support could only be provided through ACT, working on the strength of the sufferer and delivering information on the high school examinations for example. Support that can be better delivered through ACT (in clinic) Case workers felt they could still listen to the family, and provide psychological education as a ‘reference’ to the family and consider their viewpoint as a meaningful social resource through services that require a clinic visit. However, it seems the family will naturally speak in a different manner when they are at the clinic (away) and at home (home) where they feel more comfortable. In the case of males in particular, it is possible to assume that they have difficulty talking from their heart at the clinic (away).

Family research from Kyoto Some findings from the research are listed below:10 • • • • •

The time spent from the detection of abnormality until the first visit: about 1 year and 10 months. Percentage of sufferers who could acknowledge that it is a mental illness: 22.4 per cent. Over 40 per cent require monitoring (including ‘at all times’, ‘occasionally’, ‘for 24 hours a day’). Over half of the respondents have resistance to receiving examination (including ‘with reluctance’, ‘with a need of persuasion’, ‘forced’ and ‘rejection’). One in six patients has been forced to stay in a hospital after the first examination (hospitalisation for medical protection and compulsory hospitalisation), for which only the family provides support.

Overview •

Surveyed: 450 members of Kyoto Federation of Family Meetings for Mental Health Welfare Promotion.

10 Ruth Taplin • •

There were 232 respondents; 252 answers were returned (62 per cent). Basic data: – Average age of respondents (family): 68.9 years old, ±8.3 (youngest 35 years old; oldest 90 years old). – Female: 72.8 per cent; male: 27.2 per cent. – Average age of sufferers: 41.5 years old, ±9.8 (youngest 23 years old; oldest 85 years old). – Relationship: son 55.6 per cent; daughter 37.9 per cent; siblings 4.3 per cent; spouse 1.3 per cent; parent: 0.9 per cent. – Diagnosed illness (multiple answers): integration disorder syndrome 80.6 per cent; mood disorder 9.9 per cent; mental illness of the undifferentiated type 4.3 per cent; others 9.9 per cent. – Living with family: yes 76.3 per cent; no 22 per cent (including a longterm hospital stay), not known 1.7 per cent. Some further findings from the research:

•

The time spent from the first examination until the point where the condition becomes stabilised: about 13 years and 8 months. • Ages when conditions become stabilised: 35.7 years old on average (youngest 21 years old; oldest 65 years old). • Ages at the time of first examination: 22.0 years old on average (youngest 8 years old; oldest 50 years old). • Seeing a psychiatric department: 13.7 per cent said that a visit is accompanied by family or a visit paid by the family without the person concerned is taken. • Sporadic behaviour: 19.8 per cent suffer from sporadic behaviour more than once a month. • Families that have never been asked about the difficulties they face by primary physicians or other specialists: 49.6 per cent (see Tables 1.1 and 1.2). Offerings from a primary physician such as ‘emotional support’, ‘appropriate information’ and ‘swift treatment’ are highly rated but the finding shows differences in the following areas. Table 1.3 refers to who offers the greatest support for sufferers in working together and Table 1.4 refers to support by visit. Such support is ranked in order of percentage amounts in these tables. Table 1.1 Problematic experiences of the family (top five in bold) Concern for the sufferer’s health Ill health of the family Impact on job placement of family Fear of one’s life Relationship with neighbours Had experience calling the police Told nothing could be done as long as the sufferer refused treatment Atsushi Satou Session 10, pp. 68–71.

62.1% 45.3% 22.4% 15.9% 15.1% 14.7% 8.2%

Mental health care in Japan 11 Table 1.2 Whether the families have been asked about difficulties they face Not in particular Often asked, no consultation to solve problems offered Often asked, with consultations offered Asked very frequently, with consultations offered Other responses No response

49.6% 10.8% 13.8% 3.0% 6.5% 16.3%

Atsushi Satou Session 10, pp. 68–71.

Table 1.3 Working together to provide support (top five only) Family Family meetings Relatives Workshop Public health centres

40.5% 12.1% 11.5% 11.2% 10.3%

Atsushi Satou Session 10, pp. 68–71.

Table 1.4 Support by visit (top five only) None Public health centres Family Relatives Friends

44.4% 22.4% 22.4% 17.7% 10.3%

Atsushi Satou Session 10, pp. 68–71.

Quality of support through ACT • •

•

It is not necessarily true to say that anyone can offer support of the same quality through ACT if the ACT framework is established. What makes ACT unique is, first, its framework, in which support is offered by the ACT team through a home visit or for 24 hours a day throughout 365 days a year and, second, quality of support in terms of recovery and strength models for severe sufferers as well as relationships between supporters and receivers. If quality of support offered by ACT does not continue, there will be a return to bureaucratic local management.

ACT, therefore, is an increasingly important mechanism for those with mental illness and their families as the family is treated as a unit that needs to recover not just the diagnosed mentally ill person who previously was locked away in isolation rooms within the family and seen to have no impact on the family unit or treated as almost a non-family member to be hidden in shame. The increasing importance placed on mental illness and depression/suicide could be seen in the recent White Paper discussion. The most salient parts of the White

12 Ruth Taplin Paper relate to the emphasis of this book and most of the chapters concern actual care of the mentally ill and service user organisations, which empower the mentally ill to deal with their own care and issues of surviving outside of the constraints of hospitalisation. The role of administrative bodies is looked at below.

White Paper on mental health care Roles of prefectures11 Support for persons suffering from mental disorders is provided by administrative bodies in line with laws such as the Services and Support for Persons with Disabilities Act and the Mental Health Welfare and Medical Care Act. Relevant departments and sections of prefectures are required to play a role of reflecting the hopes and wishes of sufferers to policies, shaping budgets and implementing policies to their operations. In reality, policies will be promoted based on recommendations from prefectural/government programmes for persons with disabilities, local mental health welfare councils and prefectural service and support for independent councils. Service offerings are also required to be carried out by both taking into account the uniqueness and advantages of the local community and listening to sufferers as well as providers of welfare service for persons with disabilities. In this regard, prefectural bodies are required to have a broader perspective as administrative bodies and also the viewpoints of specialists such as technical experts.

Case study of Kagoshima (Kyushu) Kagoshima’s mental health welfare index is less favourable than other places in Kyushu but the average hospitalisation periods are gradually being reduced. Kagoshima has also developed a welfare plan targeted for persons with disabilities in Kagoshima, which follows the basic direction of transferring from hospital treatment to local community life in the reformist vision of mental health medical welfare care in 2004. Since 2007, Kagoshima carried out special projects for local transfer support in cooperation with designated consultation support providers that have more than one person to provide transfer support. Such support persons cooperate with mental health hospitals in the same area, offering individual support and care to assist those transferring back into the community. In Kagoshima, the number of suicides is not low, over 500 people annually during the recent period. They have set up a council to combat suicide as well as funding for the urgent strengthening of measures against suicide in the local vicinity. In 2009, an information centre for suicide prevention was set up within the mental health welfare centre. A support centre for persons with greater brain dysfunction has been established, where specialist instructions and advice, workshops and educational activities are offered for those with this particular disorder.

Mental health care in Japan 13

Cities, towns and villages The total number of local governments (municipalities) is 1,727 as of April 2010. There are 40 cities that are designated as core/central cities in accordance with the core city system that allows cities to strengthen authoritative power in order to provide administrative services to the public more locally. As one of their administrative jurisdictions is health hygiene administration, they have their own public health centres. This is when the prefectural offices transfer part of their administrative jurisdictions to city, town and village offices such as for medical cost allowance systems and handling of applications for mental health welfare notebooks. Since 2006, when the Services and Support for Persons with Disabilities Act was introduced, three disorders, physical, intellectual and mental, were systematised.

Mental health welfare services provided by Kawagoe City (Saitama) public health centre Although a public health centre in a core city does not have authority to carry out supervision of mental health hospitals and compulsory hospitalisation, it is the first contact point for the police and is cooperating with the prefectural public health centre through the provision of information. A public health centre also provides support for sufferers from hospitalisation to life after discharge, and disseminates information about mental health medical information through various media such as hospital monthly magazines. The advantage of the public health centre in the city is its ability to conduct a smooth cooperation with other relevant departments and sections. These sections and departments, dealing with mental health welfare issues, are placed within the administrative organ. In other words, the relevant departments and sections are comprised of the same civil servants. In 2006, Kawagoe City had also set up a council to combat suicide.

Future prospects A core city, being smaller than the prefecture with lesser populations, allows the public to consult more closely and non-specialists such as social workers and health nurses often deal with consultation. A core city public health centre also has to cooperate proactively in terms of health, medicine and welfare to play a key role.

Peer support Peer support,12 which has provided hope has also provided safety and relief to those who have been feeling anxious about discharge from hospital, has become a more powerful driving force for changing the situation. Saitama City is an example of what hospital discharge support services are aiming to achieve:

14 Ruth Taplin • • • • • • •

to facilitate a stable life for persons with mental disorders in the local community; recovery of a person’s humanity and respect as a human being; issues of social hospitalisation being made the issues of the community; support for hospital discharge that utilises support for a sufferer, and development of a support system of community life; cooperation with relevant organisations by sharing their individual strengths; aiming to incorporate support services to mental health welfare policies in Saitama City; creating flexible policies to meet needs. Support provided by support services personnel includes:

• • •

helping service users through discussions together about necessary support for hospital discharge; providing support that each user requires both cautiously and progressively; providing support of staying together by valuing attitudes for thinking about the circumstances of others. Support provided by support services personnel:

• • • •

support to create an image of living; support for social resources; support for experiencing an overnight stay; support for going out or for accompanying (nervousness/relief). Relating to Table 1.5 are the following data:

• •

Service users: 23. Discharged patients: 3.

Table 1.5 Results of hospital discharge support services (FY 2009) Period

Support provided until users start hoping for a discharge

Support until discharge

Support for leading a stable life after discharge

Content of services

Socialisation, workshop, individual support

Support based on care conference and care plan

Network contact group

Handling of issues

Working group to support the sufferer

Working group on family support

Working group on local community support

System working group Number of targets

102

23

3

Mental health care in Japan 15 • • • •

Patients who withdrew from the process: 2. Patients who are still using the services: 18. Integration disorder syndrome: 16; others: 2. Hospitalisation period: 13.8 years on average (shortest: 1 year; longest: 34 years).

The following data relate to support: •

•

•

•

support from life support centres: – care management: 1,481 times; – visits: 156 times; – correspondence coordination: 1,325 times; – care conference: 95 times; content of discharge support: – meeting in a hospital: 72 times; – facility use: 221 times; – support for going out: 17 times; support provided by support service personnel: – in-hospital meetings: 30 times; – accompanying going out: 187 times; – care conference: 95 times; participation in in-hospital socialisation: 621 times.

It is necessary to put into practice supporters for life as a business operation to allow them to take over the role of support service personnel so there is a smooth transition for patients during and after discharge. Development of social resources and systems The following are necessary for the development of social resources and systems: •

•

•

a public guarantor system, development of new resources such as diversification of living space, a system to provide consultation support for 24 hours a day, 365 days a year; coordination of medical institutions, health and social welfare, aiming to establish an organic coordination system, including sufferers and their family as leaders; finally, aiming to establish a mechanism to support local community life as a universal system, regardless of the existence of business operations.

People involved in providing support believe in the power of the person him/herself and recognise the importance of having the attitude that it is an issue for everyone, not for the individual person. It is viewed by service providers in Japan as a combination of cooperative strengths of the service user and service provider. A person providing support for local transfer will stay close to the service

16 Ruth Taplin user and strives to provide provision of support that can energise the power of the service user.13 Some of the issues found by service providers in Shizuoka include:14 • • •

•

•

• • • •

There is a lack of social resources (such as a facility where an overnight stay can be practised and a facility for admission to carry out day time activities). There is a limit on the use of facilities at city and town levels. Local communities lack the willingness to accept those who have been hospitalised for a long time. There is difficulty in delivering willingness through more tangible ideas. It is difficult to understand tangible ideas of life support and actual living (discharge) from the viewpoint of a medical model that tries to find issues and causes related to the illness and the person concerned. How effectively can rehabilitation be carried out (or be conceptualised) in a living space? The issues concerning persons with mental disorders are not necessarily handled in a similar manner to that for other disabilities (mental, physical and intellectual). There is a lack of understanding of relevant persons (cities and towns) towards operations/services. There is an attitude that issues concerning persons with mental disabilities are better dealt with mainly by the prefectures (public health centres). These issues are seen as a social welfare matter at the community level. The necessity for a mechanism for discussions throughout the areas, without being limited to discussions only with support councils in towns or cities. Review of roles and functions of support councils in prefectures, areas and local communities.

Example of a social welfare corporation for service users Hongo-no-Mori, Gin-nan (Ginkgo nuts) Kikaku This social welfare corporation was established in October 1988 as a group workshop, mainly by the Family Meeting at the Day Hospital, Neuropsychiatry Department of Tokyo University Hospital (hereafter DH). At that time, there was an increase in the number of patients who could not adjust to society after graduating from DH. Gin-nan Kikaku was established with the aim of becoming an institution closer to actual social life, while being located outside of the hospital, so that recovery in society (rehabilitation) of patients can be promoted effectively. In April 1992, Gin-nan Kikaku II was established. In April 1996, Gin-nan Kikaku III, followed by Home Icho (ginkgo) for six people as a living space. In the wake of the introduction of Services and Support for Persons with Disabilities Act, Ginnan Kikaku and Gin-nan Kikaku II are providing continuous support for employment Type B. Gin-nan Kikaku III has been transferred to a multi-function type, a combination of transition support for employment and continuous support for employment Type B.

Mental health care in Japan 17 The current members consist of those between 19 and 65 years old, with an average age of 42.2. In the three facilities, 93 are for continuous support for employment Type B, 7 are for transition support for employment. Integration disorder syndrome accounts for 80 per cent of service users. As of March 2010, the total number of patients since the launch in 1988 has been 343. They are normally engaged in part-time work such as direct mailing. Members often carry out a part-time job as a group. Sports, such as volley ball, are offered once to twice a week. Autonomic management is being maintained as an executive committee style at DH for matters concerning members, except for dealing with outside companies. They respect decisions made by the members, aiming to provide support for developing self-motivation and regaining confidence, for example the calculation and payout of wages, management of materials or supervising a work in progress in some areas of their work. Examples of membership 1

2

3

Female, 40s, integration disorder syndrome: fourth year at Gin-nan Kikaku. Proactive to take charge of trips and bazaar (small market), gained confidence. Good at sports. Participating in volley ball but requires a break as she tires easily. A record holder of softball throwing at the Tokyo Sports Competition for People with Disabilities. Has experience of living at a group home for 1.5 years. Since December 2009, she has been working as a cleaner two days a week (9:00–10:00) at a Chinese restaurant. Participating in a PC workshop hosted by Gin-nan Kikaku. Female, 30s, integration disorder syndrome: fourth year at Gin-nan Kikaku. Proactive to take charge of trips and a small market, gained confidence. She once suffered a problem in relationships with other female members, resulting in ill health. Participates in volley ball’s hard training without taking days off. She does muscle training as her service is weak. She is currently looking after her mother and lets her stress out through sport activities and by chatting with others at Gin-nan Kikaku. Since December 2009, she has been working as a cleaner two days a week (9:00–10:00) at a Chinese restaurant. Participating in a PC workshop hosted by Gin-nan Kikaku. Male, 30s, integration disorder syndrome: fourteenth year at Gin-nan Kikaku. Getting on with the job of executive committee member. Proactively participating in a group part time. He had experience visiting here from a hospital. In 2000, he joined Home Icho and stayed for three years. Since then, he lives alone. In 2004, he disclosed his illness while looking for jobs and he failed many times. He did not give up and since September 2005, he has been doing a cleaner job for six days a week from 07:30–11:00 at a supermarket nearby to his home before he visits Gin-nan Kikaku in the afternoon. He spends his only day off studying for examinations.

18 Ruth Taplin

Mental Health White Paper associations Other types of service user support Public health centres15 In 1937, the establishment of public health centres began with 494 centres as of June 2010, in comparison with 847 centres in 1994. The role of public health centres in mental health welfare has been defined in the notice ‘Mental health welfare at public health centres as well as in the city, town and village’, which was published in 1996. Following amendments to the Community Health Act in 2002 and the enactment of the Services and Support for Persons with Disabilities Act in 2006, the city, town or village was made the front-line organisations for social welfare and consultation services for persons with mental disabilities. As a result, the role and function of the public health centre has become more wide-reaching with specialist and technical aspects to them. THE CASE OF CHIBA PREFECTURE

In 2007, Chiba prefecture introduced a prefectural ordinance, aiming to remove discrimination against the disabled and setting up the core local community life support centre that offers support and service for 24 hours a day, 365 days a year. It offers out-reach (a visit), by cooperating with private sectors and relevant organisations. ISSUES FOR PUBLIC HEALTH CENTRES

Although public health centres have been involved in various events such as network conferences, they still face challenges such as the need for early intervention to a patient who may not be able to receive services or treatment, the handling of those who have withdrawn from treatment, educational activities and measures to combat suicide. It may also be important that they propose policies to law such as the Services and Support for Persons with Disabilities Act. Mental health welfare centres Mental health welfare centres have been created as core technical organisations with the aim to supervise and provide support to public health centres. The main tasks are divided into nine areas: planning; technical education/support; training and education; research/study; mental health welfare consultation; development of organisations; administrative work on the review of psychiatric treatment; support for independence; and judgement of mental health welfare notebooks.

Mental health care in Japan 19 ISSUES AND THE SITUATIONS IN NAGANO: AN EXAMPLE

The mental health welfare centre in Nagano has always been required to meet needs of mental health welfare throughout the prefecture. As a result of one study, the centre realised that it could cooperate with local governments that have more or less expertise on cases such as hikikomori (complete social withdrawal).16 Once such a system, in which local governments carry out consultation proactively, has become the basis, they can enhance service quality and reduce the gaps between cities and villages. Since 2007, coordinators of hospital discharge have been placed at four locations in the prefecture and they aim to achieve 230 cases of local transfer by 2011. The centre has been engaged in an anti-suicide campaign since 2008 and hosts meetings for the family left by autocide. In 2010, Nagano Peer Support Network was officially launched. Zenkoku-Seishin-Hoken-Fukushi-Renraku-Kyogikai (National Liaison Council of Mental Health Welfare) The National Liaison Council of Mental Health Welfare has been deeply involved in promoting local care for persons with disabilities. The association also acts as a central organ for prefectural associations of mental health welfare, through sharing information and suggestions, as well as in a liaison capacity with the government. Each local association is also engaged in various activities such as publication of in-house magazines, educational activities, symposia, workshops and counselling. Currently, the National Liaison Council’s activities have shifted to normalisation of persons with disabilities, local community life support and enhancement of mental health of local residents, highlighting the prevention of suicide. Shakai-Fukushi-Kyogikai (social welfare councils) Kyogikai, is defined in the Social Welfare Act and is a private organisation of a public nature and with public profitability to a high degree. A report on the future direction on local community welfare, published in 2008, suggested that Kyogikai has been playing a proactive role. Kyogikai, at the town and village levels, is engaged in various activities such as consultation/support for children to the elderly and other support activities. The main activities of Kyogikai are provision of support to persons with disabilities to use welfare services provided by the prefectural Kyogikai, which is a daily life support service, nursing or training provision service to persons with disabilities and local community life support. Kyogikai offers a legal guardian service and loans for persons with disabilities at low interest. The national Kyogikai and its 133 local Kyogikai have carried out mental health welfare support projects through ‘the Kyogikai Activities Promotion Services’ between 2002 and 2006. This activity has now become established in Kyogikai and it offers support and consultation to sufferers and family, support to create a place for sufferers to associate and employment support.

20 Ruth Taplin Recovery facilities for persons with mental disabilities It is significant that the basic principal, ‘From a hospital treatment-centred approach to a community-centred approach’, is being re-confirmed and policies focusing on the latter period are clarified in the document, ‘A further reform of mental health welfare’ in 2009. In it, support based on the sufferer’s viewpoint is emphasised. In order for a sufferer to be able to live a safe life in his/her local community, by receiving the support he/she wishes to have, the following issues have been given prominence: 1

2 3

urgent procurement of social resources that are significantly scarce, systematisation of service providers and strengthening the infrastructure of the existing offices; systematisation of a network connecting various specialist organisations such as authorities, medical institutions, social welfare, education and employment; making the most of expertise concerning a consultative support system in each relevant organisation to establish support systems that reflect the person’s own decision.

To achieve what is stipulated in ‘A further reform of mental health welfare’, budgets need to be secured. It is unclear how the change of the administration will affect policies on the disabled. It is believed that voices, from sufferers, families and personnel in relevant facilities, must be heard. Community activity support centres Article 1, Provision 80 of the Services and Support for Persons with Disabilities Act constitutes the legal base for community activity support centres. CURRENT SITUATIONS AND ISSUES

Implementation body – towns, cities and villages are running the centres according to local circumstances. As the centres are run by an individual city, town or village, it will not accept those who reside in other areas, which therefore has resulted in creating a limit on wider support and ease of use as expected. TYPE OF CENTRE

Type I – the number of users per day exceeds 20. The centre implements or contracts out consultative support service. (Expected to be the transfer destination of a community life support centre.) Type II – the number of users per day exceeds 15. Offering functional training, training for adaptation to the society, service for bathing. (Expected to be the transfer destination of a community workshop.)

Mental health care in Japan 21 Type III – the number of users per day exceeds 10. A stable management of support services through out-patients. (Expected to be the transfer destination of mainly a small-scale workshop.) In some local communities, the transfer of Type I, which offers a free space and consultation functions, has almost been completed. FUJISAWA CITY

A questionnaire to understand needs of the local community has been carried out, which showed both the importance of a free space, for example, as a ‘socialisation place’, and the issues such as out-reach and ‘individual support’. The city aims to shift from social service for illness or disabilities to the public service and is in the process of developing a consultative support system regardless of disability type. The centres are required to offer operations, focusing not only on ‘disability characteristics’ but also ‘local characteristics’. Peer help/support WHAT IS PEER SUPPORT?

Peer support17 is mutual support among sufferers having similar issues. It is based on a sense of humanity that all humans are gifted with intelligence and creativity and exist by supporting each other. Peer support includes various activities such as social support theory, sharing of knowledge and information, life support and research. Since 1990, peer support activities have grown rapidly in some areas such as social welfare, health and student support. WHO IS A PEER HELPER?

A person involved in peer support is often called a peer helper, self-helper or peer supporter but these names are not based on laws or qualifications. A peer helper is in most cases defined as a person who offers support individually to a sufferer who has similar issues, by utilising his/her own experience and knowledge through his/her own mental illness. In 2010, Osaka prefecture became the first of its kind to have carried out a project to train peer helpers for persons with disabilities in accordance with Home Helper Grade 2 training course. Advantages of using peer help include the resolution of feeling loneliness and the learning of living skills. Peer helpers are praised for their contribution to expand employment opportunities for the disabled and are considered to be able to supplement, assess, correct and reform the flaws found in the existing home helper services. PRACTICES AND ISSUES

According to a 2008 study on graduates who completed Osaka’s peer helper course (42 respondents), conducted by Seishin Shogaisha Shakai Fukki Sokushin Kyoukai

22 Ruth Taplin (Association of Promotion of Social Adaption of Persons with Mental Disability), 27 have taken a job as a nurse including a peer helper at a social welfare corporation or health care corporation, which they are using or were using in the past. Main activities include accompanying for chatting, consultation support, cleaning, cooking help. On the one hand, peer helpers realised that they regained confidence, felt more responsible for their work and they were needed and also they could become positive about their illness. On the other hand, they also faced difficulty in forming a relationship based on equality, carrying out effective work, managing their health and maintaining relationships at work. It is desirable to discuss content of training courses, find and secure employment opportunities, and to establish a support system in order to produce a peer helper system. Peer counselling WHAT IS PEER COUNSELLING?

Peer counselling is the basis of peer support and is to listen to and discuss with each other, knowing that a sufferer is the person who knows him/herself best. Peer counselling began in the early 1970s after a movement began promoting independent life in the US. Peer counselling consists of psychological support and information provision. Psychological support includes recovery of self-trust, establishment of awareness of rights. Peer counselling is offered at JHC Itabashi Kai since 1989, which has now expanded its activities such as peer advocacy. EXPANSION OF PEER COUNSELLING

Peer counselling is included as one of the support services for community life support provided in cities, towns and villages. Special services under the Special Ad-hoc Grant for Support Measures for Independence of Disabled Persons clearly include promotion of peer support and a set up of a peer support centre. In local transfer/local community settlement support services, activities of peer supporters are gaining attention. Peer counselling has given courage to people who are hospitalised and also for the first step to making for local transfer. Peer counselling is also regarded as an important factor in ACT. However, the position of peer counselling and training methods is not systematised. Self-help groups WHAT IS A SELF-HELP GROUP (SHG)?

An SHG is a group organised intentionally or voluntarily by individuals or their families who have the issues in common, to resolve the issues that cannot be settled on one’s own and to gain the power to live with such issues.

Mental health care in Japan 23 ORIGIN AND EVOLUTION

In Europe SHGs were established as early as the 1930s and Alcoholics Anonymous (AA) and the Recovery Association were the first groups organised. In Japan, the examples are the National Association to Stop Drinking established in 1963 and AA in 1974. Others are groups related to various issues such as narcotics, alcohol, anorexia, eating disorders and gambling. As for SHGs for integration disorder syndrome, the National Association of Family Meetings with Persons Suffering from Mental Illness was established in 1965 (dissolved in 2007). In 1993, the National Association of Mental Health Sufferer Groups originated from activities of community associations formed by patients under supervision of mental health hospital staff so that they could manage their life in hospitals. CHARACTERISTICS OF SHGS

Characteristics include: 1 2

voluntarism or being self-motivated for participation; bringing together sufferers who have issues in common.

The basic elements in SHGs are ‘sharing’, ‘independence’ and ‘becoming released’. CURRENT SITUATIONS AND ACTIVITIES

It is a difficult task to understand the accurate state of SHGs due to their changeable nature. Some examples: the number of registered members has decreased recently at the National Association to Stop Drinking. AA has a central office with seven local offices, offering over 900 meeting places to over 510 groups nationwide. The National Association of Mental Health Sufferer Groups has 10 prefectures as the participant groups and 120 registered members. At the prefectural levels, there are about 5,000 members and 400–500 active groups (as of May 2010). A national congress is held every two years, with one in Okayama for the year of 2010. After the National Association of Family Meetings with Persons Suffering from Mental Health was dissolved, the non-profit organisation (NPO) Association of Mental Health Welfare Organizations (Minna-Net) was created, with 47 prefectural members. The number of family meetings nationwide is 1,283 (46 fewer than the previous year) and the number of family members is 32,763 (4,000 fewer than the previous year). The reason why the number of members has been declining is that workshops that used to be run by family meetings were transferred to NPOs, as a result of the ageing of the family members and the introduction of Services and Support for Persons with Disabilities Act. It is now required to re-consider the role of the family meetings by reflecting the original intention as self-help.

24 Ruth Taplin RECENT TRENDS AND ISSUES IN THE FUTURE

In June 2010, specified non-profit corporation, Association of Nihon Bipolar Disorder Groups was established. What this means is that informal SHGs have recently developed in Japanese society to deal with issues that were not hitherto recognised or accepted as actually happening (i.e. social withdrawal or wristcutting/self-harm). There are more cases where patients who have recovered by means of self-help are now offering self-help and peer support services through a service provider organisation. In Japan, conducting research and developing together with sufferers can contribute to the development of mental health welfare and SHGs. Mental health social welfare volunteers8 MENTAL HEALTH SOCIAL WELFARE VOLUNTEERS AND THE REASON WHY THEY ARE IN NEED

In Japan, the policies to ensure that mental health sufferers can live a local community life have been moved to the centre stage after a long-term placement of the policy to segregate them to mental health hospitals. However, the issues still remain: insufficient infrastructure in local communities and opposition to building facilities. It is therefore imperative to produce a local community life for sufferers, which deepens the understanding of local residents towards those who are living with mental disorders and that they have the strength to work to build a town where sufferers can live actively, being themselves. ACTIVITIES AND EFFECTIVENESS OF MENTAL HEALTH SOCIAL WELFARE VOLUNTEERS

Currently there are 397 volunteer groups according to ‘Mental Health Volunteer Group Guide 2000’. The number of groups has dramatically increased since the 1990s. They were working at small-scale workshops or public health centres. Current activities: these include management of a salon, offering a lunch service, going-out programmes, educational activities such as lectures and concerts and support to families. Effectiveness: areas include enhancing the quality of life of sufferers, identifying and resolving potential mental health welfare issues in local areas, working as a go-between with the residents by promoting education and awareness, creating new services and functioning as the main entity to build a town where sufferers can live. ISSUES

Difficulties can be found in recruiting new members, expanding their activities and maintaining learning opportunities. Expectation from volunteers is high because a legal system, local authorities and specialists cannot solve issues on their own. As

Mental health care in Japan 25 for the organisations that are offering support to volunteer groups, they are required to act as a catalyst by offering a place for exchanging information and interest, systematising consultation and training, preparing conditions for the ability to maintain activities and receive recognition from society and forming a partnership with local authorities. Anti-stigma and recovery Tables 1.6 to 1.9 chart the trends and tendencies of society towards those who experience the social discrimination of stigma related to their mental illness. Table 1.6 Positive attitudes of the public towards mental health19 Yes

Don’t know

No

There is a possibility of becoming a mentally challenged person in the current, drastically changeable modern society

76.6

19.2

4.2

I can behave as a member of society, except for when I am in an ill state of health

39.4

51.5

9.1

I can become friends with a person who is hospitalised in a mental health institution

35.8

55.2

9.0

There are many people who can lead a social life, even if they suffer from delusions or hallucinations

29.0

52.0

19.0

Yes

Don’t know

No

It is a concern that a mentally challenged person lives alone or rents a flat with other suffers

52.4

39.2

8.4

The reason why a mental health institution is necessary is that some of the sufferers can cause violent incidents

42.8

35.7

21.5

I do not want others to know that my family member suffers from mental health problems

32.7

50.0

17.3

Sufferers are not expected to control their health by themselves so that they can prevent recurrence of their illness

22.5

52.9

24.6

It is happier to stay in a hospital without having any problems than becoming exposed to real daily life

20.7

59.3

20.0

I do not understand behaviour of sufferers at all

15.9

55.4

28.7

Source: 2010 study of Japan Foundation for Neuroscience and Mental Health.

Table 1.7 Negative attitudes of the public towards mental health

Source: 2010 study of Japan Foundation for Neuroscience and Mental Health.

26 Ruth Taplin Table 1.8 Discrimination experienced by sufferers Unfair treatment as a result of diagnosis as schizophrenia Making friends Treatment by own family Job search Receiving medical treatment Remaining in employment Socialising with neighbours Treatment by police

64% 52% 52% 44% 40% 40% 36% 36%

Source: Yuriko Suzuki, Maiko Fukazawa, Japanese Society of Social Psychiatry, 2010.

Table 1.9 Experiences of restricting own behaviour (self-stigma)

I felt that I needed to hide my diagnosis About job and education About close relationship

Yes, often

A little

No

64% 32% 20%

24% 56% 36%

12% 12% 44%

Source: Yuriko Suzuki, Maiko Fukazawa, Japanese Society of Social Psychiatry, 2010.

Stigma towards integration disorder syndrome20 Sufferers of Seishin Bunretsu Byo (this term was changed to integration disorder syndrome in 2002 as it caused discrimination) were disliked and treated as unwanted members of society when we were using such a name for their illness. Every time a serious incident occurred, the mass media suggested a link between the illness and an incident, resulting in planting a sense of fear in the public mind. Since the name of the illness has been changed to integration disorder syndrome from Seishin Bunretsu Byo, the environment surrounding the illness has substantially changed, for example, the social welfare system for mental health has been treated equally to that for physical disorders and intellectual disability. However, it is not an easy task to remove misunderstanding or stigma that has already been planted in people’s mind. Stigma is nurtured by wrong information as shown below: 1

2

The cause of the illness is genetic: overstating genetic aspects is incorrect as the cause of the illness has not yet been established. It is necessary to raise the awareness in society more than before that most cases of the illness are thought to be from non-familial causes. A genetic connection gives a tainted-forever, bad impression of a family line and is the biggest cause of stigma. Suffering from the illness makes a person violent: although sufferers can cause a seriously violent incidence at times, the rate of causing such incidents is far lower than that by a normal member of society and victims are their family members, therefore, the chance that the public faces a risk of such incidents is very low. When an incident happens, newspapers report that a suspect undergoes a psychiatric evaluation, as if he/she is a mentally-challenged person. This seems to be nurturing stigma. A psychiatric evaluation is to examine

Mental health care in Japan 27 whether a suspect was competent to execute his/her responsibility capacity at the time of the incident and the name ‘psychiatric evaluation’ should be changed to ‘mental competency evaluation’. Stigma and recovery With misunderstanding and stigma existing in the society, sufferers and their families have to bear the pressure, making their independence difficult. In the past when the authorities tried to open a social welfare facility for mental health sufferers, they could not proceed with the plan if challenged by neighbours. Misunderstanding and stigma in society is harmful to recovery of sufferers and efforts to resolve such issues should be made. The following two points are important in resolving the above issues: 1

2

Dissemination of correct information: in many cases, disseminating wrong information contributes to stigma. Although there are a very few cases where the illness is associated with genes and violence, stigma will be created as a result of delivering wrong information that the illness is all about genes and violence. Organisations are required to disseminate information based on accurate data such as a possible cause and occurrence rate to the public. It is a duty for related organisations to raise the awareness of the illness, particularly the government. Appeal to the society from recovered sufferers: in recent years, many patients have shown a better outcome, which may result from improvements in medication. There are more training facilities for recovery and many more have participated in society. Although all sufferers do not necessarily recover, some are speaking about their own experiences in front of fellow citizens. There is no doubt that misunderstanding and stigma that has been left untouched for a long time will be resolved once the public sees the sufferers who have recovered to a good state of health. Overcoming their own selfstigma and becoming courageous to speak about their own experience may allow sufferers to achieve genuine recovery.

Anti-stigma of the family21 WHY IS INTEGRATION DISORDER SYNDROME AN ILLNESS SUBJECT TO STIGMA?

In the past, similar illness including Hansen’s disease and tuberculosis were also subject to quarantine during treatment. Symptoms of integration disorder syndrome include hallucinations and delusions, which make everyone think that sufferers are having emotional instabilities. Their daily life ceases to be something understandable through common sense; they have difficulty dealing with human relationships and they cannot focus their thoughts.

28 Ruth Taplin SOCIAL STIGMA AND SELF-STIGMA

On the one hand, there is social stigma. This includes attitudes, words and behaviours that are influenced by misunderstanding and stigma to which sufferers or their family are subject to, the existence of misunderstanding and stigma in society and contempt or scorn. For example, if people say that that a family has a sufferer of integration disorder syndrome, residents become opposed to building of a social welfare facility near them or refuse to rent them property. On the other hand, although sufferers and their families acknowledge the illness with a sense of hopelessness, they do not want anyone to talk about it and do not want anyone to even know about it. This is self-stigma. For example, sufferers refuse to put their photos on a identification booklet for mental health disorders, pay treatment fees themselves and choose a hospital that is located far from their home for examination. Social and self-stigma have prevented sufferers from recovering and also make their families suffer. PROMOTION OF SUFFERER’S RECOVERY

Coming out is important during the process of recovery and includes participation in a meeting. It is also important for sufferers to let society know about their existence. They have to overcome fear and stigma themselves and can let others know what kind of a person they are. Activities for anti-stigma will bring better results and contribute to further promotion of recovery if sufferers themselves promote recovery, become healthier, commence a job and increase opportunities to participate in society through lecture meetings, study workshops or socialising. Can sufferers and their family always understand each other’s stigma? What this means is that they share each other’s stigma: self-stigma of the family who blame themselves for having failed to raise the sufferer in a proper manner and self-stigma of the sufferer who blames himself/herself for having become a person with a failure due to lack of schooling and job. How about marriage? In the society, people tend to discriminate against marriage to siblings of the sufferer as well as to the sufferer. In this situation, the sufferer will have self-stigma that he/she wishes to marry while the family will have their own self-stigma that marriage cannot be achieved and has to be abandoned. Sufferers and their family are not necessarily able to share their stigma all the time. It is important to promote activities to eradicate stigma through discussions and understanding. FINAL WORD

In order for the family to support the recovery of the sufferer, it is important to strengthen resilience (competence for self-recovery, resilience against stress, resilience against occurrence of the illness). It is important not to ruin the sufferer’s effort to achieve recovery. Physical strength is also required.

Mental health care in Japan 29

Service user groups and volunteers Mr Reiji Watanabe – volunteer questions and answers22 1 As a person involved in volunteering, what is your assessment of the recent development in psychiatric treatment? (Example: transition from treatment given at a mental health hospital to community-based treatment.) Please give your comments freely below: Taking into the circumstances where hospitals are being dissolved globally and where we used to hospitalise the mentally-challenged, such transition appears to be a natural direction to be taken. I think this trend is welcome as long as those who are suffering can become engaged smoothly in activities in local communities as a result of promotion of discharge. 2 Where do/did you find the role of ‘Clubhouse’? Please explain about the meaning and significance ‘Clubhouse’ had/has, knowing the trend that treatment for mental illness has been developed, policies have been reformed and community-based treatment methods have been expanded. I think Clubhouse is important because both sufferers and staff members who are supporting them are given equal roles when deciding something and also because it allows sufferers to deal with any matters with their own responsibilities and to discuss with other sufferers what they have been thinking and concerned with, which eventually develop their skills and strength when dealing with the matters they face. In addition, I think Clubhouse is important as sufferers can gain experiences through trials and errors by testing their own capacity, physical strength and mental strength for the purposes of obtaining a job. 3 Is there any case where sufferers become employed by offices (other than facilities where sufferers are engaged with sufferers), based on your experiences at ‘Clubhouse’ or other facilities/organisations (such as workshops) that are similar to ‘Clubhouse’. If so, how often do they get employed? Please answer as far as you know. Since the introduction of law to support independence, each workshop has become proactively engaged in business activities. As a result, activities such as simple weeding in the field have now become promoted to business in the agricultural sector and such business is taking on people as welfare employment. I think many people have been able to obtain a job, having received support from a job coach at a local employment support centre and also engaged themselves in various activities designed to obtain a job. However, as there are few job coaches who can offer support for many sufferers to find a job, the situation has arisen where we have no capacity to cope with such demand. In particular, there are many cases where suffers can find a job depending on their hazard characteristics but cannot maintain their job: by experiencing a failure once, sufferers with high pride cannot accept such failure and leave the job they had.

30 Ruth Taplin 4 Clubhouse and other facilities/organisations (such as workshops) that are similar to Clubhouse are offering an employment opportunity to the mentally-challenged. How high is ‘Employment Creation Effect’? Please provide your answer, if possible, about the past/current situation and the future prospect. The effect of creating employment opportunities is high as those who have been aiming to work at any external organisations can work within a group or under seniors with which they are intimate and familiar. However, their income is not sufficient to maintain their living. As they can find reason for living and play a role in their community through their work engagement, it is possible to keep the employment effect for them higher through continuing business activities. 5 Please provide your comments and views as volunteers on the following matters: Do the mentally-challenged have confidence that ‘they can live in the society’? Do the mentally-challenged have confidence that ‘they can join the society through gaining a job and developing relationships with others in the society’? They are confident that they can live in the society. Within the concept of recovery, they live quietly when they are not feeling well while they can proactively make an action when they are feeling well. Although they are confident to ‘live in the society’ in general, only a few are confident that they ‘can join the society through gaining a job and developing relationships with others in the society’. 6 Is there any gap in confidence levels between the mentally-challenged who are using Clubhouse or other similar facilities and who are not? I think a gap in the level of confidence is large. This is because they think about it, worry about it and make an action through drawing their own conclusion as their own issues in their daily life. 7 Whom have you been cooperating with in a series of your activities such as establishment of association or facilities? What types of persons have you been working on to seek solutions? Please answer whatever you can mention. As a mental health social volunteer, I am working to form a group, by approaching groups and organisations that can support such group, including a volunteer centre, city office, local lifestyle support centre, hospital, workshop and group form. In particular, I work with the volunteer centre to offer a volunteer training course every year, for which I do planning, management, implementation, evaluation and report. The joint work is evaluated and I have been asked to work with others every year. 8 Please tell us if you know any recent law reforms or new law making you may be concerned with or you are paying attention to. I visited the United Kingdom for 10 days in September 2008 with a group of about 20 people, consisting of medical team and social welfare team, to carry out a study tour to Rethink, where we learnt about family support as well as a reform through

Mental health care in Japan 31 early detection/early treatment. The members who participated in this study trip held a meeting on health framework and are promoting policy suggestions to the Ministry of Health, Labour and Welfare and also are pressurising them through a signature-collecting campaign. In addition, I learnt from the study trip to the UK that family support can reduce the recurrence rates to 13 per cent. In this regard, a committee is being held at the Ministry regarding ‘guardian system’ as a law for sufferer’s family and issues are being raised. Although they set forth the ratification of the law on rights of impaired persons, the development of domestic legal system has been delayed. Therefore I wish they [would] speed up the process. 9 In Japan, who has an influence on law making, law amendments and changes in policies in relation to mental health issues? Who determines policies and who influence such policies? Please give your comments on what views volunteers in general and yourself in particular have. It is a ruling party. I think that the ruling party consults with the Ministry for legislation, followed by submission to the Parliament. Some volunteers do not get involved in law making process as they regard it as something that has already been given as a condition for the issue to be solved. However, I think it is necessary that we can identify and remove the issues that would cause any obstacle to the lifestyle of sufferers and their family. I think the environments surrounding impaired persons and mental health have become substantially improved under the Democrat Party in comparison with the era under the Liberal Democrat Party. However, I am not sure how long the current Party can stay as there have been many issues such as the Tohoku earthquake, security issues between Japan and US and bribe allegation involving the Prime Minister, who is alleged to have received money from foreigners. 10 What measures or what amendments in laws will become beneficial to sufferers and volunteers? It is not easy to answer in a simple term. When the current laws are to be reformed, they will be discussed at a committee and other relevant gatherings where sufferers and their families are allowed to take part in. However, those committees or gatherings are in most cases deceptive and manipulative activities as they have already prepared whatever for legislation prior to actual discussions. In this circumstance, I think it is difficult to achieve even whatever I think is the best. I learnt about a balance score card (strategic management system) from the study trip to the UK, which can be used to clarify strategy and visions, allowing an organisation to implement it. By using this method, the UK is successful in carrying out implementation and evaluations effectively at lower costs. Mr Kazuo Kodama and Mrs Nobuko Nishida – volunteers 1 As a person involved in volunteering, what is your assessment of the recent development in psychiatric treatment? (Example: transition from treatment given

32 Ruth Taplin at a mental health hospital to community-based treatment.) Please give your comments freely below: Sufferers are left with despair and in chaos due to sudden transformation and lack of explanations that they can be convinced with. There are quite a lot of people who are feeling that they have been given up. They cannot understand why transition from a hospital to local community has been taking place without any explanations since receiving treatment their local area is the right they are given naturally. Why is there not anyone who can explain, by admitting that the existing methods were not correct? Is it allowed that nobody takes responsibility and the things are left unsolved? What can those who have been sent to a local area without sufficient preparations do? If I make a shrewd guess, I feel there are more hospital transfers than discharge. Is this a sign of the beginning of a negative circle like a revolving door? There are very few places that can act a place between a hospital and a flat, which can accommodate sufferers when they feel slightly unwell. In other words, there are very few places that are not a hospital or a flat. They can live locally if there are more such places where sufferers can visit, not for hospitalisation. 2 Where do/did you find the role of ‘Clubhouse’? Please explain about the meaning and significance ‘Clubhouse’ had/has, knowing the trend that treatment for mental illness has been developed, policies have been reformed and community-based treatment methods have been expanded. I think Clubhouse is supporting sufferers so that they can regain confidence and pride. For human beings, this is the most important thing. 3 Is there any case where sufferers become employed by offices (other than facilities where sufferers are engaged with sufferers), based on your experiences at ‘Clubhouse’ or other facilities/organisations (such as workshops) that are similar to ‘Clubhouse’. If so, how often, do they get employed? Please answer as far as you know. There are the cases where they are employed on a part-time and contract basis. However, they are recruited in a closed manner in most cases. Even if they become employed, it is highly unlikely that they stay on the job for one year due to lack of support. 4 Clubhouse and other facilities/organisations (such as workshops) that are similar to Clubhouse are offering an employment opportunity to the mentally-challenged. How high is ‘Employment Creation Effect’? Please provide your answer, if possible, about the past/current situation and the future prospect. I do not know. 5 Please provide your comments and views as volunteers on the following matters: Do the mentally-challenged have confidence that ‘they can live in the society’?

Mental health care in Japan 33 Do the mentally-challenged have confidence that ‘they can join the society through gaining a job and developing relationships with others in the society’? 6 Is there any gap in confidence levels between the mentally-challenged who are using Clubhouse or other similar facilities and who are not? Taking into account our national character that we believe, ‘If you don’t work, you don’t eat’, I do not think that they are confident. Sufferers using Clubhouse have higher confidence. I think the current situation is far from independent. 7 Whom have you been cooperating with in a series of your activities such as establishment of association or facilities? What types of persons have you been working on to seek solutions? Please answer whatever you can mention. Family associations, Council of Social Welfare Volunteer Centre, Lifestyle Support Centre, workshops, city office and local residents. 8 Please tell us if you know any recent law reforms or new law making you may be concerned or you are paying attention to. Services and Support for Persons with Disabilities Act, Public Nursing Care Insurance. 9 In Japan, who has an influence on law making, law amendments and changes in policies in relation to mental health issues? Who determines policies and who influence such policies? Please give your comments on what views volunteers in general and yourself in particular have. The ruling party has an influence. Officials from the Ministry of Health, Labour and Welfare as well as public officials and ministers work on policies, which will be influenced by the public voice. 10 What measures or what amendments in laws will become beneficial to sufferers and volunteers? • • • • •

• • •

abolition of ‘psychiatric department exceptions’; allocation of medical budgets to local support budgets; sending medical staff to local areas from hospitals; increasing a limitation on the number of employment for the impaired and making employment obligatory; duty to promote awareness of knowledge concerning mental illness and mental disorder including the subject of understanding mental illness and mental disorder in the curriculum from primary school; early detection and prevention of mental illness; training and offering support to volunteers; abolition of discrimination.

34 Ruth Taplin

Mega-dosages of drugs given to sufferers Finally, chapters by Imamura (Chapter 4) and Oketani and Akiyama (Chatper 5) bring to the attention of readers the dangers and context of giving those with mental illness in hospital mega-doses of medicines that can have adverse side effects. In addition to it being an easy way to control patients with mental illness, such practices can be linked as well to yakka.23 In Japan, the doctor’s role is not only to prescribe but to dispense drugs. Whenever a doctor prescribes the drugs the doctor or the medical institution receives yakka from the difference between the price paid for the drug from the Japanese wholesaler and that sold to the patient often through national insurance schemes. This profit for the doctors and medical institutions means that quantity and quality are affected by such yakka profits. This means as well that all patients leave with some form of medication even for a common cold. Therefore, yakka complicates the type, quality and quantity of drugs given to those suffering from mental illness as well. What this means is that the many hurdles being overcome by the mentally ill through the empowerment of service user groups and the good will of many in the profession such as psychiatrists and psychiatric social workers can still become more complicated and difficult by certain business practices of not only yakka but also private mental hospitals.

Notes 1 2 3 4

5 6 7 8 9 10 11

Japan Times, September 2010. Japan Cabinet Office, 2011. Japan Times, op. cit. Mr Shouzou Imai, who was a psychiatric social worker, wrote this article in Izumi No. 217, which was published on 28 November 2010. Mr Imai worked for the Tokyo Metropolitan Government for 30 years in total and the mental health division for 23 years. He retired 7 years ago. Since then he has been doing voluntary work for Hidamari where he handles the hikikomori family group meetings. This article by Mr Imai is drawn on for this section of the book. Mr Imai felt that the most of the families were not 100 per cent in agreement with his views as they found it difficult to accept emotionally although not logically. Source of this definition is the Daijirin Dictionary. Coordinators: Iwao Oshima, Japan College of Social Work, Professor Nobuyuki Niekawa, Japan College of Social Work, Research Fellow Toru Tsuchiya, Office Yumefusya, Director. See book by Toru Tsuchiya, Seishin-ka ban Kazoku Kyoushitsu Start-up Dokuhon (Reader for Starting-up Family Psycho-education). Tokyo: Seishin Kango Syuppan (Psychiatric Nursing Publishing Inc.), 2006. Session 10, ACT Program: Aspect of Family Support, p. 67. Session abstract written by Fumie Hisanaga, a session coordinator, ACT and IPS Centre at COMBHO. Pp. 72–5. Summary of presentation titled: Family Support in ACT Program: Strength Model Perspective. Presented by: Mariko Kamikubo, Peer Clinic, a psychiatric clinic in Shizuoka prefecture, psychiatric social worker. Session 10, Recovery Forum, pp. 68–71, PPT title: Family Support in ACT Program. Presented by: Atsushi Satou, Kyoto Notre Dame University, Associate Professor. Mental Health Welfare White Paper. Publisher: Chuo Hoki, 1 December 2010, Tokyo edition used in this chapter, 2011 (Chapter 4: Community life support; Section 2: Support organisations; 4-2-1 Prefectures).

Mental health care in Japan 35 12 Session 8, Peer Support and New Direction to Localization, p. 58. Session abstract written by Yuichi Izawa, a session coordinator. Representative of NPO known as AMI, National Consociation of Community Life Support for People with Psychiatric Disability, pp. 59–60. PPT title: Practice in Discharge Support Project in Saitama City. Presented by Mayumi Mitsuishi. Minuma Ward Center for Community Life Support for People with Disability in Saitama City. 13 Ibid. 14 Session 17, Life a la Carte: Living by Yourself, Relationships, Marriage, Child Rearing, Family, etc. p. 103. Session abstract written by Eiji Sasaki, a session coordinator counselling staff at a public health centre, p. 104. Summary of presentation titled: Life a la Carte: Living by Yourself, Relationships, Marriage, Child Rearing, Family, etc. Presented by: staff and members at Ginnan Kikaku. Ginnan Kikaku service users, i.e. consumers, did not want their names disclosed in the forum abstract. 15 Mental Health White Paper (Chapter 2; Section 4). 16 Yuko Kawanishi, Mental Health Issues Facing Contemporary Japanese Society, The ‘Lonely People’, Global Oriental, 2009. 17 Mental Health White Paper (Chapter 4: Community life support; Section 3: Self-help activities; 4-3-1 Peer helper). 18 Mental Health White Paper (4-3-5 Mental health social welfare volunteer 16). 19 Session 6: Anti-stigma and Recovery: Stigma Inside and Stigma from Without, p. 43. Session abstract written by Kiyohisa Takahashi, a session coordinator, Japan Foundation of Neuroscience and Mental Health, administrative director, p. 44, background information 1 and 2: put together by Kiyohisa Takahashi, p. 45, background information 3 and 4: data from a survey report in 2010 by the Japan Foundation of Neuroscience and Mental Health, p. 46, background information 5 and 6: data from a research by Yuriko Suzuki and Maiko Fukazawa (2010) ‘Jyudo no Seishin Shikkan o motsu Hitobito wo meguru Sabetu ni kansuru Keiken: Ryouteki Bunseki to Shitsuteki Bunseki (Discrimination against people with severe psychiatric illness: quantitative and qualitative analysis)’. Journal of Japanese Society of Social Psychiatry 18(3), pp. 310–20. 20 P. 50, summary of presentation titled: Anti-stigma and Recovery. Presented by: Naohiro Terao, Family Association for the Mentally Ill in Chiba prefecture, administrative director. 21 P. 53, summary of presentation titled: Anti-stigma and Recovery: Anti-stigma for Families. Presented by: Kazuo Honjyou, Family Association at National Center Hospital, NCNP (National Center for Neurology and Psychiatry). 22 The editors of this book created a questionnaire to ask a number of volunteers to the service user groups to share their experiences and enlighten others. Reiji Watanabe is the former Chair of the Tokyo Mental Health Welfare Volunteering Group and is now Chair of the Mental Health Volunteering Group Ippono Kai, Hatiouji City, Tokyo. Kazuo Kodama belongs to the mental health volunteering group Hidamari (former Chair) in Kodaira City and volunteers at Habataki Clubhouse. Mrs Nobuko Nishida, who assisted him in answering these questions, holds the qualification of psychiatric social worker and is an active member of Hidamari and was Secretary to a patient family group in a large national mental hospital. 23 Simon G. Thomas (2003) ‘Case study transactions in the biotechnology industry between Japan and the UK’, in Exploiting Patent Rights and a New Climate for Innovation in Japan, edited by Ruth Taplin, London: IPI, pp. 58–9.

2

Mental health policy and services Where we stand Hiroto Ito

Introduction A fundamental challenge in mental health policy is to establish a system that provides better mental health care. To accomplish this goal, it is necessary to improve access to mental health care and to provide quality services, while at the same time controlling costs. It is difficult, however, to establish a system that maintains a balance between access, costs and quality care. In addition, there are increasing calls for community care, rather than inpatient care, for persons with mental illness. To date, Japan has developed many initiatives to address these issues. In 1961, when Japan was entering an era of high economic growth, the government implemented a universal health insurance system that provides free access to health care by allowing people to use health insurance at any medical facility.1 The number of psychiatric hospital beds was concurrently increased so that persons with mental illness, who had not otherwise had access to psychiatric care, could receive appropriate treatment. As 50 years have now passed since the universal health care system was introduced, certain institutional problems have begun to emerge. Although the need for a transition from inpatient care to community care was identified in the 1960s, no notable changes have been made, at least as far as the number of psychiatric beds is concerned. Because of the high economic growth achieved early on ahead of other Asian countries, Japan has been faced with issues relating to the universal health care system and an excess of psychiatric beds since the 1980s. Japan’s health policy has not received much international attention. Consequently, the large number of existing psychiatric beds has continued to be raised as an issue, despite the fact that Japan’s mental health policy and services have changed considerably.2,3 In this chapter, current developments in mental health policies in Japan are reviewed for a better future.

Mental health policy and services 37

Mental health needs Health care for people with mental disorders Figure 2.1 shows changes in the number of patients’ visits over time according to the Patient Survey, which is conducted every three years by the Japan Ministry of Health, Labour and Welfare. The numbers of patients with cancer, acute myocardial infarction, stroke and diabetes have not changed so much, but that of mental disorders has increased since 2002, primarily due to the increase of outpatients with depression. About one million people are medically treated. Patients with schizophrenia were used to being hospitalised, and those who admitted in 1950–70 are now long-stay elderly patients. In recent years, however, the proportion of young long-stay patients has decreased, and newly admitted patients are discharged sooner. A new facility other than a hospital is required for this patient group in the community where physical care is also available. In Japan, patients with dementia have been treated in psychiatry. Although patients suffering from dementia are common in general hospitals and geriatric facilities in reality, the dementia unit can be established in only psychiatry under the health care system. As the society is rapidly ageing in Japan, it affects more and more people, and a national strategy is urgently needed.

Mental health in the general population Japan has had one of the world’s highest suicide rates for years, and it remains above 30,000 for the thirteenth straight year. The suicide rate rose from 18.8 suicides (Thousand) 3,500 3,000 2,500

Mental disorders Diabetes Stroke Cancer Acute myocardial infraction

2,000 1,500 1,000 500 0 1996

1999

Figure 2.1 Number of patients.* Note: * Patient Survey.

2002

2005

2008

38 Hiroto Ito per 100,000 population in 1997 to 24.9 per 100,000 in 2010.4 A prolonged recession seems to affect this trend. The National Police Agency suggested common reasons including health concerns, unemployment and financial difficulties. As suicide is a major issue in Japan, the Basic Act on Suicide Prevention was enacted in 2006. Multidimensional countermeasures are being implemented through both the highrisk group approach and population approach, but unfortunately the suicide rate does not appear to be declining as expected. The Japanese Medical Association developed and distributed the Manual for Suicide Prevention for General Practitioners: Early Detection and Treatment of Depression to educate physicians via training programmes. A nationwide suicide prevention study has accumulated data since 2005. The results will be reported soon. Further effective plans based on those results are needed. On 11 March 2011, Japan experienced a devastating earthquake, the biggest one since 869, in east Japan. The subsequent tsunami with more than 30-metre waves killed nearly 16,000 people. More than 3,000 are still missing. Also, the Fukushima Nuclear Plants were seriously damaged by the tsunami. The three tragedies (earthquake, tsunami and radioactive contamination) simultaneously affected the mental health of the earthquake and tsunami survivors. Long-term care should be prepared for the affected people, especially children.

Mental health services Acute psychiatric inpatient care Case A: a 35-year-old man with schizophrenia. Onset occurred at the age of 20 when he was in his third year of university and he was involuntarily admitted to a psychiatric emergency unit. After 40 days, he was discharged to outpatient care and returned to university. The patient obtained a bachelor’s degree, and worked part-time after repeating a year. He then started work at a small factory owned by his father. At age 28, the patient relapsed because he did not comply with his medication regimes, and he was voluntarily admitted to an acute psychiatric care unit for 20 days. Since then, the patient has been able to control his condition, and he visits the outpatient clinic twice a month and continues to hold down a job while taking medication. The increase in the number of psychiatric beds, which started in the 1950s, came to an end in the late 1980s, when the beds were divided into acute psychiatric units and long-term care units. Then, in 1996, with a focus clearly on health insurance reimbursement, acute psychiatric care units were established under a provision that limited hospital stays to approximately three months, generating one and a half times higher reimbursement than that of general inpatient psychiatric units. Furthermore, in 2002, psychiatric emergency units were established in community hospitals with approximately three times higher reimbursement than that of general inpatient psychiatric units. In Japan, there are approximately 100 hospitals with a psychiatric emergency unit and approximately 200 hospitals with an acute

Mental health policy and services 39 psychiatric unit. These two types of units are operated under a provision that limits the length of hospital stays and that more than 40 per cent of the patients be discharged into the community within a specified period. Community care provided by psychiatric hospitals Case B: a 58-year-old man with schizophrenia; he developed the condition when he was 18 years old. Highly resistant to being seen by a psychiatrist, he remained untreated. At age 25, he was, at the behest of his family, admitted to a psychiatric hospital built nearby. At the time, patients were often long-term inpatients. He was hospitalised for 15 years. When the hospital director was succeeded by his son, the treatment policies were changed, and the new hospital director recommended that he should be discharged. Several facts became apparent regarding this longterm inpatient. He had no friends and his parents were elderly so he could not live with them. He had resided at the hospital for many years and was anxious about leaving, so he was discharged to a group home near the hospital. Upon discharge, he initially had periodic outpatient visits and used day care services, but he gradually became accustomed to communal life with patients who had been similarly discharged. Until recently, he helped out at a bread factory started by the hospital while receiving job assistance. He is currently working with a meal service run by the hospital to provide meals to elderly nearby. He delivers meals to the homes of the elderly by bicycle. Elderly clients appreciate the service and he finds the work worthwhile. More than 80 per cent of Japan’s psychiatric hospitals are privately run. Taking advantage of financial support for construction of psychiatric hospitals in the 1950s and 1960s, outpatient clinics built up psychiatric beds and subsequently became psychiatric hospitals. In the 1990s, these facilities were no longer able to increase the number of beds. In addition, revenue per day for treatment in a long-term care unit was equivalent to revenue per day for community care combining outpatient care and day care. To increase the number of admissions of new inpatients and utilise beds for acute inpatient care (which offered substantial medical fee reimbursements), hospitals began gradually discharging long-term inpatients. Discharged patients transfer to group homes built by psychiatric hospitals. However, patients who cannot be provided with a discharge destination, e.g. a group home, remain as long-term inpatients. Many of these individuals have already reached age 65, they have diminished activities of daily living (ADL), and they also have physical conditions as well. As things stand, these individuals still cannot be discharged. Community care team Case C: a 40-year-old male with schizophrenia has received nurse’s home visits from a visiting nurse station for the past five years. The nurse visits him about twice a week. In addition to making sure that he takes his medication, the nurse advises

40 Hiroto Ito him on everyday activities. He is prescribed an antipsychotic by a clinic twice a month. When his condition worsens, he receives almost daily visits by the nurse, and at times he also sees the clinic’s psychiatrist. Prior to receiving visiting care, he was hospitalised about three times a year, but in the last five years he has only had two short stays in hospital. Amendments to the Mental Hygiene Act in 1965 required the establishment of publicly run community mental health centres, and public health centres were positioned as the first line of community mental health services. Home visit services were increased until the early 1990s. Due to financial difficulties faced by local government, provision of these public services has been scaled down since the late 1990s. Home visit services are limited in public health centres and mental health and welfare centres. Since the late 1990s, care has primarily taken the form of visiting care for persons with mental illness who live in the community. Visiting care originally began as a service with reimbursed medical fees that involved home visits to the elderly, but this service is now provided by community service departments of psychiatric hospitals and persons with mental illness are now visited by nurses from independent visiting nurse stations. As of 2008, 47.7 per cent of visiting nurse stations conduct visits to persons with mental illness. In recent years, clinics and outpatient departments of hospitals have combined home visits by nurses and visiting care by physicians to begin offering services that provide assertive community treatment (ACT).5 ACT provides assertive and comprehensive community-based services by a multidisciplinary team to persons with severe and persistent mental disorders. The government recommends these services and in 2011 began creating model communities through financial assistance to communities and hospitals to enhance outreach services. Outpatient clinics Case D: a 35-year-old male working at a large firm felt depressed by his mistakes at work and was diagnosed with major depression by a psychiatric clinic. He took sick leave for three months. Initially, he visited the clinic, but at the recommendation of his primary physician he was admitted for a month to a stress care unit at a psychiatric hospital. When his condition stabilised, he was discharged. He participated in the clinic’s return-to-work programme after discharge. He began with simple tasks two days a week in the day care office, which resembled the office setting where he worked. He gradually began participating more often and had the same starting and finishing times as he did at work. He became accustomed to the programme, so talks were held with a company physician and a psychologist involved in the return-to-work programme. He subsequently returned to work at his old company. He continues to visit the hospital twice a month. Socioeconomic factors are impacting the mental health of employees. In the current economic downturn, more and more employees have mental problems, and

Mental health policy and services 41 workplace mental health is a vital issue in Japan. Prevention, treatment and rehabilitation programmes can be provided in and out of the workplace. The employees can return to work in most of the large corporations and public organisations, however, those who work for medium-sized corporations often lose their jobs. Support services for such people are needed. Dementia care Case E: accompanied by family, a 75-year-old male was seen by the Centre for Dementia Care. Tests, including brain imaging, led to a diagnosis of dementia of the Alzheimer type. A year later, his spouse passed away; he became restless and began wandering. He began accusing his family of hiding his belongings and would forget to put out his cigarettes, so he was admitted to a dementia unit in a psychiatric hospital. His family was told by hospital staff that he would be hospitalised for a maximum of three months, so they began looking for discharge destinations immediately after his admission. However, many facilities for the elderly had a waiting list of over 100 people and he was turned away by numerous residential facilities and group homes since they could not accept patients with dementia and problem behaviour. Two months later, the family finally found a facility that would accept him. The proportion of older people is increasing at a rapid pace in Japan. The number of patients who have dementia but no facility to accept them is rapidly increasing and facilities will have to fill their empty beds with patients with dementia. This trend is already becoming apparent: inpatients age 65 and over accounted for 47 per cent of inpatients in 2008, and this number is predicted to increase further in the future. If this situation continues, medical expenses for persons with mental illness will turn into medical expenses for the elderly. This presents a major policy dilemma that is being debated even now.

Mental health system Legislation Mental health policies in Japan have been stipulated by general laws such as the Medical Care Act, Health Insurance Act and Mental Health and Welfare Act, which regulates psychiatric care such as involuntary admission, seclusion and restraint. Also, a forensic mental health law was enacted after the school massacre in 2001 in which many school children were killed and injured by a man with a long history of mental illness. The government plays a key role in setting overall policy, implementing health services based on the legislation, and standardising health care fees in co-ordination with providers, consumers and payers.6 Medical fees were revised every two years whilst the Mental Health and Welfare Act was amended every five years. Importantly, a roadmap for mental health reform, ‘A Vision for Reform of the

42 Hiroto Ito Mental Health Care System’, was released by the Minister of Health, Labour and Welfare in September 2004, addressing the direction of mental health and welfare policies up to 2014.7 It has two aims that it hopes to achieve over the coming decade. First, at least 90 per cent of citizens will recognise that mental illness is a common disease that can affect anyone, similar to lifestyle-related diseases. Second, the focus of services will shift from hospitals to the community by shortening the length of stay, discharging long-stay patients and developing community services. This roadmap is a basis of the government’s policy. Since 2004, revisions have been made in medical fees and the Mental Health and Welfare Act according to this roadmap.

Psychiatric beds It was stated for the first time in 1950 in the Mental Hygiene Act that persons with mental illness have a right to medical care. Until that time, under the Mentally Disordered Persons Supervision and Protection Act, legislation provided protection more to society than to the persons with mental illness themselves. The Mental Hygiene Act was renamed through a series of amendments and is presently the Mental Health and Welfare Act. Because the establishment of public psychiatric hospitals in every prefecture did not move quickly, despite the recommendations for such institutions in the Mental Hygiene Act, the Medical Care Act was revised in 1958 to set a staff-to-beds ratio for psychiatric care units to half that for other clinical departments. The amendment enabled many private psychiatric clinics to upgrade their beds, which led in turn to an increase in the total number of psychiatric beds available. Today, Japan is unique in that 83 per cent (as of 2009) of existing psychiatric beds are provided by private hospitals. Private hospitals in Japan are non-profit organisations and are disallowed from distributing any profits. However, this policy resulted in an increase in the number of beds without a concurrent increase in the number of personnel, and this small staff-to-patient ratio put a halt to subsequent quality improvement of inpatient psychiatric care. As a result of these policies, Japan is characterised by a large number of psychiatric beds per capita, compared not only to Asia but also the world. As Table 2.1 shows, there were 27 beds per 10,000 population in 2010. It should be noted, however, that the number of registered psychiatric beds has been gradually decreasing because of an upper limit put in place by the 1985 revision of the Medical Service Act. Although not much has changed with regard to inpatient numbers, there have been changes in inpatient characteristics and bed utilisation. The number of acute care psychiatric beds is on the rise because the majority of inpatients in recent years are discharged within approximately two months, as described in Case B. However, patients who have been hospitalised for more than one year generally have longterm mental illness and are mostly elderly. As far as the number of acute care beds is concerned, the number per capita is close to that of South Korea. Changes in the numbers of psychiatric inpatients in different age groups are shown in Figure 2.2. Although the total number of inpatients showed no change,

Mental health policy and services 43 Table 2.1 Psychiatric beds in Asia Total number of psychiatric beds (per 10,000 population) Brunei Cambodia China Indonesia Japan Laos Malaysia Mongolia Myanmar Philippines Singapore South Korea Thailand Vietnam

1.2 0 1.06 0.4 28.4 (9.8*) 0.07 2.7 2.4 0.55 0.9 6.1 13.8 (6.2*) 1.4 0.63

Note: * Number of inpatients staying less than one year.

the number of inpatients older than 65 years increased, while those younger than 65 years decreased. This suggests that psychiatric care has been functionally divided into long-term care units for elderly persons with mental illness and acute care units for young adults with mental illness. Rather than focusing on the number of psychiatric beds available in Japan, current issues are emphasising the need to establish measures to treat long-stay patients. (Thousand) 450 400 350 300 250 200 150 100 50 0 1977

1987

1996

1999

2002

2005

2008

Total ≥ 65 (%)

327 62 19.0

326 96 29.5

329 109 33.1

321 123 38.3

324 139 42.8

307 145 47.4

282 24 8.4

75 and older 65–74 65 years old 55–64 45–54 35–44 25–34 15–24