International

Pergamon

Journal of Law and Psychiatry,Vol. 19, No. 3/4, pp. 413435,1996 Copyright 0 1996 Elsevier Science Ltd Printed in the USA. All rights reserved 0160.2527196 $15.00 + .OO

PI1 SO160-2527(96)00015-5

The Japanese Mental Health System and Law:

Social and Structural Impediments
James M. Mandiberg*

to Reform

Introduction In 1987 Japan passed a revision to its 1950 mental health law, a law that had come under a great deal of criticism from at home and abroad as being out of step with the rest of the industrialized world on basic issues of individual human rights (Harding, Schneider, & Visotsky, 1985; Totsuka, 1989; Kobayashi, 1989, 1991a, 1991b, 1993; Harding, 1991; International Commission of Jurists, 1992). Japan had also been under a great deal of internal and external criticism for its mental health system being overwhelmingly institutionally based while other advanced industrialized countries had moved to community-based services (Clark, 1968; 1988; Mandiberg, 1993; Takizawa, 1993). Many viewed the 1987 revised law as an attempt to respond to these criticisms (Salzberg, 1991; Mino, Kodera, & Ebbington, 1990; Koizumi & Harris, 1992; Appelbaum, 1994). It established laws and procedures that appeared to protect some of the individual human rights the 1950 law did not, and it allowed for the creation of some community-based program models that had always existed in Japan, but which were not officially authorized (Mandiberg, 1993). However, the 1987 law was seen by many critics and advocates as a weak and conservative attempt by the government to preserve the essence of the current system, while appearing to be responsive to criticism (Kobayashi, 1993; Salzberg, 1991; Takizawa, 1993; Mandiberg, 1993). In its three reviews of the Japanese mental health system (1985,1988,1992), the International Commission of Jurists (ICJ)), a United Nations affiliated nongovernmental organi-

*Ph.D.

Candidate

Ave., Ann Arbor.

in Social Work MI 48104. USA.

and Organizational of my parents.

Psychology,

University

of Michigan.

818 Dewey

This article is dedicated a car accident in September

to the memory 1995.

Perle and Arnold

Mandiberg,

who were killed in

I want to thank Mariko Aratani. Nobuko Kobayashi, Pamela Cohen, David Tucker, Takehisa Takizawa, and Noe Aratani-Mandiberg for their assistance with various aspects of this study. Some of the research for this study occurred through a faculty research grant from Shikoku Gakuin University in 1992.
413

414

JAMES M. MANDIBERG

zation, had been instrumental in forcing the Japanese government to confront many of the problems in its mental health law and system. Coincident with its hosting the World Federation of Mental Health meeting in 1993, the Japanese government had committed to review the implementation of the 1987 law. Some advocates had expected this review to yield even further reforms. However, in the view of many, it did not. The Japanese government again reviewed the mental health law in 1995. The name of the law was changed, for the first time mental illness was legally acknowledged as a disability, and an entitlement program was established creating benefits similar to those available to other disabled populations. In the view of some internal critics, however, these changes to the law represented little more than a name change and an attempt to shift the cost of care and treatment from the government to insurance programs and families (Kobayashi, 1995). From an outside perspective, Japanese mental health policymaking can appear to be indecisive, paradoxical, and even incompetent (Mandiberg, 1993). However, the development of the Japanese mental health system and laws is complex, with political, cultural, social, historical, and economic factors that make this outside perspective too limited. Additionally, as Foucault (1965) has demonstrated with Europe, mental health policy is among the most complex, since the mad1 challenge many core social assumptions of rationality, order, and self-perception. This is no less the case with Japan. This study reviews the development of the Japanese mental health system and laws for clues in determining social factors affecting how Japanese mental health policies have developed. The study also explores the likelihood of reform. The major thesis of the paper is that the Japanese government has followed the consistent practice since the mid-nineteenth century of officially committing itself to Western mental health models, yet not implementing them. This inconsistent practice of implementation results from core conflicts between the social foundations of the models, and those of Japanese society. The study explores historically the advantage of officially adopting Western models, yet at the same time the advantage of not actually implementing them. In the end, the study finds Western model progressive reform unlikely in Japan because of the core conflicts involved. It further asserts that of two potential options, fundamentally changing core social assumptions or exploring progressive indigenous mental health models, the latter holds greater promise. In the course of reaching these conclusions, the study explores several important features of the Japanese mental health system and laws since the midnineteenth century. First, the goal of Japanese mental health law up to the 1995 reforms, and perhaps including them, has been to maintain social order and social control. This makes the system seem paradoxical to those utilizing other analytical frames. Second, although the Japanese government has, over

The language used to refer to those people that society regards as mentally ill is problematic, infused with historical baggage, bias, and questionable attributions. This study will use the relatively more neutral term mad when referring to periods prior to the medicalization of this population, and those considered to be/diagnosed as/deemed to be mentally ill when referring to postmedicalization periods.

THE JAPANESE

MENTAL HEALTH SYSTEM

415

time, moved toward assuming responsibility for other dependent populations, it has explicitly avoided doing so for those deemed mentally ill. Rather, the consistent policy has been to keep families responsible. Third, the Japanese mental health system has overwhelmingly relied on custodial, and since the 1950s on institutional forms. Community-based mental health programs are underspecified and underfunded, and the appropriate goals for these programs and their clients in Japanese society are not clear.

A Historical Context

Japan has a rich indigenous history of both social welfare and social control (Tatara, 1975). As in other societies, the distinction between social welfare and social control is often difficult to distinguish (Polyanyi, 1944; Piven & Cloward, 1971; Abramovitz, 1988; Calder, 1988; Gluck, 1985). The indigenous history often appears quite different from what those accustomed to Western models of social welfare and control find familiar. The dominant external influence on early Japan was from China and Korea, and so frequently the social welfare and control practices of pre-nineteenth-century Japan appear similar to those of China, influenced by Confucian notions of hierarchy, family and obligation (Tatara, 1975; Mandiberg & Miyaoka, 1994). Like many other things in Japan, social welfare and social control took an intentional and radical redirection during the Meiji Period (1868-1912). PreMeiji Japan was intensely inwardly focused, believing that its island isolation would protect it from outside influence and domination (Reischauer, 1981). The Meiji period was a time when the Japanese government realized that it could not successfully maintain its isolationist posture, especially toward an increasingly intrusive West. A reform-oriented group, in the name of the Emperor, overturned 265 years of feudalistic Tokugawa rule (1603-1867), and embarked the country on a period of rapid modernization and industrialization, seeing parity and competition as the best strategy to prevent foreign domination (Westney, 1987; Pempel, 1978; Reischauer, 1981). Pempel and Tsunekawa (1979) call this a policy of defensive industrialization. This brought the country from feudalism to being the only non-Western country to claim equal standing with Europe and America within only 50 years. Proof of this was Japans military domination over two much larger countries, China and Russia, at the turn of the century (Weswood, 1986; Lone, 1994). The Japanese governments strategy for modernization and industrialization meant looking to the West for models Japan could copy and incorporate. Individuals were sent around the industrialized world to bring back models and practices that could be adopted by Japan. This included manufacturing, the military, the school system, medical practices, legal systems, and social welfare systems (Westney, 1987; Morris-Suzuki, 1994). Although Japan had always imported ideas and technology from its Asian neighbors, this marks the beginning of a modern period of rejecting native approaches in favor of imported models, while infusing these models with native meaning. This practice included the importation of Western models of social welfare and social control.

416

JAMES M. MANDIBERG

A Brief History of Japanese Mental Health

Traditional Practice Toward the Mad Through the Tokugawa Era2

Traditionally in Japan, madness was not perceived as a medical problem, but as a spiritual problem or one of social relations, often attributed to possession such as by foxes and badgers (Kuwabara & True, 1976; Eguchi, 1991; Matsuoka, 1991). Various means were employed to rid individuals of the possession, including turning to shamans and purification (Russell, 1988). Organized religions were also turned to for help, including both Shinto, the polytheistic native religion of Japan, and Buddhism, which came to Japan from China and Korea around A.D. 522 (Reischauer, 1981). At times, Shinto shrines and Buddhist temples served as places of refuge for the mad, and certain shrines and temples came to be known especially for their ability to help. As today, families were still left to deal with the upset their family member generated when the current methods did not ameliorate the madness. Until the early twentieth century, the most common method for dealing with the mad was to construct a locked room or cell (zmhiki-ro) at the family home to confine them. This was a practice common throughout Asia until very recently, and it is similar to practice in the West during pre- and early industrial periods. Other forms also existed. Pre-Meiji Japan3 was overwhelmingly rural, and like other rural societies, the mad were often incorporated into the daily life of the community. Throughout its history, Japan also developed urban-based ways of dealing with the mad, especially those who collected around shrines and temples. The best known is Iwakura in Kyoto. Similar to Gheel in Belgium, which grew from the mad remaining at a Catholic shrine known to remedy madness (Earle, 1994; Liegevis, 1991) Iwakura grew spontaneously in the community surrounding a Buddhist temple (Kuwabara & True, 1976; Veith, 1978; Russell, 1988). Families living near the temple took in mad borders, and over time they developed sophisticated ways of assisting them. Many of these native approaches to helping the mad only disappeared in the 1950s when hospitalization became the exclusive method, under law, of dealing with the mentally ill. The Tokugawa period was a time of great political and social stability in Japan. The power of the Emperor was diminished in this period, and a complex feudalistic structure controlled by the shogunate was maintained. During this time, too, the Japanese government was extremely isolationist, believing that through this it could control foreign influence. During the Tokugawa period, the household (ie) became the dominant social unit among the upper classes of Japanese society, but over time it also spread to other social classes (Murakami, 1984,1985; Smith, 1985; Munakata,

*The Tokugawa

Era was from 1603-1867.

3The Meiji Era began in 1868. There is not a direct English equivalent for ie. Murakami (1985) has commented that ie is often mistranslated as family, which yields a false impression. A better translation is household, which is used here. However. he notes that even this is misleading. According to Murakami, a management unit for sustenance captures the sense better. There is an intense debate in the Japan studies literature concerning

THE JAPANESE

MENTAL HEALTH SYSTEM

417

1986; Russell, 1988). The household head came to be held responsible for the actions and the welfare of household members, including the mad. The overwhelming concern was not for the welfare of the individual, but rather for maintaining public order. Households, and their heads, could be severely punished if they failed to supervise their mad family members adequately. Russell (1988) identifies two common Tokugawa period family practices toward the mad. The first was to remove the mad persons name from the family register, the equivalent of disowning the individual in Western practice, but with much harsher social implications in being excluded from the primary social group. The second was four different kinds of confinement, all aimed at maintaining social order: home confinement, imprisonment, confinement with medical care, and temple custody. Home confinement (z&z&i-ro) requirements were explicit. The mad were to be confined in uniformly specified cells, constructed in or adjacent to the family home, on approval of the police. Public imprisonment could be utilized whether or not the mad had committed a criminal offense. As the major concern was for maintaining social order, control, not care, was the focus (Russell, 1988). Confinement with medical care was under the supervision of hinin, individuals occupying the lowest rank in Tokugawa society (Salzberg, 1991). This confinement included not just the mad, but also those who committed minor offenses, vagrants, ex-convicts, and others. In this way, these appe,ar similar to the early development of hospitals in Europe, and eighteenth- and nineteenth-century American almshouses (Grob, 1983). In temple custody, households transferred care responsibilities to Buddhist temples, where the mad served as temple apprentices or were cared for by monks.

Mental Health Law and Practice in the Meiji Era

Tokugawa order began to dissipate toward the mid-nineteenth century, with social disorder, riots, and protest becoming more common, although not

interpretations of Japans development. One side, often known as the Nihonjinron perspective. maintains that because of features unique to Japan. over and above the uniqueness any society has. it cannot be compared with the development of any other society. The centrality of ie as a social organizing theme is often cited as one of these unique features. While I am not a supporter of this perspective. ie is central to understanding problems with the mental health law. Both Japan and the West used outcasts and individuals from low socioeconomic groups to manage the mad. The West frequently used prisoners during this same period. Japanese outcasts have a very different history from Western outcast prisoners (De Vos & Wagatsuma. 1967; Yoshino & Murakoshi. 1977). Japanese outcasts were social classes created by decree early in the Tokugawa period. while Western prisoners were perceived as creating their own outcast status through illegal acts. To be sure. many of these prisoners were poor. and many would claim they became prisoners due to class. race. and ethnicity-based discrimination and lack of opportunity. Of the two Japanese outcast groups. historically referred to as hirtin and etn. two very derogatory terms literally meaning nonpeople and dirty, respectively, the hinin were used to care for the mad. Although official caste status was abolished in the Meiji period, extreme discrimination still exists against hisabetsu Buraku people (literally, discriminated village people), formerly known by the derogatory term era. See De Vos (1992) for a treatment of the psychological consequences of outcast status in contemporary Japan.

418

JAMES M. MANDIBERG

widespread (Totman, 1981; Reischauer, 1981; Hane, 1982). This coincided with foreign demands to open the Japanese economy to trade, precipitating profound political and social change. Entrenched political and bureaucratic relationships began to shift, including the dissolution of daimyo (lords) and samurai local control and national influence. Thus, during the last years of the old order of the Tokugawa shogunate and the early years of the re-emerging emperor system and reform government known as the Meiji Restoration (1868-1912) roughly the mid-nineteenth century, there was a great deal of focus on how to maintain, or in some cases create, social order in the face of profound economic and social change (Gluck, 1985). During this period, there was increased social unrest at all levels. At the lowest social level, for example, 8.9% of the population was indigent in the 1890s. This led to expanded police powers, and a focus on maintaining social order (Kumasaka & Yoshioka, 1968). Gluck (1985) describes the intentional policy of Meiji leaders to transform the social disorder through ideological manipulation. She credits this period as the origin of the notions of homogeneity among the Japanese, a unique Japanese lineage, emperor worship, common struggle and self-sacrifice for the common good, and others. This was also the period when the concept of household (ie) was encouraged as an ideological mechanism to maintain social order. The mad were seen as potentially having a negative effect on the ability to establish and maintain social order. The first official acts toward the mad were a series of police orders issued between 1879 and 1884, later to be codified in the first mental health law. (Kuwabara & True, 1976; Salzberg, 1991). These also served to establish in law what had been longstanding practice since the Tokugawa period. Reflecting the social and political turmoil of this period, one incident was very influential in the development of mental health law in Japan. The Daimyo for the Soma region, Viscount Soma Tomotane, was confined by his family in a home cell (zashiki-ro), and later transferred to Sugamo Hospital, which, renamed as Matsuzawa Hospital, historically has been the most prominent psychiatric hospital in Japan. One of Somas retainers thought that he was being confined unjustly by a family who wanted to control his interests. The retainer kidnapped Soma from the hospital in 1877 and made the conditions of his confinement public. This incident received wide national and even international press coverage and was used by a political party still loyal to Tokugawa policies as a way of challenging the Meiji government. Meiji leaders were very concerned that Japan might be perceived as backward in not having formal mental health laws and procedures, especially to the international community (Russell, 1988; Salzberg, 1991). As a result, the Japanese government passed its first mental health law in 1900. The international influence on Meiji era policies went much further than influencing mental health law and practice. In intentional policy decisions, the Japanese government decided to meet the perceived threat of the West by importing those Western ideas and forms that would be useful to them and that would fit Japanese culture. For example, the navy and merchant marine systems were taken from England, the medical and army systems from Germany, the local government and legal systems from France, and business methods

THE JAPANESE

MENTAL HEALTH SYSTEM

419

from America (Westney, 1987; Reischauer, 1981). Within a short 50-year period, Japan went from feudal isolation to become one of the major, and the only non-Western, industrial and military powers.
The 1900 Mental Health Act and Beyond

Meiji social welfare period and law were based on the household and local community. Meiji officials tried to enforce reliance on the household for the destitute and the deviant, and in instances where this failed, on local community groups (Anderson, 1993; Mandiberg & Miyaoka, 1994). Some government funds did exist for the relief of the poor and for disasters, but this was extremely limited and only for the most destitute (Anderson, 1993). In 1874 a poor law (Jukkyu kisoku) was introduced as a way of coping with the social disorder (Mandiberg & Miyaoka, 1994). It utilized the English Poor Law principle of less eligibility, i.e., that a laborer had to reach pauper status before relief could begin. The neighborhood groups were used to determine eligibility (Anderson, 1993). However, government-based assistance was by no means widespread, and for the most part households were obligated to assist their own members. The Meiji government also copied some of the social-control aspects of the English poor laws. Just as the English poor laws differentiated between the worthy and unworthy poor, those in Japan who worked and relied on family for support were called good citizens, while those who relied on the state were referred to as idlers (damin). Social welfare, in the form of land grants and pension payments (onkyu), existed for soldiers, officials, and others serving the government. However, the first major government social welfare expenditures appear to be those following the Great Earthquake in 1925. With this as background, it is significant that in 1900 the Japanese government passed a law that was explicitly concerned with mental health, the Law for the Confinement and Protection of the Mentally I11 (Seishinbyosha Kangoho). This occurred very early in the history of Japanese social welfare legislation. The laws two most significant features were officially permitting the practice of building locked cells for the mad in family quarters (zashikiro), and mandating that a household member be legally and financially responsible for any problems mad family members might create, and for their supervision (Kumasaka & Yashioka, 1968; Kuwabara & True, 1976; Salzberg, 1991; Russell, 1988). Officially, the 1900 mental health act, in part a reaction to the Soma Tomotane incident described earlier, was to protect mad citizens from illegal and unnecessary confinement. In reality, it served to encourage the confinement of the mad by codifying that households were responsible, including specifying punishments for not upholding their responsibility, and by stipulating a method for maintaining supervision through household-built locked cells. These two aspects formalized in law what had been the traditional practice. The core of the 1900 law was a concern for maintaining public order. Salzberg (1991) finds that public safety was the only concern of the legislation. There was no primary medical function, for example. Physicians were used on occasion to verify that the individual was mad, but treatment, if it was done at all,

420

JAMES M. MANDIBERG

was performed by shamans (Kuwabara & True, 1976). Enforcement of the act was under the Home Ministry and its local agents, the police, and it wasnt until 1947 that responsibility for local mental health administration was transferred from the police (Salzberg, 1991). In 1904 the police issued detailed regulations regarding the design of locked cells in homes, making them almost identical to the required design for jail cells. The law allowed the hospitalization of the mad by the household, as long as the household bore the expense, but described the hospital as a cluster of cells built according to the policy regulations (Kumasaka & Yoshioka, 1968). The 1900 law established an officially designated guardianship system (kangogimusha, or duty to provide protective supervision), a system that persists in only slightly altered form today (Salzberg, 1991). It specified in detail who in the nuclear family was responsible for the mad family member, stipulating an order for selection in case some members were unable to perform their responsibility. Notably, this contrasts with the Civil Code of the day, which was based on the extended households (ie) responsibility for household members.6 The point of this appears to have been to limit as much as possible the transference of responsibility to the state. Psychiatric hospitals providing some medical care did exist during this period. The most prominent, and the only public hospital, was Sugamo Hospital in Tokyo, later to be called Matsuzawa Hospital. The remainder were private facilities predominately for use by wealthy patients whose families could afford the expense. Ironically, the only other individuals hospitalized in these facilities were the destitute, whose care was covered at municipal expense (Russell, 1988). This left those in the middle, the majority, to rely on household-based means, such as home confinement. The government conducted an epidemiological survey in 1915, finding that 34,748 of the 41,920 mad people identified in the study, or 82%, were not under confinement and protection (Kuwabara & True, 1976). In 1918 Kure Shuzo, a professor of psychiatry at Tokyo University and director of Tokyos municipal psychiatric hospital (Matsuzawa), who had studied under Emile Kraeplin in Germany, conducted his own survey of the conditions of the mad. Kure was an advocate of an open door policy and the minimal use of restraints, and was known as the Japanese Pinel, Pine1 being the great reformer of French mental hospitals. Kure found that the mad were living in deplorable conditions in home confinement, and that 60% were confined unreasonably or were inadequately treated (Kumasaka & Yoshioka, 1968; Kuwabara & True, 1976; Russell, 1988; Salzberg, 1991; Utena & Niwa, 1992). These studies were instrumental in the passage of the 1919 Mental Hospital Act (Se&in Byoinho), which called for treating madness as an illness, for treating people with mental illness in hospitals, and for government-subsidized construction of prefecture-operated hospitals. It also provided one-half

hMy thanks to the noted that reliance on tion that commitment for maintaining social

anonymous reviewer for clarifying the kangoginmsha provision. The reviewer also the immediate family, rather than the extended household (ie), may be tacit recognito the household system was ideological, but in fact could not always be relied upon control.

THE JAPANESE

MENTAL HEALTH SYSTEM

421

of the cost of hospitalization in public facilities and one-sixth of the cost in private hospitals. It further allowed the prefectures to designate existing private mental hospitals in lieu of building public ones (Kumasaka & Yoshioka, 1968; Russell, 1988; Salzberg, 1991). Although each prefecture was supposed to build a public facility, few did. Most designated existing private facilities or ignored the act, and by World War II only six public mental hospitals had ever been built. The government continued to conduct a yearly epidemiological survey similar to that begun in 1915. Evidence of the lack of impact from the 1919 Mental Hospital Act is shown by the 1928 statistics, where out of 69,553 identified mad people, 57,079 (82%) were still not under confinement or protection (Kuwabara & True, 1976). While there was not a sharp rise in the number of hospitals, there was a steady increase, mostly in private hospitals, in part due to the availability of partial government reimbursement. The number of public and private mental hospitals increased from 19 in 1900 to 26 in 1910, and 92 in 1935, with 2,344 public and 16,576 private (87.6%) hospital beds (Kuwabara & True, 1976; Salzberg, 1991). A similar count in 1937 found only six prefectural hospitals with 2,328 beds, and 52 private hospitals with 17,544 beds (Kumasaka & Yoshioka, 1968). This same approximate percentage of private hospital beds has persisted in the Japanese mental health system to the present time.
World War II

Germanys 1933 eugenics law influenced the passage of a Japanese eugenics law in 1940. Although it did not call for the extermination of mentally ill individuals, as the German law did, Kuwabara and True (1976) credit it with influencing the neglect of the mentally ill during the war. Russell (1988) notes that the number of psychiatric hospital beds stood at 24,000 in 1941, but dropped to 4,000 by 1945. The mortality rate at Matsuzawa Mental Hospital in Tokyo was 31% in 1944, and 41% in 1945. These deaths were mostly due to starvation, as food was a very scarce resource throughout Japan during this period, and other populations had higher priority for the food that was available (Kumasaka & Yoshioka, 1968; Kuwabara & True, 1976). Seeking food became the major duty of the hospital staff (Russell, 1988).
The Postwar Period

The Allied occupation of Japan brought with it a great number of Western ideas, especially American ideas, about the nature of government, the responsibility of the government to its citizenry, and social welfare (Social Workers International Club, 1958). Allied occupation authorities were alarmed about the treatment, or, more accurately, the lack of treatment, the mentally ill received. Economic and social conditions were poor throughout Japan in the immediate postwar period, and this made conditions for the poorest and most dependent in the society, including the mentally ill, even worse. Occupation authorities were concerned about the lack of hospitalization facilities for the

422

JAMES M. MANDIBERG

mentally ill and the traditional practice of maintaining them in locked cells at homes (Mandiberg, 1993).7 In 1950, the Japanese government passed the Mental Hygiene Law (Seishin Eisei Ho). The basis of the law remained the maintenance of social order and had several significant features. First, it outlawed the practice of locked cells at homes (zashiki-ro). Kumasaka and Yoshioka (1968) report a Ministry of Health and Welfare (MHW) count of 2,671 locked cells in 1950. By the next survey in 1965, they report none.8 Second, the 1950 law strengthened the obligation of a member of the family to act as guardian for mentally ill family members and changed the name to hogogimusha (duty to protect). Combined with the Civil Code, the Mental Hygiene Law made the hogogimusha financially and legally responsible for any acts committed by their wards (Salzberg, 1991; Oshima & Nakai, 1993; Mandiberg, 1993; Kobayashi, 1993). Additionally, the 1950 law, for the first time, defined madness as a medical problem that required treatment by physicians in hospitals (Russell, 1988). Thus, the officially sanctioned locked cells were replaced by officially sanctioned locked ward hospitals. Finally, to implement the medicalization of the mad, the law required the prefectures, as it had in 1919, to build public hospitals and also encouraged the building of private hospitals. However, like the 1919 law, it allowed prefectures to designate private hospitals in lieu of building their own, and many prefectures availed themselves of this option. This same situation still exists today in several prefectures (Takizawa, 1993), with four prefectures remaining without prefecture-operated facilities (N. Kobayashi, personal communication, July 6,1995). The decision to build a hospital-based system had already begun to be implemented under the 1948 Medical Service Law, which allowed any licensed physician to open a hospital-clinic in any medical area of specialization. To facilitate this, the Medical Facilities Financing Corporation, created in 1960, provided government-backed low-interest loans. The result was an unprecedented increase in the number of psychiatric hospital beds, especially in the 1960s and 197Os, from 2 per 10,000 in 1950 (Oshima & Nakai, 1993) to 28.9 per 10,000 population in 1991 (Kobayashi, 1993).9 The 1948 Medical Services Law also permitted a lower ratio of staff to patients in psychiatric hospitals than in medical hospitals (Koizumi & Harris, 1992; Kobayashi, 1993). This is often interpreted by critics of the mental health system as an incentive to privatize the hospital system by lowering operating costs. From the perspective of the private hospitals it is perceived as a means of keeping the governments hospitalization reimbursement rate artificially low (Takahashi, 1993; Lin, Asai & Ta-

This information was gathered from interviews with various Japanese mental cially hospital directors and other psychiatrists, during 199G1993. The American islation requires more complete investigation in a future study.

health practitioners, espeinfluence on the 1950 legreports that number of

*Takizawa Takehisa, the Executive Director of ZENKAREN, in a personal communication, the police encouraged home confinement (zashiki-ro) as late as 1965 because of inadequate available hospital beds.

gMino et al. (1990) report rates in Japan of 32 per 100,000 population in 1953 and 260 per 100,000 in 1984 versus rates in England of 344 per 100,000 in 1954 and 141 per 100,000 in 1984.

THE JAPANESE

MENTAL HEALTH SYSTEM

423

kahashi, 1991). The effect seemed to be both. There was a rapid growth in private psychiatric hospitals, and the low reimbursement rate virtually guaranteed that the hospitals would be custodial (Munakata, 1986). The 1950 law permitted three types of hospitalization (Salzberg, 1991; Kobayashi, 1993; Russell, 1988). Under Article 29, compulsory admission by order of the prefectural governor (sochi nyuin), any citizen or official could request that a psychiatric examination be performed to protect public safety. If the person was found to be both mentally disordered and dangerous to self or others, the individual could be hospitalized by order of the governor. Salzberg (1991) notes, however, that there were no criteria for establishing dangerousness. Article 33, compulsory admission by the legal guardian (doi nyuin or hospitalization with consent), allowed guardians (hogogimusha) to hospitalize their charge. Article 34 concerned provisional compulsory admission by order of the prefectural governor (kari nyuin), and was used relatively infrequently. Consistent with the view that the family is responsible for decisions concerning family members, Article 33 hospitalization was considered hospitalization with consent. It did not matter that the individual did not consent. Similarly, Article 34 hospitalization was not considered involuntary because it was provisional, it was deemed necessary, and consent by the governor was sought. Thus, only Article 29 hospitalization was considered to be involuntary by the Japanese government, causing confusion in dialogue and reports between it and international bodies (Salzberg, 1991; Russell, 1988). Problems With the 1950 Law In 1983, 80.1% of hospital admissions were under Article 33, and 13.5% were under Article 29. Additionally, 50% of the inpatients in that same year had been hospitalized more than 5 years (Mino et al., 1990). The 1950 law had produced a system based on involuntary and relatively permanent hospitalization. Permanent hospitalization served the interest of several groups. First. it fulfilled the governments perceived need to preserve social order. Also, because the guardians (hogogimusha) were financially and legally responsible for any problems caused by their wards in the community, hospitalization kept them protected. Additionally, having a mentally ill family member had severe social consequences for families, including negatively affecting the marriage chances of relatives. Thus, keeping patients out of sight and mind in hospitals was seen as desirable (Mandiberg, 1993). There were also other problems with hospitalization under the 1950 Law. Chief among these was that the law made no provisions for periodic review of the decisions for any of the three types of hospitalization. This meant that unless someone raised the issue, it was never addressed (Salzberg, 1991; Cohen, 1995). However, there was no one involved whose interests were served by raising the issue. (Kobayashi (1993) points out that one of the worst aspects of the Japanese guardian system was that it forced the guardian (hogogimusha) to consider the patients interest and the familys interest as if they were the same. This placed families in a double bind. The legal and financial responsibilities of the guardian, and the social implications of having a mentally ill

424

JAMES M. MANDIBERG

family member, meant that the families would always perceive it as being in their interest to keep family members hospitalized, despite what they might feel would be best for the individual. Additionally, because the hospitals received guaranteed reimbursement for those hospitalized, hospitals had no incentive to review cases for the appropriateness of continuing hospitalization. Finally, the patients saw themselves as shameful members of the family. Given social attitudes about those perceived to be mentally ill, it was common for patients to want to remain in the hospital to save their families from shame and problems in their communities. The result of all of this was that relatively few people were ever discharged. The reported rate of mental illness increased dramatically in the postwar period. In 1955 it was 67 per 100,000 population; 207 per 100,000 in 1965; 269 per 100,000 in 1975; and in 1987 it was 339 per 100,000 population (Koizumi & Harris, 1992). Because it is unlikely that such a dramatic increase reflects an actual increase in incidence, it must be due to other factors, such as an increase in the rate of identification (Mino et al., 1990). A 1958 epidemiological study identified 1,300,OOOpeople as mentally ill in Japan, 91% of whom were untreated. The 1968 study found that, of 1,240,OOO identified mentally ill, 64.7% were untreated (Kuwabara & True, 1976). The intervening factor, of course, was the 1960 Medical Facilities Financing Corporation and the vast increase in the number of psychiatric hospital beds. The imperative to hospitalize, influenced by the strict hogogimusha requirements, contributed to this process of identification. In 1987, 79% of those identified as mentally ill were hospitalized (Koizumi & Harris, 1992). The increase in the hospitalization rate of those identified as mentally ill appears limited only by the availability of hospital beds, as most hospitals maintain 100% occupancy rates (Kuwabara & True, 1976; Koizumi & Harris, 1992), with some periods in the 1960s where higher than 100% occupancy existed (Russell, 1988). Finally, the 1950 law created no provisions for community-based services. Screening services were a function of the hospitals themselves and existed to facilitate hospital admissions. Discharge was rare and, when it occurred, posthospitalization care was a family responsibility, thus obviating the need for formal aftercare services. Prevention services were also a missing feature of the law. From the perspective of comparative international prewar mental health services, the lack of community-based services does not look unusual. No countries had extensive community-based services. However, there was a good deal of international ferment in mental health during the immediate postwar period, and community-based models of various sorts were beginning to be implemented. Thus, while the Japanese government did borrow Western models for the 1950 law. it did not avail itself of the latest mental health models.
Problems With Practice Based on the 1950 Law

In addition to legally created structural problems, there were also practice problems. Japanese law allowed any physician to practice psychiatry, with no additional training, and any physician could open a psychiatric hospital. As a result, the level of psychiatric sophistication was often quite low. This too contributed to the custodial nature of the hospitals. Additionally, when phenothi-

THE JAPANESE

MENTAL HEALTH SYSTEM

425

azines were introduced to Japan in 1955, the hospitals used them as a means of controlling the wards, in essence as chemical restraints, rather than as a means of achieving a policy of deinstitutionalization, as they were sometimes used in the West (Kuwabara & True, 1976; Russell, 1988). Psychotropic medications were also used by the hospitals to reduce their operating expenses since they no longer needed to rely on staff as much for ward management. Additionally, mental health policy and practice was creating, as Munakata (1986) called them, a race of hospital people. That is, there was no prospect for community placement. Hospitalization was the sole option for the mad. Natural support systems and native means of community care had been effectively eliminated through the legal and social requirement to hospitalize and the lack of funding for community supports. Mino et al. (1990), for example, identifies only 125 recognized mental health day care facilities for all of Japan as late as 1988. The eventual effect of this was predictable-in fact, was predicted by Clark (1968, 1988)-and paralleled what occurred in the West. That is, if there is no incentive to discharge, and if community supports are not developed, the cost of caring for increasing numbers of permanently and semipermanently hospitalized patients will unendingly rise. As occurred in the United States, the net effect is inevitably that the hospitalized population will increasingly be elders. This is in fact what has occurred, and some provisions of the 1995 mental health law appear to be aimed at relabelling aging mental patients as elderly, and relabelling their facilities as nursing homes (Munakata. 1986; Kobayashi, 1995).
Community Mental Health?

In 1965, the American Ambassador to Japan. Edwin Reischauer, was stabbed by a 19-year-old with a history of psychiatric hospitalization. This was a great source of shame for Japan in the international community. It was taken by Japanese to reflect that Japan was not in control of its national household (Kuwabara & True, 1976; Salzberg, 1991). At the same time, American ideas of community mental health began to come to Japan. In the aftermath of the Reischauer incident, the police militated for increased police powers toward the mentally ill (Koizumi & Harris, 1992). This was countered by progressives demanding community mental health centers so that those patients who were in the community could receive treatment and support. These demands included implementing a provision in the 1950 law calling for public health center nurses to make home visits to the mentally ill living out of the hospital (Sukegawa, 1993). Thus, in 1965 a mental hygiene law was passed stipulating that each prefecture should have at least one community mental health center that was to act as the coordinating and educating body for the local public health centers, which were to be the primary community treatment providers (Sukegawa, 1993; Mino et al., 1990). However, as in prior laws, the intent of the 1965 legislation was to promote social order, not to provide effective treatment and care. Additionally, implementation of the mental health centers was slow; the treatment orientation of the mental health centers conflicted with the prevention approach of the public health centers; mental health centers were frequently built in remote and

426

JAMES M. MANDIBERG

inaccessible locations; and one mental health center per prefecture was too few to have much impact (Sukegawa, 1993; Mandiberg, 1993; Okada, 1988). This equivocal implementation of community mental health has limited its potential effectiveness. The Contemporary Mental Health Law and System In 1984, at Utsunomiya Hospital in Tochigi Prefecture, it was revealed that two patients had been beaten to death at the hands of hospital staff. A subsequent investigation uncovered that there had been 222 deaths at that psychiatric hospital between 1981 and 1984, but only 27 of them had been properly accounted for by death certificates and police records. Investigations also revealed financial improprieties, corruption, medical malpractice, the use of unqualified staff, and other extreme problems (Cohen, 1995; Kobayashi, 1993; Salzberg, 1991; Russell, 1988). Like the Soma incident a century earlier, the Utsonomiya incident received worldwide attention. Through this incident, Japanese mental health advocates were able to call attention to the conditions of those deemed mentally ill. They held that the structure of the system itself led to this kind of abuse. The public and international nature of the revelations, as well as appeals to the United Nations and other international bodies by advocates, forced the government to confront the problems (Totsuka, 1989). In 1985, at the invitation of Japanese mental health advocates, the International Commission of Jurists (ICJ) and the International Association of Health Professionals (ICHP) both conducted an investigation of the Japanese mental health system and law. Their report found major problems, especially around the protection of individual rights and the availability of communitybased services (Harding et al., 1985; Salzberg, 1991; Kobayashi, 1993; Cohen, 1995). In a 1988 follow-up visit, this time at the invitation of the Japanese government, conditions had improved only slightly (Totsuka, 1989; Harding, 1991). The 1987 Mental Health Law and problems with it are covered in detail in Salzberg (1991), Kobayashi (1993) and Cohen (1995). In brief, the law included a provision for voluntary hospitalization, prohibited restrictions on communication outside the hospital from patients within, recognized a limited number of categories of community-based programs, and instituted a Psychiatric Review Board (PRB) to review the hospitalization of those patients requesting it (see especially Cohen, 1995, for a review of PRBs). Consistent with Japan looking to the West for mental health models (Mandiberg, 1993) the PRBs were modeled after the British system (Kobayashi, 1993). Kobayashi (1993) and Cohen (1995) document in some detail problems with the implementations of the PRB system in Japan. This includes psychiatrists serving on PRBs reviewing cases from their own hospitals, simple chart reviews of appeals by as few as one PRB member, inadequate knowledge by patients of PRB procedures, inconsistent PRB requirements and procedures across different prefectures, lack of established procedures for legal representation for patients, and many others. The bulk of the work of the PRBs is an automatic periodic review of all involuntary hospitalizations. However, there

THE JAPANESE

MENTAL HEALTH SYSTEM

427

appear to be problems in the area of patient-initiated appeals for review of their involuntary status. Few patient-initiated PRB review applications are filed, and the few of those that are filed result in recommendations for discharge or change in treatment. Cohen (1995) cities in fiscal year 1991 only 825 out of 349,190 psychiatric inpatients in Japan filing PRB applications, a rate of about 0.2%. Of these, 11 resulted in recommendations for discharge and 5 resulted in recommendations for change in treatment. The consequence of how the PRB system was designed and implemented is that it appears unworkable. Whether this was intentional or not, the effect is that Japan has adopted a policy of rights protection, but has not been able to implement it in a way that it can be effective. Structurally, this appears parallel to the hospitalization policy of the 1919 law and the community mental health policy of the 1965 law. This same phenomenon can be seen in other aspects of the 1987 law and resulting regulations. Mandiberg (1993) notes that the community-based program models approved in the 1987 law are not only the most conservative Western origin models, but the government failed to provide any meaningful level of funding for them. Thus again, although the official policy is to implement these models, it is impossible to do so. An Analysis of the Development of Japanese Mental Health Policy and the Possibility of Reform An overriding feature of the Japanese mental health system, from the Meiji period through today, is its concern for maintaining social order and the perception that the mentally ill somehow contribute to social disorder. This makes analyzing the system paradoxical for those domestic and international critics who view the system from other vantage points, such as treatment. Additionally, those who view the Japanese social welfare system as unified, with a single, progressive purpose, are similarly mystified by mental health policy. Mental health policy appears inconsistent with other social welfare goals and practices. Japan, as other societies, has long adopted the social and organizational forms of other cultures. In early historical periods Japan borrowed most heavily from China and Korea. Since the Meiji era this has shifted to Europe and America. What often marks Japan as different in this borrowing of the forms of other countries is the focused intention in doing so, and the success in eventually adapting various foreign forms to Japanese circumstances. In her study of Japanese imitation of Western organizational forms during the Meiji Era, Westney (1987) documents that the rational shopper image of Japanese imitation of foreign forms is inaccurate. The rational shopper image represents Japan as presciently pursuing just the right foreign forms to fit Japanese conditions. Instead, she demonstrates that Meiji Era adoption of foreign forms was more incidental and random, and followed a more competitive and evolutionary path, with a considerable amount of Japanese innovation to make the forms work. Nonetheless, it is clear that Japan did look to the West for forms in business, government, education, social policy, and other areas. This looking to the West to import, and innovate, Western forms was also

428

JAMES M. MANDIBERG

strong during the period immediately following World War II, and it continues today, along with recent trends of Western imitation of Japanese business and production models. Japanese imitation of Western models has also occurred in mental health. Meiji Era policy adopted Western hospital forms in the 1900 and 1919 laws. However, unlike Western forms in government and business, the psychiatric hospitals were not widely implemented. Thus, this produced the peculiar phenomenon of a Western model in the formal pubic policy, but the traditional practice of home confinement (zashiki-ru), and even more numerous instances of no hospitalization or home confinement, in fact. This duality lasted for 40 years. Several factors appear to have influenced the perceived need to adopt Western hospital models on the surface, as official policy. Meiji Japan felt the necessity to present itself to the West as a modern nation (Westney, 1987; Gluck, 1985; Reischauer, 1981). Meiji leaders saw modernization, and the appearance of modernization, as the core strategy to be accepted as a nation equal with the West. Being a modern nation included moral hospitalization, not merely confinement, of the mentally ill. Studies such as Kures documentation of the abuses incurred by those in home confinement (zashiki-ro), and the Soma incident, highlighted domestically and internationally that Japan was not a modern nation in its treatment of the mentally ill. However, for psychiatric hospitals to be implemented in fact, and not just as policy, they had to provide benefits over home confinement (zashiki-ro) and doing nothing. However, they did not. One factor of overall influence was the relationship between state and citizen. Mandiberg (1993) has noted that prior to the Allied occupation of Japan and the imposed new constitution, the obligations of citizens to the state were much clearer than the obligations of the state to its citizens. Implementation of hospitals required a clear state-to-citizen obligation in the form of state financial involvement. This is something the Japanese government was extremely reluctant to commit to. Additionally, hospitalization itself, and the funding of hospitals, potentially undercut the states interest in promoting family responsibility for the social welfare of family members, and the responsibility that the family exercise control over its members. Hospitals began to become more numerous in the 1920s and 1930s a time when Japans increased industrialization led to greater urbanization and increased population mobility. These social trends meant that families were less able to care for, or provide home confinement for, mentally ill family members. Finally, moral hospitalization assumed the goal of treatment. However, this was not the goal of policy toward the mad during the Meiji Era; and this does not appear to be the goal of policy today. Rather, social control has remained the consistent goal. Thus, in these three areas, minimizing state financial involvement, retaining family responsibility for family members, and social control, hospitals would have had to provide benefits over home confinement. They clearly did not. That left Japan with the contradictory need in mental health to appear modern but in fact retain traditional practice and goals. This contradiction continues today.

THE JAPANESE

MENTAL HEALTH SYSTEM

429

Institutional theory explains this phenomenon as peripherd isomorphism. Peripheral isomorphism is when an organization, or in this case organization writ large as government or society, strives to protect its COY~ by modifying its surface to appear similar to others in its environment (DiMaggio & Powell, 1983). In this instance, Japan felt the need to protect core social values and practices, but at the same time appear modern, as defined by others. This is somewhat different from the imitation and innovation described by Westney (1987). In the forms adopted by the police, schools, and newspapers, Westney describes a kind of imitative isomorphism (DiMaggio & Powell, 1983) where borrowed forms were adopted as policy and they were actually implemented. Imitative isomorphism is an assertive and competitive strategy. whereas peripheral isomorphism is a protective and conservative strategy. Thus, in the Meiji Era through the World War II period, there was no impetus to change the traditional policies and practice toward the mad. Home confinement fulfilled the function of maintaining social control, and the official but unimplemented policy of hospitalization fulfilled the need to appear modern. Although an acknowledged major world power, Japan was still peripheral enough as a nation, and mental health policy was marginal enough as social policy, that this duality was left unchallenged both domestically and .internationally. However, this changed dramatically during the postwar occupation. The occupation of Japan included American social workers and others, brought to enlighten Japan on the workings of a modern democratic nation and welfare state (Mandiberg & Miyaoka, 1994; Social Workers International Club, 1958). These social workers and other occupation authorities were highly critical of home confinement (zashiki-ro) and other conditions of the mentally ill, especially during the war and immediate postwar period. Influenced by this criticism, the official, but unimplemented, policy of hospitalization was finally put into place. This was later codified in law. Given that home confinement was no longer an option, hospitalization had several advantages. First, it preserved the primary mental health policy goal of social order by indefinitely confining individuals, much as home confinement did. Second, by adopting a policy that encouraged the building of private psychiatric hospitals, the government distanced itself from a primary social wellitre role vis-a-vis the mentally ill and their families. Third, and an extension of this, although hospitalization was not as good as home confinement in preserving family responsibility for family members, hospitalization in private psychiatric hospitals did preserve many of the features of family responsibility. The guardian (hogogimusha) system was strengthened and institutionalized to a greater extent, which served to reinforce family responsibility. That is, although no longer obligated to confine within the family home, family responsibility, including financial responsibility, was strengthened. Further, the vast majority of hospitalizations were consent hospitalizations (Article 33), meaning consent of the guardian. In that way, the government was out of the loop. The government paid for a part of the hospitalization costs, but the family-government relationship was distant and mediated through the hospitals. The fact that the vast majority of hospitals were, and are. private allowed for even more distancing by both national and prefectural governments.

430

JAMES M. MANDIBERG

Relative to other dependent populations, older people have benefited more than others as Japan switched from a focus on economic growth to more balanced growth (Campbell, 1979). In that same vein, the mentally ill have perhaps benefitted the least. Part of the explanation is certainly the relationship of social welfare and economic policy. Populations and sectors directly affected by economic policy have benefitted the most in the development of social welfare policy. There was an implicit obligation toward those who sacrificed in the immediate postwar economic boom, and are now elders. Additionally, urban and economic growth patterns have broken down the tradition of the oldest sons family caring for aging parents. The wives of the oldest sons, on whom this responsibility fell, are often working now themselves or are otherwise unable or unwilling to assume this role. Social welfare policy toward families and children has also benefitted, largely driven by economic concerns. Educational policy is directly tied to economic policy (Pempel, 1978). Other family benefits are similarly tied to economic issues. Family-allowance benefits encourage families to have children, a concern as Japan experiences a declining birth rate and a declining work force. Japans famous permanent employment system has only applied to men, as women are used as parttime and nonpermanent employees without benefits. Japans numerous public day care facilities free women to work in these jobs. Even Japans welfare policy toward itinerant workers, who are required for Japans seasonal and dirty and dangerous jobs, while far from adequate, is a focus of social welfare policy and structured to create a consistently available periodic work force. In contrast, the mentally ill have had almost no role in the Japanese economy except as a cornmodified group for the psychiatric hospitals. As individuals and as a group, they have not been needed in the economy.
How Likely Is Change?

Given the perspective thus far presented, fundamental change in the Japanese health system appears unlikely. Change would require several factors, all of which do not appear possible in the short term. Although the government has been active in developing progressive social welfare policies for many populations, this has been pursued most aggressively as it benefits or is an outcome of the economy. The mentally ill do not fit into that equation in any obvious way. To that extent, they will remain beyond the concern of policy development. While there have been consistent internal critics of Japanese mental health policy at least since Kure in 1918, the government has been notably unresponsive to them. This is in contrast to the observations of Pempel (1978), who found government policy change in Japan responsive to squeaky wheels. Calder (1988) found that in general Japanese policy followed a crisis and compensation mode. However, this too does not appear to be the case with mental health policy. Numerous internal scandals over mental health issues in Japan have resulted in no compensation action at any significant level. Although there have been Japanese critics of the governments mental health policy throughout its history, significant mental health policy change

THE JAPANESE

MENTAL HEALTH SYSTEM

431

has occurred when international attention has accompanied this internal criticism. The first example of this was the Viscount Soma Tomotane incident, but it continues in more contemporary times with the wounding of Ambassador Reischauer, the Utsonomiya Hospital scandal recounted earlier, and the International Commission of Jurists investigations. However, even international pressure appears to be having a declining effect in influencing further reform. Many of the internal critics of the Japanese governments mental health policies, from Kure until today, have been Western trained or have used Western standards of evaluation. This use of Western standards has also been true of the foreign critics. The combined effect has been to push the Japanese government even further toward officially adopting Western model solutions to mental health problems. This is consonant with the governments own tendency, at least since the Meiji Era. One of the main points of this study is that this tendency to utilize Western models, or at least to say that Western models will be used, has created a situation that may be untenable for the government, and perhaps Japanese society. Reform has come to mean Western-style reform, stressing individual rights, social reintegration, and government responsibility. Yet these appear to run counter to some core Japanese social and historical values. Thus, further Western-style reform would require fundamental social change in several areas. First, the overall concern of mental health policy would need to change from the maintenance of social order to something else-treatment or rehabilitation, for example. However, there are several problems militating against this. Japan retains a very strong social stigma toward mental illness, the mentally ill, and families with mentally ill members. This excludes the mentally ill from being considered a part of the social group. Consequently, their reintegration into the wider society becomes problematic. The problem is, reintegrate them into what? One way out of the dilemma is to adopt the goal of independence. This has been the solution of many social reintegration programs in the West. True to adopting Western mental health forms, the relatively few Japanese community-based mental health programs that exist frequently voice the same goal. The appropriateness of this goal is questionable in the Western context, but it is incomprehensible in a Japanese context, where ones relationship to the social group is so important. Another option is to reintegrate the mentally ill into viable subcultures. However, even the subcultures that exist in Japanese society are not recognized, or certainly not recognized as viable. Like individualism, subcultural or group identity that falls outside of the norms for general Japanese identity is to be avoided. Those who opt for independence or subculture in Japan pay a tremendous social and emotional cost for it. In this situation, the mentally ill individual has little chance at community survival. Further, when Japanese policymakers look to the West for indications of treatment or rehabilitation success in community-based mental health programs, they see few examples to recommend a change in policy. When weighing its policy of hospital care against the specter of the homeless mentally ill in America, for example, Japanese policymakers see no advantages to deinstitutionalization.

432

JAMES M. MANDIBERG

Moreover, the government would have to be willing to assume a social welfare responsibility for the mentally ill, taking this responsibility from the family. While there has been a willingness to do this for other populations, the government has displayed consistent ambivalence about assuming this responsibility for the mentally ill. This ambivalence is again reflected in the 1995 revisions to the mental health law, retitled the Law Related to the Mental Health and Social Welfare of Mentally Ill People (Seishin Hokken oyobi Seishin Shogaisha Fukushi ni Kansuru Ho&u). The revised law first asserts that the local and national government have the responsibility to promote the independence of the mentally ill. It then creates health and welfare benefits for the mentally ill that parallel similar benefits for people with physical disabilities and for those with developmental impediments. Additionally, the law removes the last remaining responsibility of prefectural governments to pay for psychiatric hospitalization costs, and it transfers it to the various medical insurance plans. Finally, it allows for the decertification of designated psychiatric hospitals that have become unsuitable. On the surface, the new law appears to move in a progressive direction, especially when viewed from a Western paradigm. It appears to promote independence, community care and treatment, equality of benefits with other disabled populations, the joining of mental health benefits with other medical benefits, and the ability to close inappropriate facilities. However, in her analysis of the new law, Kobayashi (1995) questions whether the impetus for some of these reforms may have less to do with progressive reform of the mental health system and more to do with the need to create resources for the growing number of elderly in Japan. She points out that 1993 was the first time since the construction boom in the 1950s that the number of psychiatric beds was reduced in Japan. However, the beds were not eliminated. They were converted to facilities for the elderly. Similarly, she notes that much of the savings the government realized in shifting the cost of hospitalization from the prefectures to medical insurance plans went to fund programs for seniors. She finally shows that in 1992, only 4% of the total mental health expenditure went toward rehabilitation. If one of the driving factors of mental health reform is the need to create services for seniors, aspects of the 1995 law appear less progressive. The provision in the law allowing for the decertification of psychiatric hospitals may be aimed at creating more nursing facilities for seniors. The final shift in paying for the costs of psychiatric hospitalization from the prefectures to the insurance plans might be aimed at creating more resources for seniors. If the reforms in the law were truly aimed at the rehabilitation and reintegration of mentally ill people, one would expect to see a significant portion of these saving allocated for community-based programming for the mentally ill. However, the national and prefectural governments have yet to mount serious efforts in this area. Consequently, although the 1995 law creates health and welfare benefits parallel to those available to other disabled populations, the limited number of programs available in the community limit the usefulness of this provision. The relationship between the individual and the society is the foundation of Western community-based mental health policy. However, many have noted

THE JAPANESE

MENTAL HEALTH SYSTEM

433

that Japanese society is more collectivist, and while individuals are recognized, their needs are of secondary importance to the needs of social groups. In this way, Japan has done itself a disservice by looking to the West for mental health forms to import and adapt rather than looking for indigenous models that may be more appropriate given Japanese social assumptions. It is an unfortunate fact, however, that Japan has consistently undercut indigenous models such as Iwakura historically and Yadokari no Sato (Yanaka, 1993) in contemporary times in favor of individually based models that have little prospect of success in Japan.lO The practice of looking outside of Japan for models to import and adapt may have worked well in economic development, but this appears particularly bankrupt in mental health, an area so intimately tied to social values, customs, and prejudices. In addition to the human suffering imposed by Japans mental health policies, a real tragedy is that Japan has all but ignored existing native models, or the germination of new models, that are at once progressive and in consonance with Japanese social values. References
Abramovitz, M. (1988). Regulating the lives of women: Sociul welfare policy from colonial times to the presenr. Boston: South End Press. Anderson, S. J. (1993). Welfare policy and politics in Japan: Beyond the developmental state. New York: Paragon House. Appelbaum, P. S. (1994). Mental health law and ethics in transition: A report from Japan. Hospital and Community Psychiatry, 4_5(7), 635644. Calder, K. E. (1988). Crisis and compensation: Public policy and political stability in Japan. Princeton, NJ: Princeton University Press. Campbell, J. C. (1979). The old people boom and Japanese policy-making. Journal of Japanese Studies, 5(2), 321-357. Clark, D. H. (1968). Assignment Report, November 1967-February IY68. Geneva: Regional Office for the Western Pacific, World Health Organization. Clark. D. H. (1988). Japanese mental health services 1988: Report of visit and comments. Appendix 2. Geneva: International Commission of Jurists. Cohen. P. S. (1995). Psychiatric commitment in Japan: International concern and domestic reform. UCLA Pacific Basin Law Journal, 14 (1). 28-74. DeVos, G. A. (1992). Social cohesion and alienation: Minorities in the United Stares and Japan. Boulder: Westview Press. DeVos, G. A., & Wagatsuma, H. Japans invisible face. Berkeley: University of California Press. DiMaggio, P., & Powell, W. (1983). The iron cage revisited: Institutional isomorphism and collective rationality in organizational fields. American Sociological Review, 48, 147-160. Earle, P. (1994). Gheel. American Journal of Psychiatry (Reprinted from the American Journal of Insanity, 1851), 151(6, Suppl.), 1619. Eguchi, S. (1991). Between folk concepts of illness and psychiatric diagnosis: Kitsune-Tsuki (Fox Possession) in a mountain village of Western Japan. Culture. Medicine and Psychiatry, 15, 421451. Foucault, M. (1965). Madness and civilization: A history of insanity in the age of reason, New York: Pantheon Books.

Please see Mandiberg (Innovations in Japanese Mental Health, 1993) for a discussion of this. For example. the model program of Japans National Institute for Mental Health for 20 years has been day treatment, an individually based model that is even discredited in the West. Similarly, newer Western models touted in recent revisions to the law, sheltered workshops and residential programs, are similarly based on supporting and then discharging individuals. This is in sharp contrast to a program like Yadokari no Sato, for example, which is based on the social group (Yanaka, 1993).

434

JAMES M. MANDIBERG

Cluck, C. (1985). Japans modern myth: Ideology in the late Meiji period. Princeton, NJ: Princeton University Press. Grob, G. (1983). Mentnl Illness and American Society, 1875-1940. Princeton, NJ: Princeton University Press. Hane, M. (1982). Peasants, rebels, & outcastes: The underside of modern Japan. New York: Pantheon. Harding, T. W. (1991). Ethical issues in the delivery of mental health services: Abuses in Japan. In S. Bloch & P. Chodoff (Eds.), Psychiatric ethic.r (2nd Ed.). Oxford: Oxford University Press. Harding, T. W., Schneider, J., & Visotsky. H. M. (1985). Human rights and mentnl patients in Japan. Geneva: International Commission of Jurists. International Commission of Jurists. (1992). Recommendations and conclusions: The third International Commission of Jurists Commission. Geneva: Author. Kobayashi. N. (1989, August) Report on the Tokyo Center for Human Rights and Mental Health. Paper presented at the World Federation for Mental Health Congress, Aukland, New Zealand. Kobayashi, N. (1991a, December). Conflict of human rights between individual and family systems in the context ofcultural issues. Paper presented at the conference Psychiatric Rehabilitation: The Asian Experience. the University of Hong Kong. Kobayashi, N. (1991b, August). One aspect of the Japanese mental health system and human rights in transitional implementation. Paper presented at the World Federation for Mental Health Congress, Mexico City. Kobayashi, N. (1993). Toddling advocacy in Japan. In J. M. Mandiberg (Ed.), Innovations in Japanese mental health services. San Francisco: Jossey-Bass. Kobayashi, N. (1995. August). Mental health and public policy based on human rights. Paper presented at the World Federation for Mental Health Congress, Dublin. Ireland. Koizumi, K., & Harris, P. (1992). Mental health care in Japan. Hospital and Community Psychiatry, 43(11), 1100-1103. Kumasaka, Y., & Yoshioka, S. (1968). The law of private imprisonment: Fifty dark years for mentally ill in Japan. American Journal of Psychiatry, 125(2), 109-112. Kuwabara, H., & True, R. II. (1976). National social policy toward the mentally ill in Japan and its consequences. Internntional Journal of Mental Henlth, 5(3), 95-108. Liegevis. A. (1991). Historiography of psychiatry in Belgium. History of Psychiatry, 2(7, part 3), 263-270. Lin, T.. Asai, K., & Takahashi, T. (1991). Mental hospitals as a base for community mental health in Asian cultures. Tokyo: Keimei. Lone, S. (1994). Japan's first modern war: Army and society in the conflict with China, 1894-95. New York: St. Martins Press. Mandiberg, J. M. (1993). Between a rock and a hard place: The mental health system in Japan. In J. M. Mandiberg (Ed.), Innovations in Japanese mental health. San Francisco: Jossey Bass. Mandiberg, J. M., & Miyaoka. K. (1994). Using the PIE system to teach social work in skills Japan. In J. M. Karls & K. E. Wandrei (Eds.), Per.ron-in-environment system. Washington, DC: NASW Press. Matsuoka. E. (1991). The interpretations of fox possession: Illness as a metaphor. Culture, Medicine and Psychiatry, 15, 453-477. Mino. Y., Kodera, R., 6r Ebbington. P. (1990). A comparative study of psychiatric services in Japan and England. British Journal ofPsychiatry, 157, 4161120. Morris-Suzuki, T. (1994). Technological transformation of Japan: From the seventeenth century to the twentyfirst century. Cambridge: Cambridge University Press. Munakata. T. (1986). Sociocultural background of the mental health system in Japan. Culture, Medicine, and Psychiatry, 10, 351-365. Murakami, Y. (1984). Ie society as a pattern of civilization. Journal ofJapunese Studies, ZO(2), 281-363. Murakami, Y. (1985). Ie society as a pattern of civilization: Response to criticism. Journal of Japanese Studies, lJ(2). 401-421. Okada, K. (1988). Psychosocial rehabilitation centers in Osaka Prefecture. Infernational Journal of Mental Health, 17(2), 38-47. Oshima. I., & Nakai, K. (1993). The Japanese mental health system and family movement: History, present status, and research findings. In J. M. Mandiberg (Ed.), Innovations in Japanese mental health services. San Francisco: Jossey-Bass. Pempel, T. J. (1978). Patterns o,f Japanese policymaking: Experiences from higher education. Boulder, CO: Westview Press. Pempel, T. J., & Tsunekawa, K. (1979). Coporatism without labor? The Japanese anomaly. In P. C. Schmitter & Lehmbruch (Eds.). Trends toward coporatist intermediation (pp. 231-270). Beverly Hills: Sage Publications.

THE JAPANESE

MENTAL HEALTH SYSTEM

435

Piven, F. F.. & Cloward,

R. A. (lY71). Regulating

the Poor:

The functions

ofpuhlic

welfare.

New York: Ran-

dom House. Polanyi, K. (1944). The great trunsformation: Thepolitical and economic origins ofour time. Boston: Beacon Press. Reischauer, E. 0. (1981). Jupan: The story of a nation. New York: Alfred A. Knopf. Russell, J. G. (1988). Descendants of Susano: Marginalization and psychiatric instittrtionulization in Japan. Unpublished doctoral dissertation, Harvard University. Cambridge, MA. Salzberg, S. M. (1991). Japans new mental health law: More light shed on dark places? Ir~trrnational .Journal of Law and Psychiatry, 14, 137-168.

Smith, R. J. (1985). A pattern of Japanese society: le society or acknowledgement of interdependence. Joltrnal of Japanese Studies, 11(l), 2946. Social Workers International Club. (1958). Glimpses of social work irl Japan. Kyoto: Author. Sukegawa. Y. (1993). Community support system for mentally disabled people: Public health and mental health centers in Kanegawa Prefecture. In J. M. Mandiberg (Ed.). Innovations in Jupane~e mental health servxe5. San Francisco: Jossey-Bass. Takahashi. T. (1993). Hospital care of the mentally disahled in Japan. In J. M. Mandiherg (Ed.). innovations in Japanese mental health services. San Francisco: Jossey-Bass. Takizawa, T. (1993). Patients and their families in Japanese mental health. In J. Mandiberg (Ed.), Irmovations in Japanese mental health services (pp. 25-34). San Francisco: Jossey-Bass. Tatara. T. (1975). 1400 years of Japanese social work from its origins through the Allied Occupation, 5521952. Unpublished doctoral dissertation. Bryn Mawr College. the Graduate School of Social work and Social Research, Bryn Mawr, PA. Totman, C. (1981). Japan before Perry: A short history. Berkeley: University of California Press. Totsuka. E. (1989). The changing face of mental health legislation in Japan. International Commission of
Jurists. Review, June, 67-81.

Utena. H., & Niwa, S. (1992). The history of schizophrenia research in Japan. Schizophrenia Bulletin, 18(l), 67-73. Veith. 1. (1978). Psychiatric foundations in the far east. Psychiarric Annals, K(6). 275-289. Westney, D. E. (1987). imitation and innovution: The transfer of western organizational pattc~rns to Meiji Japan. Cambridge: Harvard University Press. Weswood. J. N. (1986). Russia against Japun. 1904-1905: A new look ut the Rllsso-Japanese War. Albany: State University of New York Press. Yanaka. T. (1993). The village of the hermit crab. In J. Mandiberg (Ed.). Innovatiom in Japanese mental health srrvicry (pp. 57-66). San Francisco: Jossey-Bass.