It has been 10 years since I was last in Japan. I started going in the late 1990s to lecture and advise on government-sponsored efforts to reform their mental health care system. Japan then had two to three times the number of psychiatric beds per 1,000 population as did the U.S. or UK, making it a considerable outlier internationally, still heavily reliant on inpatient treatment. Though I have only visited a few times, over the years I helped arrange numerous U.S. visits for groups of psychiatrists, government officials and administrators; I also have had the opportunity to review professional publications and legislative proposals. As a result, I was familiar with the transformation of mental health services in this country of 125 million people where courtesy and community reign.
Mostly, however, I have had the privilege of maintaining friendships with a small group of Japanese professional colleagues. A group of doctors had been scheduled to visit New York last spring but had to cancel to deploy to the disaster area in the north of Japan in the wake of the catastrophic trio of earthquake, tsunami, and nuclear plant radiation leak. So when a third-generation psychiatrist leader, whom I have known for many years, asked me to come this year to help them accelerate the development of community mental health services, my reserve about flying halfway around the world for a dizzying few days of meetings (and taking leave time from my day job in New York) melted right away. I would spend a few days in Kanazawa, on the west coast of the island, followed by a brief stay in Tokyo.
Throughout the 1900s, Japan's mental health system was hospital-based. About 2,000 psychiatric hospitals were established after WWII. They were largely privately owned (often by their medical directors) but as not-for-profit facilities (Japanese law does not permit hospitals to make a profit), and were spawned principally by post-war government legislative and economic policies. These psychiatric leaders established family-run medical "businesses" that have served their country for over a half-century and have been the backbone of psychiatric care in Japan. Even in the 1990s, there were hardly any community mental health services and hospital stays were exceedingly long, with kind but typically custodial care. Stigma was great since mental illness was not well understood, and the marriageability of children in a family could be terribly compromised if it was know they had a mentally ill family member. While it was clear to many that it was time to introduce reform of the mental health system and modernize attitudes toward mental illness in Japan, doing so meant changing medical practices that had existed, successfully, for a very long time. When Japan began on its reform journey some 15 years ago I was fortunate to be invited onto the caravan. My contribution might come from having been part of this journey in the U.S., since the transformation away from long-stay hospital treatment to recovery-oriented, community-based services is one we have pursued over the past 40 to 50 years, with our share of successes and problems.
Japanese culture is deeply tradition-based. Change in mental health practices, it was understood, would have to come slowly and incrementally. Change would require champions who would have to take on established practices, beliefs and even economic interests. The champions would have to be psychiatric leaders as well as directors of mental health agencies in the national government (their National Institute of Mental Health). There is a saying in Japan that "a nail that sticks out from a board will get hammered." I was going back to Japan this year to help some of those nails not get so hammered.
What I saw on this visit was how a few leaders were chipping away at established attitudes and hospital practices. Among the most challenging I have seen in Japan (and not so long ago in the U.S.) is a view that seriously ill psychiatric patients are better off in the hospital than they would be in the community. Indeed, because mental health services and housing that enables normalized living in the community are still scarce in Japan, there is reason for concern about patients leaving hospitals, especially long-stay patients (and there still are many in Japan, as there were not so long ago in this country). But many countries have proven that people with serious mental illness can have good quality of life with relationships and social contributions living independently, with accessible clinical services and support, in the community. Not easy to achieve, but possible and worth doing when successful. My trip was heartening since I saw how a select group of doctors and government officials were carefully but insistently disrupting their status quo.
In a question and answer session after a lecture I gave on community mental health, as well as in meetings and dinners, I saw what my Japanese colleagues were up against. There are tough questions they face -- like how could patients know what was good for them? How could they care for themselves? What would be the burden on families? Would change create economic hardship for hospitals if they operated fewer beds (i.e., if more people lived in the community); in other words, could the hospital system as it exists today survive? (For some, this meant, "What would be the fate of my family business?") Would homelessness increase? Would safety for communities and families be compromised?
While there are thoughtful clinical and social approaches today that aim to respond to these questions and concerns, some now well-developed in many countries (not just ours), there are no guarantees. It is a risk to steer a path to a new world, in medical practice as it is for societies and for each and every one of us as well. Who dares to take those risks? They are people of conviction and fortitude who think first of the people they mean to serve -- how they can make their patients' lives better. But these disruptive doctors and government officials risk being criticized or shunned; some are willing to put patients before their own financial considerations. Their mission is to make clinical care better, to maneuver psychiatric practices from where they are to where they need to be. This type of leadership is rare; it is vitally necessary throughout the medical world. Without this kind of leadership, paraphrasing Margaret Mead, we will never see the changes we need.
As I write this post en route back to New York, to my government job, I think that this trip has strengthened my commitment to make mental health services better for those whose lives I may touch. I thank my Japanese friends for bringing me to their country to see anew what has to be done in our field and to witness true leaders in action.
I also am reminded of what Gandhi said: "First they ignore you, then they laugh at you, then they fight you, then you win."
[1.] Ito, H, Sederer, LI: "Mental Health Services Reform in Japan," Harvard Review of Psychiatry, 1999.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
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