Mental Illness in Japan and its Cultural Causes

Japan’s bustling cities and beautiful culture have captured the hearts of many travelers. However, just as with any other location, Japan suffers from its unique problems that arise from the country’s cultural dogma. This is very clear when addressing mental health in Japan. While the Tokyo lights shine and the sun rises over Mount Fuji, there is an epidemic of mental illness occurring across the country.

Cultural Stressors

Collectivism

To understand the mental health crisis in Japan, it is important to first learn about the country’s culture. According to Hofstede Insights, Japan scores 46 in individualism. This refers to how much members of society see themselves independently from others. Japan’s low number indicates that the culture puts strong emphasis on the harmony of the group rather than the rights of the individual. Therefore, the importance of the group overshadows a person’s opinions. This may seem harsh to those who value individual freedom. However, this is a type of social contract Japan makes to provide stability in many sectors of life. Japan’s collectivist perspective blends into many cultural acts.

The Japanese terms tatemae and honne exemplify the relationship between the group and the individual. Tatemae translates to a person’s public face. It is the mask Japanese people wear when speaking to coworkers, friends, and family. Characteristics are over politeness or making socially expected conversation. It does not matter if one lies. Rather, tatemae is the face of social obligation everyone must wear. By contrast, honne translates to one’s ‘real voice.’ People express honne with the closest of friends. People drink alcohol as a socially accepted and popular excuse to show one’s honne.

While every culture exhibits forms of tatemae and honne, the concept of a public façade is strong in Japanese culture. It stands to reason that tatemae aids in the greater good of the collective whole. Regarding mental illness, its stigmatization can arise from tatemae’s encouragement of group thinking. Even if an individual may not believe it personally, they might vocally agree in shaming mentally ill people as a form of tatemae.

Treatment of Individuality

Although restricting autonomy does build a more stable society, it also breeds isolation. This is becuase Japan often rejects individuality. As the famous Japanese proverb states, ‘the nail that stands up will be hammered down.’ The saying indicates that people value conformity in order to achieve a well-run country.

Japan’s education systems instill this mindset early on in children. Schools have a large amount of bullying. Until recently, it had gone far underreported. Since the passing of anti-bullying legislation in 2012, Japan has seen an increase in reported bullying. Moreover, classroom harassment happens to anyone who is ‘different.’ Bullies may target students who are too pretty or exceptional in class, for example. Likewise, it is particularly hard for mixed-race students to fit in.

It all starts with Japan’s ideals of collectivism. Children form groups and single their target out. While this may happen in any school, Japanese bullies are notoriously vicious. Whole classrooms may participate in bullying one student as they all fear being a target. This makes victims feel even more alone. All this has accumulated to incredibly high suicide rates for children. Just last year, suicide reached a record high in those aged 10-19, making it the leading cause of death for this age group.

The ostracization of those who are different does not end in grade school. Rather, it continues into the workplace. Thus, the treatment of those who are even slightly different may contribute to Japan’s mental health issues.

Culture-Bound Disorders

Culture-bound disorders are behaviors unique to a culture. This phenomenon can result in physical symptoms, mental cognitions, or odd conduct. Also known as folk illnesses, culture-bound disorders are present throughout the world. Because of Japan’s beliefs, some Japanese exhibit syndromes as a direct result of the culture.

Taijin Kyofusho

Taijin kyofusho is an anxiety disorder related to social phobias. The term translates to the ‘fear of interpersonal relations’ and has been studied since the 1920s. Those who suffer from taijin kyofusho display intense anxiety around others. It can manifest as a fear of eye contact, one’s own appearance, and of having body odor. As it impacts social relationships, those afflicted feel isolated and lonely.

Researchers have attempted to differentiate taijin kyofusho from general social phobia. Social phobia stems from the fear of embarrassing oneself. People with taijin kyofusho worry about embarrassing others. This demonstrates the effects of individualistic societies compared to collectivist ones. People in Japan view themselves as part of a group. Accordingly, a person’s actions and behaviors are reflective of the entire group. It explains why a person’s actions may bring shame to their entire family. In fact, researchers conceptualize taijin kyofusho as an obsession with shame. The overwhelming pressure to represent the group manifests itself as anxiety in failing to maintain the group’s image.  

Hikikomori

Compared to taijin kyofusho, hikikomori is more extreme in its symptoms. The social occurrence translates to ‘pulling away and confining.’ It affects mostly younger adults with research on the disorder only starting a few decades ago. For hikikomori, life is full of self-confinement and social withdrawal. The Japanese Ministry of Health, Labor, and Welfare define a person with the condition as centered at home with no interest in personal relationships for at least six months. Hikikomori has become a widespread issue in Japan. Some state that 1.5% of Japan’s population suffers from this illness. However, numbers can be higher since it can take years for hikikomori to seek help.

Researchers also believe that addictive usage of the internet has deepened the sense of isolation. This may be because the internet provides a comfortable space to speak freely, something that may not feel possible in Japanese society.

Yet, internet addiction is not the main reason why most hikikomori decide to become modern day hermits. There is a general disillusionment these young adults have towards the world. Japan’s culture accentuates shame in those who may not conform to the collective. The same applies to hikikomori who, out of fear of judgement, decide to remove themselves from the group entirely. Typically, childhood bullying is associated with those suffering from the disorder. This along with other factors can embitter people into becoming a hikikomori.

Treatment of Mentally Ill People

Stigma

Mental illness in Japan has long since been a social taboo. It is a personal matter that a person must deal with on their own instead of seeking professional help. Any type of disorder is inherently shameful. Many Japanese view mental illness as a lack of one’s own willpower. As a result, those affected are less likely to tell others. This also explains why almost two-thirds of people suffering from mental illness never seek out medical care.

Yet it is not only shame that stops people from getting help. Those affected strongly fear how they might be treated if others found out they were mentally ill. Being that mental illness equates to a lack of self-control, those afflicted dread that they might be shunned socially and professionally. This fear is not without basis. In one review of mental-health stigma, studies showed that people have greater distance in closer relationships with those who have schizophrenia or depression. What this means is that many people do not want to marry or be family members of a mentally ill person. Social stigma can also affect work life. In an online survey, 48-61% responded that they would not employ someone with schizophrenia.

Depression and Schizophrenia

Specific disorders have faced varied forms of stigmatization. Depression has had more acceptance since the 1990s but with damaging effects. During that time, pharmaceutical companies determined to sell Prozac to the Japanese market. Hence, marketing campaigns labeled depression as ‘kokoro no kaze,’ or ‘a cold of the soul.’ The campaign was wildly successful. Although it did make depression a more talked about issue, it also created an overreliance on drugs. The perception was that depression could only be cured by taking medication for the rest of one’s life. In place of therapy, people with depression are given prescriptions and little emotional support.

As depression has gained attention, public perception is still distrusting of those with schizophrenia. Most think those with the disorder are dangerous. In a survey, 56% believed that schizophrenic patients could harm children. Another study among industrial workers and government employees reported 74% agreed schizophrenic people should be hospitalized. Such extreme biases resulted in the psychiatric society changing the Japanese name of schizophrenia in 2002. Previously seishi buntetsu byo (split-mind disorder), the disorder was renamed to shiccho sho (loss of coordination disorder) to minimize prejudices. Nonetheless, the public categorizes people with schizophrenia as a danger to the tranquil society Japan tries to uphold.

History of Health Care

Japan has a dark history in its treatment of the mentally ill. Right at the turn of the century, Japan implemented new laws concerning people with mental illness. The Law for the Custody for Insane People of 1900 meant to confine the mentally ill under police supervision. Small rooms called zashiki-rou acted as subsitute jail cells. Also responsible for monitoring the individuals were family members. Evidently, the main goal of the law was to make mental health issues a private matter outside of the public eye.

The mid 1900s saw the extreme rise of private mental hospitals. Because zashiki-rou had been abolished, Japan needed a new solution. They found it in the form of private mental hospitals. Under the Eugenics Protection Law, the government considered mentally ill people as having undesirable hereditary traits. Thus, mental hospitals were the same as zashiki-rou in their goal of confining patients away from society. The government invested heavily in these facilities. High subsidies were given out for sochi nyuin, meaning the involuntary hospitalization by administrative order. Consequently, sochi nyuin cases grew to 37.5% of all patients. By the 1980s, the government was questioning hospitals about their treatment of patients. One investigation revealed that 222 patients had died from suspicious circumstances in a single hospital. This began the long and ongoing road towards deinstitutionalization.

Current Psychiatric Care

Recently, Japan has attempted to shift the care of the mentally ill towards community-based resources. The government has promoted rehabilitation programs and social participation. However, there has not been a substantial change in hospitalization. Japan has one of the highest numbers of psychiatric beds per capita. Moreover, the average length of stay was reported to be 292 days in 2012. While most new admitted patients leave within a year, there are many patients who stay in the hospital for ten or more years. This over dependence on hospitals contributes to the rejection and neglect mentally ill people face by their community. With little contact between mentally ill people and the public, it is easy to understand why there are many negative stereotypes associated with this group.

Suicide

In the last thirty years, the Land of the Rising Sun has become notorious for its high rates of suicide. Just four years ago, Japan ranked seventh in having the highest suicide rates. One popular suicide location, Aokigahara forest, has even inspired several international movies. In evaluating the history and motives of suicide, culture plays a heavy hand in the act of self-murder.

Seppuku

Some look at suicide as a way to take responsibility. This derives from samurai’s use of seppuku. Disgraced warriors performed the ritual suicide. Those wanting to express their intense grief likewise committed seppuku. Although it may seem like an ancient practice, there have been famous cases of seppuku in the 20^th century. In 1912, General Nogi Maresuke committed the act out of grief for the dead Emperor Meiji. The last well-known case was when famous novelist and nationalist Yokio Mishima failed a coup against the Japanese government in 1970. He soon performed the ritual suicide. Some interpret his final act as a political expression. Both cases demonstrate how culturally ingrained the idea of suicide is.

Motives

The top two motives currently for suicide among the Japanese are health and financial issues. Japan categorizes mental health issues the same as physical ones. Because of this, it is difficult to investigate how many suicides are caused by mental illness. But seeing as how ‘health issues’ make up 49% of suicidal motives, it can be assumed to be a significant portion.

Financial distress is another leading cause. Those burdened with debt feel that their sole solution is suicide. Insurance companies have only encouraged this. Post-World War II saw many Japanese struggling financially. To seek financial aid for their loved ones, people took out life insurance policies and would immediately take their lives. Although insurance companies have placed more restrictions to combat this, the practice is still done today. This motive can be related to cultural ideas around taking responsibility for oneself.

COVID’s Impact

Throughout the world, the pandemic has worsened mental health issues and financial ordeals. It may be shocking to know that more people in Japan are dying from suicide than from COVID-19 during the pandemic. In recent years, Japan’s suicide rates have been steadily decreasing. 2019 saw the lowest number of suicides in 42 years. Yet, the spread of COVID in 2020 has caused a tremendous surge in suicides. In the month of October alone, there were more suicides than there had been COVID deaths in the entire year. The country has also seen suicides by women increase 80%. This follows as quarantine orders worldwide have put more women at risk of domestic violence. As a response, Japan has budgeted $34 million for suicide prevention.

Significance in Anthropology

Much to do with the treatment of mental illness in Japan is tied into its cultural standards. In understanding where prejudices come from, Japan can take steps forward in aiding the mentally ill. Yet, this has not been possible without anthropological research. For example, medical anthropologists are the ones who investigate culture-bound disorders like hikikomori. Japan’s beliefs influence every facet of life, including the treatment of mental illness. In evaluating the issue of mental illness, anthropologists gain a deeper understanding of Japan’s culture.