Japan’s Hidden Youths: Mainstreaming the Emotionally Distressed in Japan
One of the most talked-about social issues in Japan in recent years has been the problem of the nation’s purportedly one million “hidden” youths, known as hikikomori (literally, “the withdrawn”). Most observers agree that the category of hikikomori encompasses a wide range of problems and provocations. The fact that these various dilemmas lead to the shared outcome of shutting oneself away at home is the point of departure here. The article explores the spheres of mental health care, education and family, focusing on the reluctance to highlight underlying psychological dimensions of hikikomori and the desire on the part of schools and families to “mainstream” Japanese children, accommodating as many as possible within standardized public education. Hikikomori can perhaps be seen as a manifestation of Japanese democracy, in which the good society is imagined as cohesive, protective and secure, rather than one in which the individual can freely exercise the right to be different. Schools, families and the sphere of mental health care have focused on producing social inclusion but have discouraged citizens from being labeled as “different”—even when such a distinction might help them. The dearth of facilities and discourse for caring for the mentally ill or learning disabled is, in many respects, the darker side of Japan’s successes. Those who cannot adjust are cared for through the institutions of families, companies and various other spheres that offer spaces to rest and to temporarily “drop out”; however, the expectation is that rest will eventually lead to a re-entry into mainstream society. Often the psychological problem or disability that led to the problem goes unnamed and untreated (hikikomori, psychiatry, special education, youth, family, Japan).
The problem of Japan’s purportedly one million hidden youths (hikikomori) who have shut themselves away in their parents’ homes, refusing to leave for months or even years on end, has captured a great deal of attention both within Japan and internationally (Jones 2006; Rees 2006; Saitō 2003; Yoshimoto 2004; Zielenziger 2005). Social commentators who have claimed attention in the Western media see hikikomori victims as healthy outsiders in a society that makes unhealthy social demands: rebels, who resist social conformity by withdrawing. Saitō Tamaki, perhaps the most widely cited psychiatrist on the topic in both Japan and in the United States, writes in Hikikomori Bunkaron that the Japanese self is permanently engaged in an early phase of social development, forever emulating and responding to the expectations of others (seken) (Saitō 2003:89). The journalist Michael Zielenziger’s recent and widely reviewed book, Shutting Out the Sun: How Japan Created Its Own Lost Generation (2005), discusses the problem of hikikomori as an emblem of Japan’s broader social and economic dilemmas: a society that preaches the importance of obedience, discipline, self-inhibition and group harmony. Zielenziger suggests that Japanese hikikomori victims would, in a freer society, be designing computer games, handcrafting furniture or launching small software startups.
In this analysis, I take a somewhat different tact. I argue that hikikomori is best understood not as a specific problem but, rather, as the outcome of multiple kinds of social, medical or emotional problems. The fact that these various dilemmas may lead to the shared outcome of shutting oneself away at home is remarkable, and that is one aspect of the problem that I focus on here. My second concern is the management of difference in a society that has historically prioritized inclusion and mainstreaming as key elements of democracy, over the expression of individual rights. My analysis is based on several years of research on Japanese mental health care, along with a limited number of interviews with psychiatrists, social workers and school counselors, experience attending support groups for parents of withdrawn children and attendance at a support group for withdrawn young adults. I have also visited two hikikomori rehabilitation facilities. My analysis is not an attempt to pinpoint the social or medical cause of hikikomori but, rather, to consider the phenomenon of hiding away as a window into Japanese management of mental health, social welfare and the institutions and practices that have shaped Japan’s postwar social landscape more broadly.
Most observers agree that the category of hikikomori encompasses a wide variety of problems and provocations. Some hikikomori victims appear to have neurotic symptoms that would make it difficult to function in the classroom: the case reported in Maggie Jones’s (2006) recent New York Times article, for example, describes a teen who wore thick gloves to ward off germs and another who scrubbed the tiles of his family’s shower several times a day, substantially raising the household water bills (47).1 Many hikikomori cases start out as “school refusal syndrome” (tōkō kyohi or futōkō), where children gradually fail to thrive in school and eventually refuse to attend, resulting in prolonged periods of absence. Such cases are often precipitated by some form of school bullying, which can begin as early as elementary school. Bullies typically target children who are “different” in some way: physically fragile, developmentally delayed or emotionally removed (for example, children who refuse to greet others). Others retreat later in life, after graduating from college and failing to find a compelling job or direction and lacking a sense of belonging.
Although it is tempting to characterize hikikomori as simply a manifestation of repressive social conformity and, accordingly, to see hikikomori victims as adopting a stance of self-conscious resistance or protest, I argue that the problem is perhaps better understood as part of the darker side of a Japanese commitment to social equality and the desire to incorporate as many as possible within the spectrum of middle-class values. In the following, I focus on three related institutions that seem salient to the management of social deviance and the outcome of hikikomori: mental health care and the broader resistance to labeling, diagnosing and treating individuals in a way that will permanently set certain youths apart from others; the imposition of equality through standardized education and the limits of special education; and the social support offered by institutions such as the family as a key sphere of Japanese social welfare. Japanese education and health care resist measures that will marginalize, differentiate or remove young people from the mainstream of school, work and social life. Japan’s postwar education and health care have aggressively promoted relative equality and shared social values as a key to a healthy and productive society. At the same time, society offers limited and highly constrained alternatives to mainstream social experience. Instead, through the welfare system provided by families, companies and, to a limited extent, the state, society has created spaces for citizens to retreat to, in the hopes that they will rejoin society when the time comes.
In the spheres of education and mental health care itself, there is what might be described as a kind of “antipsychology” or “antipsychiatry” bias in Japan (Lock 1986:106), by which I mean not an opposition to psychiatry itself but, rather, a web of ideas and institutions that militate against pathologizing the individual and that, instead, make it possible to view a vast array of human differences and distress as potentially manageable and containable through reliance on self-discipline, coping and support from family and others. Both mental health care and Japanese public school pedagogy emphasize the effects of the environment in learning and human development, minimizing the consequences of innate abilities and predispositions. The assumption that, if the environment is healthful, children will thrive underlies the tendency to resist categories and labels. It also leads to the treatment of a vast array of psychological and social problems as correctible.
The heavy emphasis on “mainstreaming” and the powerful association of health with social integration creates a situation in which the line between the normal and the pathological—between a problem that is manageable through behavior modification or socialization and one that requires more specific or totalizing forms of care—becomes difficult to draw. Hikikomori may be a manifestation of a system that has worked hard to “mainstream” the vast middle swath of citizens into middle-class values and social life in Japan, but offers chiefly “custodial” forms of care for those who simply cannot accommodate the demands of normal, everyday life.
Japanese Mental Health Care
In the late 1990s, when the problem of hikikomori began to capture the public’s attention in Japan, I was surprised by the extent to which treatment discourses emphasized accepting these youths as they were—slowly drawing them back into social life through strategies such as setting small goals, big brother and big sister programs and continuing parental care. The issue was chiefly how to reintegrate these isolated individuals into mainstream social participation (see Rees 2006; Saitō 2003, 2004).
There has been a general resistance among clinicians, parents, social workers and school teachers to pathologize youth problems, or to mark these hidden youths as inherently different in a significant way. Since 1992, the Japanese Ministry of Education (now Monbukagakushō; Ministry of Education, Culture, Sports, Science, and Technology 2006) has stated that the refusal to attend school, seen as a related problem, is a syndrome that can occur in “any family” and “any child” (donna katei no donna ko ni mo okirieru), and that the problem of futōkō must be regarded as a socially produced problem, rather than an individual or a familial one (Saitō 2003:10, 2004:27–38).2 The psychiatrist Saitō Tamaki, one of the most widely cited and respected specialists in hikikomori care, also sees hikikomori as evidence of constraining social structures rather than individual problems. He argues that families shouldering hikikomori youths tend to be middle- to upper middle-class families, few of whom could be seen as “broken families” (hatan shita kazoku wa mushiro shosūha desu) (76). Saitō sees hikikomori as a “condition” (hikikomori jōtai), not itself a disorder or disease, rooted in a malfunctioning of the communication system among individual, family, and society; the system then reproduces itself (71–75). Saitō’s widely cited idea of “social hikikomori” (shakai teki hikikomori) refers to hikikomori not rooted in clinical pathology (72, 103–105), and plays into deeply held beliefs about normality, illness consciousness, and problem-solving in the institutions that shape daily life, including schools, families and companies.3
The Japanese have long managed with a remarkably minimal outpatient mental health care system, with few private clinics or therapists (there is still no government licensing system for nonphysicians, such as clinical psychologists or social workers) and few outpatient services outside of major hospitals. SSRIs (selective serotonin reuptake inhibitors), a milder form of antidepressants with fewer side effects than previous generations of pharmaceuticals, were first made available in Japan in 1999, 11 years after the adoption and rapid increase in use of these drugs in the United States. In 1989 when Eli Lilly & Co. tested the waters for Prozac in Japan, they were told by local experts that “the Japanese barely suffer from depression” and decided the market was not worth the investment (Applbaum 2006:89).
Indeed, Japan (along with other East Asian nations) stands in contrast with the United States and most European Union nations for its relatively low incidence of self-reported mental illness (based on World Health Organization diagnostics) and its low incidence of help-seeking from psychiatrists or other mental-health professionals for reported problems. (Approximately one in five with moderate to severe symptoms seeks medical help of any kind [Kawakami et al. 2006; Naganuma et al. 2007].)4 And, among the most assertive help-seekers—those reporting mood disorders—only one-quarter seek help specifically from mental health professionals.5
The numbers reflect the stigmatization of mental illness in Japan. Doctors, aware of the sensitivity of the families, avoid diagnosing major psychopathology to the extent that it is possible. Psychiatrists may refrain from using the term “depression” or “depressive illness” (utsu byō), relying instead on such ambiguous labels as “depressive state” (utsu jōtai) and “neurosis” (noirōze) which imply that the condition is not innate or enduring (Kawanishi 2006:31).
Therapy for a depressed business man, a child refusing to go to school or a housewife who becomes tearful every time she enters the kitchen … consists of giving the patient permission to rest for a short while from their social role … allowing patient and family to come to terms with a lower standard for role performance than was originally aspired to, and then easing the patient back into the social system when the time is deemed right. Medication may help this process; it can relieve physical symptoms (which may include symptoms of depression or anxiety…), but personal adjustment, largely through development of the qualities of perseverance (gaman) and resignation (akirame) are essential. (106; see also Lock 1993a, b:28)7
In the support group I attended over the course of a year for a small group of reclusive young adults, the member of the group who most strongly presented a depressive affect, K-san, had never seen a psychiatrist. K-san was frail-looking and spoke quietly, only when asked. Her family, who owned a small shop, had undergone considerable hardship when Japan’s economic bubble burst in the early 1990s, and K-san had refused to go to school on and off for most of her compulsory years. She remained at home, taking care of her elderly grandfather and doing odd jobs around the house. Despite the fact that her mother was described in the case record as speaking in a monotone and having “depressive affect” (utsu jōtai) and that her sister had seen a psychiatrist, the social worker declined to refer her to a psychiatrist and felt strongly that K-san’s life problems were “not merely a matter of getting the right medicine.” In consultation with another psychologist, it was decided that K-san’s continuing participation in the sociality of the group offered the most promising path of help (field notes, July 16, 2003).8
The outcome of this pattern is that, at least until relatively recently, Japanese physicians have resisted cosmetic psychopharmacology—that is, relying on SSRIs and other medications to allow patients to become, in the words Peter Kramer (1997:xvi) made famous in his early book Listening to Prozac, “better than well.” At the same time, evidence suggests that major depression has been underdiagnosed in Japan, and that those suffering from systemic chemical imbalances have been left largely to fend for themselves, take the path of least resistance, keep up the best they can and, in moments of desperation, find ways to drop out altogether.9
This is the important context for the hikikomori phenomenon. In 2006, when I visited two facilities that offer residential treatment programs and support for hikikomori youths, I found youths with a seemingly wide array of problems, from severe obsessive-compulsive behavior, to mild retardation, to suspected cases of depression, and some young adults who, for whatever reason, have simply been unable to weather life’s setbacks. Nonetheless, despite the recognition on the part of staff members—when asked—that many of these hidden youths may suffer from clinical pathologies, the care in such groups consistently emphasizes the importance of rehoning one’s social skills and accepting basic social values.
Neither of the facilities emphasizes the psychological, developmental or even familial issues that were potentially at play in the youth’s retreat. Rather, the emphasis is almost exclusively placed on healing through instilling “social skills” (shakairyoku o yōsei suru). One of the nonprofit residential centers describes its recovery mission as teaching youths to learn to take care of basic necessities of life through cooperative living (kyōdō seikatsu), engaging with peers (ooku no nakama to no fureai) and hearing testimonials of “survivors” (taikendan). It also owns a small coffee shop and bakery in a relatively low-rent district of Chiba, where the residents work. The Web site for this center states that such jobs instill a sense among residents of “wanting to be useful” (yakudachitai). In addition, the center leads its members on a week-long walk trough the temples of one of the old Buddhist pilgrimages in an attempt to teach endurance, patience and perseverance. Only a small percentage of residents in these facilities see physicians (though some staff members acknowledge that more may need such care), and there are no clinicians on-site. In one case, the staff is comprised largely of hikikomori survivors.
In my experience observing outpatient mental health care over the years, I have found that where counseling is offered in the context of community clinics or private hospitals, conversations largely focus on behavior modification—changing life patterns, regulating sleeping patterns, returning to work and accepting responsibility for family and motherhood. Indeed such an emphasis on “healing” and the management of conflict through social reintegration has been a foundational insight offered by anthropological studies of health, care-seeking, and therapy in postwar Japan (see, e.g., Lock 1986:105–106, 1987, 1988, 1993a:206–216, 1993b:28–19; Long 1996; Ohnuki-Tierney 1984; Ozawa-de Silva 2006; Reynolds 1987:124–125). The inclination to see difference as containable through behavior modifications and the desire to socially integrate those who may be marginal are closely connected to the reluctance to see problems as innate and to rely on DSM categories. Instead, resting, rehabilitating and remaining in various custodial forms of care become dominant options for care in such conditions. Writes Lock (1993b: 28), “Family, employer, and friends can be very patient and supportive during this process and insurance companies allow very long stays in hospital. The ultimate objective of therapy is not to provide symptom relief but to facilitate integration into one’s own social role….” This orientation is evident in Japanese indigenous forms of “psychotherapy,” in particular, Naikan therapy, a treatment still used, which, through meditational techniques, seeks to instill a renewed appreciation of a sense of connectedness to others and “the immeasurability of what he or she has received from others … and indebtedness … that cannot be repaid” (Ozawa-de Silva 2006:75).
Mainstreaming and Normalizing in Education and Special Education
Attitudes toward difference and mental illness are rooted in broader cultural ideals of equality. The tendency to mainstream is evident from the earliest stages of education and socialization.10 The agenda of the Japanese public education system is to educate all children equally, at least through the years of compulsory education (gimu kyōiku; through ninth grade). Public-school students in the same classroom are not tracked or offered different curricula based on ability; the notion of “excelled learning” or schools within schools for advanced students, familiar in the United States, is virtually unknown in these early years. (Sorting occurs later, as students compete to enter high schools of different standing.)11 Teachers and counselors shy away from public discussions of innate, differing abilities of each student, and IQ tests were abandoned in the 1960s.12 Success in the national standardized examination system is heavily rooted in memorization, thus there is a general awareness that diligence and effort, in addition to innate cognitive skills, greatly impact the educational outcome (Rohlen 1983:97–101).
The years of compulsory education are seen as important years of socialization for children, and the state has viewed inculcating shared values and national identity as the mandate of public education. Schools explicitly embrace the mandate of “character formation” (jinkaku keisei), social capacities (shakaisei) and moral education (dōtoku kyōiku), in addition to learning and memorization (White 1988:30–33). Teachers emphasize the importance of “daily life habits” (seikatsu shūkan) and “comportment” in identifying and managing troubled children in Japanese middle schools (LeTendre 1995:176–178). Although teachers visit students’ homes yearly and find it appropriate to inquire into daily routines, eating habits, sleeping habits and the orderliness of the household, they consider topics such as family relationships or the possibility of individual psychological problems off-limits and highly charged, and they are loath to broach such topics with parents. In her ethnography of how parents cope with major mental illness in children, Kawanishi (2006:25) notes that the patterns of school refusal or even violent behavior by children at home (tied to school refusal) are rarely linked to the possibility of psychiatric problem.
Ethnographic studies of Japanese early education (preschool through elementary) reveal that teachers are quite tolerant of chaos and hyperactivity (or what we might call hyperactivity) and are similarly casual in dealing with hitting and other bad behavior. What they tend to flag as worrisome or unacceptable is children’s failure to participate in group activities (Peak 1989:105).13 In the later years of the compulsory education system, skillful teachers find ways to accommodate the different needs and talents of each student—developing strategies to adapt materials for students who are learning more slowly, without singling them out.
The emphasis on equality can be seen as very much a double-edged sword. On the one hand, historically it has sustained an ideology of inclusion. The strong belief that Down syndrome children should be accepted in the “normal” classroom was associated with the idealistic belief that inclusion would allow stronger children to overcome their discrimination, and allow disabled children to benefit from mingling with mainstream peers. At the same time, inclusion is undeniably linked to an ideology of “sameness”—and the pressure to hide problems and assimilate into mainstream values.
This is manifested in the strong preference that most parents feel for placing their children in “regular classrooms” (futsū gakkyū), even in the face of evidence that their child would function more productively with special attention. The pressure to mainstream children—to keep all students in the same classroom roughly on the same level—is strong, and it is remarkable that one can still find children with mild Down syndrome, for example, in regular elementary and sometimes middle-school classrooms. As in T-kun’s case, parents may also rely on cram schools, designed to prepare students for high-school and college entrance examinations, to supplement class learning and support a faltering child. The question of when individual problems cross a line so that they can no longer be addressed through extra attention, closer integration and character cultivation is perhaps the central tension in the management of deviance in education.
The moment at which a counselor must confront a parent to suggest that the child be seen by a doctor or psychiatrist, or to ask permission to place a child in supporting or special educational classes, is widely regarded as a tense and difficult one, and in many cases permission is not granted. In one counselor’s recounting, if a counselor or teacher does not approach a parent appropriately, he or she runs the risk of cultivating in the parents a sense that the child has already been labeled as a “problem child” (mondaiji) and thus adversely affected.
The flip side of this emphasis on equality is that for those who fall behind, the road is ambiguous. According to counselors and teachers, students may spend wasted years, sometimes getting bullied or frustrated in their inability to keep up. Some students are bullied; others withdraw. The momentum of mainstreaming pushes toward including as many students in conventional pedagogy and socialization as possible, while offering little except places in which to withdraw for those who simply cannot fit within the normal.
An incident reported in the newspapers not long ago betrays the hazards of such an approach (Asahi Shinbun 2006). A sixth-grade child from a Tokyo public school, “T-kun,” got lost in the mountains while on a school trip. Through a counselor affiliated with T-kun’s school, I later learned that some teachers had noticed that T-kun seemed to have some developmental issues: he lacked age-appropriate verbal skills and was noticeably physically uncoordinated. After straying from his group, he ended up spending the night in the mountains alone, when helicopters could not locate him in the dark. The following morning he was found.
Why were special precautions not taken, and why had the problem not been formally recognized and addressed? In various ways, the school, the health-care system, special education and the family had all devoted significant resources to allow T-kun to continue to function in mainstream schooling. T-kun’s mother had been called on a number of times to accompany him when the class went on field trips or held special performances and it was felt that he needed special supervision. In kindergarten, when T-kun could not yet speak much, he was assigned a special attendant (kaijoin), furnished by the school, who would facilitate his classroom participation. And from first to fourth grade, T-kun attended a supplementary speech class twice a week (kotoba no gakkyū), also in the public school system, although by the time he was in fourth grade his parents were told that this was no longer necessary. At preparatory school (juku), the teacher allowed T-kun to work at his own pace, sending home photocopies of work unfinished in class, and the family had deliberately chosen a juku with a small number of students and ample individual attention.
At a meeting between the mother and the school counselor, which I attended, one year after the incident in the mountains, it was still not clear that the child had been formally diagnosed, or whether his parents thought of him as different in any important way.
Mainstreaming seems in part to be rooted in a belief that socialization and social environment strongly shape a child’s outcome, in addition to innate abilities and predispositions. There is a sense that, as one counselor paraphrased, “children raised in a healthy environment will naturally grow up to be healthy” (kodomo wa kankyō ga yokereba sukusuku sodatsu). The emphasis on the importance of the environment in influencing a child’s outcome carries the possibility of equality, since presumably any child can rise to the level of his social environment. At the same time it assumes that all children will mold to social expectations and carries the potential to ignore or dismiss special needs.14
The emphasis placed on environment in early pedagogy also fosters responsibility among teachers, and for these reasons teachers themselves are reluctant to address a problem. When confronted by school counselors (who tend to be more attuned to psychological and developmental issues) about a problem child, they may hear recommendations for special care for certain children as an indictment of their teaching skills or material. Because of the emphasis on effort and comportment, teachers also often lack awareness of how to classify or differentiate slovenliness or disobedience from a more systemic developmental problem or illness. Teachers often quickly assume that behavioral problems are the result of carelessness, selfishness or “poor upbringing” (sodachi ga warui). Thus medical diagnosis carries the potential to bring relief and clarity to a situation that had generated confusion and ill will.
Although education for children with severe physical handicaps, blindness, deafness, autism or severe mental retardation has become highly developed since it came to be considered a legal right in the early postwar years, for those children who veer less drastically from the normal, special education (tokushū kyōiku) is often limited to a few hours a week, and is sometimes (but not always) taught by teachers who have no formal credentials in special education. Supplemental services for students with developmental delays (hattatsu shōgai), learning disabilities (LDs), or cognitive problems (chiteki shōgai) often take the form of rooms at a school where students spend a few hours a week, known as “commuter classrooms” (tsūkyū gakkyū). (There are also special education classrooms in normal schools where disabled students spend the entire day, through these are fewer in number [compared with commuter classrooms] for students with more mild forms of cognitive or emotional problems.15 Students who are severely retarded or physically disabled attend specially designated schools for the disabled with special facilities, yōgo gakkō.) In commuter and on-site special education, students with “emotional problems” (jōcho shōgai) such as Asperger’s syndrome are often lumped together with students suffering from cognitive or developmental issues (LeTendre and Shimizu 1999:6).16 Of the four classrooms that I have visited, all commuter classrooms, teachers have reported that most of the children attending do not have official diagnoses.17
Although special education classrooms are an attempt to emphasize kobetsu gakushū, or “individualized education,” as opposed to shūdan kyōiku in the regular classroom, they too appear to emphasize immersion in social life (shakai sei) as much as they do technical problem-solving or focused therapy. Mottoes posted on the wall of a school support center I visited (in Sumida-ku) read, “We teach students the importance of basic life habits” (kihon-teki seikatsu shūkan), including, listed beneath, “attending class,” “changing clothing,” “communication through speech” and “joining in school meals.”
There are far fewer special education classrooms for children with special needs in junior high than in elementary school, and virtually none in regular public high schools, since high schools are not included in compulsory education and are fiercely competitive by ability. Thus Monbukagakushō statistics reveal that there is a small exodus of those with cognitive and emotional problems from the regular school system into special schools (yōgo gakkō) between elementary and middle school, and between middle and high school, when pedagogy becomes almost entirely geared toward entrance exam preparation (Ministry of Education, Culture, Sports, Science, and Technology 2006:41, 48).
In elementary and junior high schools, a growing number of spheres for marginal students have come to function as quasi-legitimate spaces where children with a variety of problems can spend the day. The school nurse’s office (yōgo no sensei), school counselor’s office, “step classrooms” for school-refusers and school “support centers” all function as such hubs. Alternative classrooms offer loose, flexible structures, independent of regular schools, to accommodate children who refuse to attend school.18 Children who inhabit these alternative spaces may suffer from wide-ranging problems such as Asperger’s syndrome, compulsive overeating, refusing to attend class for various reasons (including bullying or fear of bullying), being developmentally delayed and even one case of Tourette syndrome. These institutions allow students to accumulate the credits needed to graduate, without pushing to diagnose, differentiate or track them.19
The small group of students who populate school counselors’ and school nurses’ offices often befriend one another, creating their own small social unit. I have spent an afternoon with such a small gathering of students, who, supervised by a school counselor, special education aid and judo teacher, shared their stories with one another, played name games and had an impromptu birthday party. In such contexts, what the school and health-care system accomplishes is the “warehousing” of marginal students, so that they may remain affiliated with and supported by key social institutions; they are prevented from dropping out or being stigmatized as special or different, yet at the same time, they do not receive the specific care they deserve—clinical or educational. The hope is that, through care, patience and continued contact, with others, they will gradually rejoin the social fold.
Such a coping method defines the hikikomori phenomenon, and one could argue that such spaces of withdrawal exist in other corners of Japanese society, beyond the home and school. One wonders what other unnamed havens exist in Japanese society: internet cafes, where it is reported that disenfranchised youths increasingly spend the night, homeless encampments or even locations outside of Japan, where Japanese youths increasingly seek escapes that become long-term. The growing communities of students working in pleasant foreign cities such as Vancouver on “work-holiday” visas (wa-hori), where they cultivate bounded social worlds, free of the social expectations and the constraints of the Japanese education system, may constitute another such haven.20
Warehousing and Rehabilitating the Mentally Ill and the Deviant
In the European and American context, psychiatry, cloaked in the science of medicine, became that institution which stepped in to name, separate and manage manifold forms of human dilemmas, previously addressed through other idioms, including religion (Foucault 1973:5–8; Kleinman 1988a:4–6, 244–246, 1988b; Lock 1987:13). In Japan (and Asia more broadly), psychiatry has yet to gain such a presence in defining normality, despite the growing presence of psychiatric discourse in public culture (Applbaum 2006; Kitanaka 2007:115–123; Vickery 2007). Psychiatry has had a thin presence historically, and in its place, family, community and multiple institutions supported by the state have sheltered those with disabilities and other differences that prevented them from functioning in mainstream society (Norbeck 1978:342).21
The state’s vision of social welfare has been to promote families and communities to care for themselves, in what later came to be described opportunistically as a “Japanese-style welfare society” (Nihon gata fukushi shakai) (Garon 1997:26, 38–41; Peng 2002:419). The postwar system, in which state-sponsored welfare and social services are limited and, instead, industry offers basic benefits, job stability, a family wage and pensions, is the realization of that vision.
Corporate welfare, in the decades of rapid economic growth following the war, meant that while the state subsidized comparatively little unemployment compensation or social welfare, midsized and large firms stepped in to meet the basic human needs of workers, in return for their long-term commitment to the company. In midsized and large firms, employees can be granted long-term leaves for illness (kyūshoku or chōki kyūka), up to years at a time. Although after a certain point salary ceases to be paid, subsidized health insurance covers medical costs and job security is maintained, although the employee may be taken off the most ambitious promotional track.
“Japanese-style welfare” creates spaces where those who are disaffected or disabled can retreat or rest, including long hospital stays through what is known as “social admission.”22 Long recoveries may transpire in the total absence of an identifying diagnosis, causing pain and confusion for those who suffer. This is indeed what one psychiatrist referred to as a “Japanese-style treatment” (Nihonryū no chiryō) for mental illness: private coping, and subsidized and socially legitimate spaces for rest, but not necessarily cure—a kind of warehousing of the nonfunctional in hopes that, over time, they will eventually rehabilitate and rejoin society.
The stay-at-home mother, subsidized through the family wage, is central to this vision. Wives and mothers have sustained Japanese social welfare, caring for the elderly, managing their children’s education and contributing to community maintenance (Brinton 1993; Lock 1993a:83–106; Long 1996:165–169; White 1988). The presence of middle-class women at home in relatively larger numbers than in many other industrialized nations, and the notion of the home as a sphere of social support, has created the very conditions for the phenomenon of hikikomori—making it possible for poorly functioning youths to retreat into the home and continue to be fed and cared for. Children’s prolonged dependence on the family has also been unquestioned, and to this day, many youths remain at home until they get married, and then even still continue to rely heavily on family financial and other support. The line between childhood and adulthood, or between dependence and independence, is not clearly drawn, and parents feel responsibility for their children’s behavior often even into adulthood (Borovoy 2005:150–160; Saitō 2003:47).23
Women’s labor extends well beyond the home. The system that treats children similarly and standardizes care and education depends in part on the labor of families (mothers) to make it work. In addition to student aids (kaijoin) of the kind who assisted T-kun in kindergarten, mothers themselves are sometimes asked to step in, and I have heard of instances in which retarded or severely disabled children are accompanied by their mothers throughout the day, or for substantial portions of it, while functioning in a normal classroom. The mother of a junior-high-school student diagnosed with Asperger’s syndrome reported that when her son was an elementary-school student, she had been requested to travel incognito with his class on an overnight trip, staying at a nearby hotel in case the teachers needed her.
The expectation that the family will care for its own disabled or dysfunctional children is accompanied by a relatively high number of inpatient psychiatric beds compared with that in other industrialized nations (Vickery 2007:9–10). While at first glance the two seem incompatible, some have discerned a pattern in which families cope as best they can with the problem in the context of a dearth of outpatient counseling and consulting services, until, finally, they must (sometimes forcibly) commit their family member to an institution (Kawanishi 2006:25–27; Munakata 1986:371–372).24 On the process through which a family comes to terms with the reality of a child’s mental illness, Kawanishi (2006) writes, “Usually, out of shame, the family tries to hide this domestic situation and refuses intervention from the outside until the point when it becomes uncontrollable” (25). Both coping at home and, ultimately, committing an individual to inpatient care fall into the category of “custodial care,” what Vickery (2007:11) aptly describes as the dominant form of care for the mentally ill in Japan still today.
The case of Tamura-san helps illustrate the way in which the home serves as a repository for those who cannot assimilate to mainstream society. The question of whether remaining at home in such cases is a salvation or a condemnation to a cloistered life in a society that copes inadequately with social difference is the question I explore here.
Tamura-san was a vivacious woman in her early thirties who participated in a weekly support group, run by a large, private, well-respected hospital. Of the members of the group, she was the most lively and outspoken. She was from an upper-middle-class family; her father owned a large paper products company, and her mother could afford to stay at home. Tamura-san suffered from epilepsy as a child and experienced mild developmental delays that grew more severe. She attended the local public elementary school, but when it came time to move on to middle school, where children get less individualized attention, she was transferred to a private junior high school that seemed more flexible than the public ones. Her family ensured her admission by making a substantial donation to the school; her mother joined the PTA. Tamura-san was good at memorization, so she did well in some subjects, though poorly in math, science and writing. She barely graduated from junior high, and eventually it became clear, and was accepted by the family, that Tamura-san was mildly retarded.
Nonetheless, her parents persisted in mainstreaming her, building her credentials as best they could given their daughter’s limitations. After graduating from high school, she attended an English school run by the YWCA, something within her range that would also enhance her pedigree in the absence of a college degree. (The school largely catered to young women hoping to enhance their credentials for marriage: in Japan, known as “bride-training” [hana yome shūgyō].) After her training, Tamura-san’s parents declined to register her as disabled through the state and to receive financial assistance on her behalf. In doing so, they discouraged her from participating in a network of centers sponsored by the government for those with physical and mental disabilities (fukushi sagyōsho), where members work according to their ability, making hand towels or other small items, cooking, sharing sociality and earning a small but symbolic wage. If she had been registered as disabled, Tamura-san might also have gained a measure of independence by doing such work, or even working for a larger company (Japanese companies are subsidized and legally obligated to hire a certain number of disabled people). Instead, Tamura-san’s parents preferred to continue caring for their daughter at home, preventing her from acquiring skills toward independence and making friends or getting married. Despite the fact that Tamura-san’s disability does not prohibit work or social engagement, today Tamura-san lives in relative isolation at home, does volunteer work and commutes to the hospital for her weekly group.
Normalizing, Coping and Defining the Manageable
The definition of a vast range of problems as being within the spectrum of “the normal,” along with the notion of the home as the bedrock of social care, leads to the sense among parents that children’s problems, no matter how disruptive or demanding, should be “manageable” within the home, given enough time, patience and endurance. In this context, “coping” expands to include a range of social care that is beyond what is commonly associated with the home in many industrial societies. The stories of parents who have coped with mental illness in the family are filled with the experiences that betray the exhaustion associated with this blurred line between healthy and ill, manageable and unmanageable, normal and abnormal (Kawanishi 2006).
In a three-hour-long support group I attended for parents of children who are school-refusers, run by a grassroots group that is known and respected by public clinics, there was a consistent emphasis on “hearing the child’s voice” (kodomo no koe o kiku), “accepting” the child who will not attend school (futōkō no kodomo o mitomeru), allowing them to rest (yasumi o mitomeru) and letting them take steps at their own initiative to return to school. The discussion affirmed the value of the home as a source of support and stability. A father attending the group reported that the family had felt reassured by a doctor’s advice that “a child will always get better with a parent’s good care” (oya no sesshikata ni yotte kanarazu ii hōkō ni iku). Discussion at the meeting focused heavily on allowing time for a child to heal slowly and improving daily rhythms and life habits. At one point in the conversation, one of the facilitators responded to a father’s story about taking his daughter to a “specialist” (senmonka) by saying that problems were most often resolved through “close, trusting relationships” (ningen tai ningen no shinrai kankei). As the parents talked about their experiences consulting various specialists, one woman, a long-standing member of the group, said, “What is a specialist? If a parent can’t help a child, then how can a specialist?… The starting point of our treatment should be to make the child more comfortable” (Kodomo jishin ga raku ni naru no ga shuppatsuten). Although the advice echoed the beliefs of the founders of this grassroots group, rooted in a critique of the school system, their ideas were sustained by the deeply rooted assumption that no sacrifice can be too great to help a child.25
There is always a cause for children’s violence. Instead of asking yourself, “How shall I respond?” try asking, “What is the matter?” My son once destroyed the inside of the house in a fit of violence, and I think that happened because I didn’t understand him as a parent. If you really understand your son, he will not behave violently (zettai abarenai). The problem is one of parent–child relations.
The woman who had originally asked about the violence of her son replied, dejectedly, but a bit tartly, “So I’m supposed to be quiet and just get beaten (damatte butareru)?” A brief discussion ensued about whether the child should be seen by a doctor and medicated, but many felt that such a way of interpreting the problem was mistaken.
Although such counsel does not reflect most clinical interpretations of domestic violence, the advice is fully compatible with what is commonly expected from mothers: to smooth over problems and nurture troubled family members, to be the central resource for social issues in a context that resists viewing children’s problems as deeper medical or psychological problems. It is the sphere of the family, particularly the mother, as the endless provider, which allows youths who have ceased to function in the broader world of education or employment to hide in the home and to stay there, endlessly—an outcome that is more secure and, perhaps, more socially acceptable than seeking professional help or living one’s life with a diagnostic label, but that ultimately leads to confinement to the safe parameters of one’s own room.
How should we understand Japan and its hidden? Japan makes a striking contrast with the United States, where diagnoses of learning and emotional disabilities and disorders proliferate—with some public schools in wealthier areas “classifying” 10–15% of their student bodies as having special curricular needs. At the same time many in American public schools remain vastly undereducated, with marked rates of illiteracy. In contrast, the Japanese public education system educates the vast majority of its youths similarly while, at the same time, often allowing special needs to go unseen or unmet.
The foundations of Japanese democracy have made it possible for the Japanese to function remarkably well with minimal outpatient mental health care, without early school tracking, without aggressive labeling and diagnosis of learning disabilities and without cosmetic psychopharmacology. The sanctuaries of space created as “holding areas” in Japan (step classrooms, prolonged sick leave, the home) allow youths to withdraw but also to stay afloat without being subjected to proactive psychiatric treatment or the aggressive application of diagnostic labels. One social worker remarked to me that the impulse to “hide away” (hikkomu) when something is wrong is itself an entirely healthy and natural impulse in survival.27 Such views may be associated with the system of corporate welfare that shaped a significant portion of middle-class society in the high-growth era, and the accepted reliance on family and national health care as spheres that fill in for the welfare state. From this perspective, Zielenziger’s assertion that, in a freer society (like ours), the hikikomori victims would be creating software startups is surely romantic. Perhaps they would simply be medicated with antidepressants, or the stimulants commonly used to help children “focus,” Ritalin and Adderall, and returned to their studies. Too often in the United States, in the absence of a mother at home and a time and place to rest or rehabilitate, individuals too quickly embrace the identity of the patient and rely on outpatient mental health care and medications for the long-term management of life’s endemic struggles.28
In a recent book analyzing the dramatically rising rates of diagnoses of ADD-ADHD and the prescription of Ritalin among children in the United States, Lawrence Diller (1998) asks whether some part of the problem may be that we are simply asking too much of our children. Behavior that is commonly associated with a chemical imbalance, argues Diller, may in part be the product of a “living imbalance”: greater numbers of women working full-time, greater social mobility, leading to less support from extended family, and rising academic pressures on children from an early age—all are part of the declining capacity on the part of well-intentioned parents to provide the kind of time and patience needed to gradually discipline and work with children, particularly those who need special attention (Diller 1998:75–82, 97–100).
Japan is not alone in its emphasis on the importance of family as a “buffer” for modern social life and a sphere of caring for mental health, and in some contexts this discussion has explicitly taken the form of a critique of the West (see, e.g., Cohen’s discussion of Alzheimer’s in India [1998:87–106]). In an early discussion of the Japanese cultural attitudes toward mental health care that still carries resonance, Munakata (1986) notes that the family in the American context does not function highly as a sphere of care for the mentally ill. When a patient is discharged from a mental hospital, he or she is too frequently thrown on inadequate and poorly supported community facilities, in which there is the great potential for recidivism or vulnerability to abuse. At the same time, Munakata notes, the family in the Japanese context has been overly protective of Japanese patients, and families have not fully come to terms with the nature of mental illness or the limits of custodial care (377–378). “Consequently, whether at home or in hospital, [Japanese] mental patients have been overprotected and deprived of their freedom as individuals” (278). The goal of care, suggests Munakata, should be to neither abandon responsibility for the sick in communities and families nor to take it on naively, in the absence of medical knowledge. Communities should offer better visiting services, consultations and education to support families so that they can offer a modicum of care (without abandoning their members to inpatient facilities) but do not have to shoulder the burden entirely alone.
Approaches to mental illness are changing in Japan as SSRIs such as Paxil and Luvox have gradually made their way into the Japanese market, although the figures are still well behind American rates.29 Vickery (2007:18) notes that, since the late 1980s, the “psychiatric purview has indeed expanded” to include a small but growing interest in psychodynamic approaches among psychiatrists and other clinicians, and a much expanded public interest and vocabulary for psychiatric disorder, in the context of a growing public discussion of the “backwardness” of Japanese mental health care and a recent push by pharmaceutical companies to lighten the image of depression through marketing (18).30 Psychopathology such as depression is seen as being increasingly mainstream, within the bounds of “the normal” and treatable. Luvox (Depromel in Japan), the first SSRI to be available in Japan (approved in 1999), was marketed in collaboration with Fujisawa Pharmaceutical as a treatment for “a cold of the heart” (kokoro no kaze), avoiding the stigmatized phrase “depression” and analogizing depression to a common complaint—physiological (not mental) and entirely remediable (Applbaum 2006:100–101; Landers 2002; Schulz 2004).31
Perhaps the increasing use of these pharmaceuticals will begin shifting the perceptions of illness itself. But the question of how psychiatrists and patients understand illness and experience in relation to these drugs is quite complicated, and remains embedded in its social context (Luhrmann 1999:204–212; Martin 2007:197–202, 216–220).32 There is evidence to suggest that the resistance to biologizing mental issues is still pervasive. Junko Kitanaka (2006) has shown how the entry of SSRIs into the pharmaceutical market and the accompanying campaigns that integrate depression into daily discourse have created an ethical conflict for Japanese psychiatrists. The normalization of depression has produced concerns about overdiagnosis among psychiatrists and has pressured some psychiatrists to make ever-careful distinctions between the “biological” and the “psychological,” the consequences of individual biological vulnerability versus a stress-inducing social environment (Kitanaka 2006:23, 132, 2007). Such concerns would seem to be motivated by broader social and cultural questions concerning what constitutes a healthy society, and the strong emphasis on inclusion, equality and shared values through socialization, associated with democracy in postwar Japan.
The greater use of SSRIs need not replicate the U.S. pattern, in which illnesses become reified through their response to pharmaceuticals. In some cases, as Vickery and Kitanaka have noted, the label of depression seems to be serving as an entry point into broader conversations concerning unhealthy social demands (as in the case of “death from overwork” syndrome, or karōshi) or individual psychodynamic issues—what Vickery calls the “psychologization” of human problems (see also Breslau 2000, 2004; Kitanaka 2007; Vickery 2006:28, 2007).33 In other words, the increasing medicalization of discontent in Japan is being accompanied by something different from mere pharmaceuticalization; medicalization in Japan may prove to be an effective instrument through which to generate public discourse on social and psychological problems, in a context in which such discourse finds few other venues.
Already, left-leaning think tanks on education in Japan are identifying the potential for overdiagnosis in the Ministry of Education’s recent initiatives to diagnose more children and provide more extensive services for those with learning disabilities and developmental delays. A pamphlet entitled “Children’s Brains Are Being Targeted” (Kodomo no Nō ga Nerawarete Iru), published by the National Education Research Center (Kokumin Kyōiku Bunka Sōgō Kenkyūjo),34 offers reflections on new directions in special education in the form of a dialogue among a psychiatrist, a psychologist, and a special education teacher. Three specialists acknowledge that increased awareness of delays and disabilities is important, since a child with an unidentified problem is likely to be mischaracterized as “antisocial” (hanshakai teki) (2006:19). However, the authors worry that labels such as ADHD are ambiguous and situationally defined. Once parents begin to embrace labels such as ADHD, the authors argue, they ask fewer questions about “cause” and are less conscious of their own responsibility for their child’s behavior; instead, the increasingly ability of parents to declare, “My child has ADHD” (uchi no ko wa ‘ADHD’ janai deshō ka), allows them to simply accept their child as he or she is (sono mama ukeirerareru) (Ishikawa et al. 2004:46). The authors also worry that the act of separating children by ability (nōryoku shugi) allows children who are doing well (dekiru ko) to do even better, but that it is a minus for those who are falling behind (32, 39).
The emphasis on conformity and Confucian harmony, at the expense of attention to individual needs, has been a key theme in explorations of Japanese notions of illness. And yet now, through the reflecting glass of recent developments in American psychiatry and the heavy penetration of the pharmaceutical industry, one can appreciate the more humane dimensions of a society that has historically provided the resources for building an inclusive middle class. American institutions pay little attention to cultivating the mainstream and instead increasingly manage difference through aggressive diagnosis, individual educational plans and high rates of prescriptions of stimulants and psychopharmaceuticals for youths under age 20. The ability of the Japanese system to care for the many, if not the few, continues to offer grounds for reflection in our current times and suggests the potential inhumanity of both of these extremes.
At the dining hall of a Tokyo youth support center, a live-in facility for hikikomori youth, I witnessed a teen rinse each bowl and dish with carefully measured amounts of boiled water, before placing his food in the bowls.
Saitō’s (2004) informational book on hikikomori, published with Japan Broadcasting (NHK), takes the question-and-answer format and explores a number of case studies. Most of the cases are young adults who withdraw owing to some setback, the death of a parent or failure in school, rather than chronic emotional or adjustment problems.
The notion of “social hikikomori” has been widely taken up, and Saitō himself disproportionately emphasizes this aspect of normality in his writings. However, many psychiatrists, public health-care workers, school counselors and others simultaneously recognize that some cases of hikikomori involve psychopathology.
Five and six-tenths percent of the total population experienced a severe or moderate disorder in the past 12 months; 2.4% of the total population experienced a severe or moderate form of major depression in the previous 12 months.
The rate of help-seeking is lower at both ends of the spectrum of educational attainment. Those who have not achieved a high-school education may lack awareness or resources to seek help. Those who are highly educated may experience a sense of social stigma or pressure to conceal their problem.
The four survey sites for this study were in Western Japan. None contained a metropolitan city with a population greater than one million. It is possible that a more densely urban center would show higher rates of incidence of self-reported mental illness and more frequent help-seeking.
Among those reporting mood disorders, 25.1% use mental health care of any kind (psychiatrists, nonpsychiatrists, others); 10.2% seek help from general medical practitioners. The comparable rates in the U.S. are 55.5% seeking help from mental health professionals and 47.5% seeking help from general medical practitioner (Naganuma et al. 2007:246). The latter number does not necessarily suggest a lack of awareness of mental health problems but, rather, the way in which internists and primary care physicians, targeted by advertising and awareness campaigns directed at them by pharmaceutical companies, have increasingly encroached on the terrain of psychiatrists by prescribing psychopharmaceuticals.
In his ethnography of aging and the place of the elderly in society, John Traphagan writes that the common perception of senility (“boke,” a Japanese term describing the social remoteness of the elderly, loosely translated as “senility”) “has the potential to be controlled through activity” and that “self-building and effort are fundamental to being a good person…. Indeed, the idea that one may have at least some degree of control over the onset and progression of boke implies both a degree of hope that one can remain a viable social entity and the idea that one should focus one’s attention and effort on doing whatever one can to ensure that this happens” (Traphagan 2003:66).
Susan O. Long (2000:17–21) discusses how common expressions of reconciliation (shikata ga nai, or “it can’t be helped”) allow patients at the end of life to make distinctions between that which they can (and should) control and that which they are comfortable letting go of.
In another essay, Lock (1993b:29) writes that, in contrast with the psychoanalytic paradigm in which the patient aspires to construct his or her own consciousness free of social pressures and constraints, the goal of mental health therapies in Japan more often tends to be reintegrative: “to help a person adjust to a given social situation, however intolerable it may appear.
Although young men purportedly count for the vast majority of hikikomori cases, this may be because their presence in the home is more likely to be pathologized than a young woman’s (because it is associated with a failure to earn a wage). In the support groups and facilities I have observed I have found a number of adult women who remain at home, often helping with basic household tasks, caring for aging grandparents or managing the budget. Many of them have escaped even the label of “hikikomori.”
One hears stories from foreigners who visit a Japanese home and find a socially retired figure quietly sitting in the back room or kitchen. Nothing is said, yet the family member has clearly ceased to function socially. Families may shelter the depressed, particularly women. It is not syntactically clear here whether the women are doing the sheltering or whether they are the depressed.
Lois Peak’s ethnography of social control at a Japanese daycare center shows how from the earliest stage of child socialization, the thrust of education is to minimize difference by continually encouraging students to reintegrate. Peak shows that teachers surround and smother rebellion not through discipline and punishment but, rather, through redirection, gentle cajoling and empathy. Peak (1989) writes that students who resist integration with the daily structure of the school find themselves “boxing with an army of friendly shadows.”
A range of curricula for all subjects is nationally prescribed, including suggested lesson plans. Although middle-class (and upper-class) children can buy extra education, which increases their chances of success, the crucial ideological premise undergirding the standardized exam system is the presumption of a level playing field. For most public-school students, school becomes hypercompetitive at the close of compulsory education, as students begin to prepare for high-school entrance exams. High schools vary radically in quality and ambition (see Rohlen 1983:11–42), and thus students are eventually sorted in ways that closely shape their future careers and class status.
Public-school students now take the Sanford-Binet Intelligence Scale at the time of entry into a school, but the test is considered very general, differentiating only those students who are markedly disabled or delayed. Results are not shared with parents, and parents have the right to refuse to submit their child to the test.
The importance of Peak’s point with respect to the question of special education was clarified for me in a paper by Colin Pfeiffer (2008).
Karen Nakamura’s (2006:7, 28–29, 88–89) discussion of deafness in Japan and the resistance to signing among prewar deaf citizens who felt it was marginalizing (and also the attempt to mimic verbal language in Japanese signing) is a fascinating exploration of the trade-offs of such mainstreaming of the disabled.
The Ministry of Education shows that elementary schools across Japan have a total of 311 special classrooms for children with language disabilities (classrooms where children spend the whole day). The number for middle schools is 27. For cognitive disabilities the number is 12,465 for elementary schools and 6131 for middle schools (Monbukagakushō 2006:41).
LeTendre reports, in a preliminary study of special education in Japan from the late 1980s, that he observed a special-education classroom that included one child with Down syndrome, one with epilepsy and another who appeared to be “extremely nervous and shy.” Several others seemed to have developmental delays that affected their language and learning abilities (LeTendre and Shimizu 1999:6).
Some scholars have noted that the system of early detection and referral is highly developed in Japan (LeTendre and Shimizu 1999; Peak 1989; Hendry 1986 [cited in LeTendre and Shimizu 1999:6]). And yet such detection, occurring in the early years of kindergarten and elementary school or before, through health-care services or childcare providers, is probably most effective in discovering major disabilities, including blindness, deafness, retardation and so forth. More subtle problems, such as autism spectrum disorders or learning disabilities, can cause major social maladjustment in a context in which everyone is expected to keep apace and to share closely woven social values. These more subtle problems, even when discovered by teachers or other care providers, are often met with the desire on the part of parents to continue with mainstream education and to refrain from treating the child any differently than others.
More intensive classrooms, still located in normal schools, exist for more intensive problems, such as retardation and severe chronic illnesses that affect the capacity to learn and function, as well as other disabilities. And in Tokyo six specialized schools, or yōgo gakkō, exist for severely retarded or disabled children, where the facilities are fantastic, teacher-student ratios are low and the teachers are highly trained.
The Ministry of Education has been working to reform its special education agenda, which it has now relabeled as “special encouragement” (tokubetsu shien). The Ministry is aware that children who need special education are often not getting it and appear to be attempting to accommodate the recognized need for special education with the social ideal of educating all children together. It now advocates that more children commute to these specialized classrooms and has prescribed internal structures and procedures for identifying troubled children. (Although few schools seem to have the resources or knowledge to closely abide by these prescriptions.) At the same time it mandates that all children who attend special schools for the disabled (yōgo gakkō) and those who commute to special schools must also have an affiliation with a regular classroom (tsūjō gakkyū), even if they only attend this classroom for sports day or special activities. The agenda seems conflicted, and the Ministry’s embrace of the contemporary American trend toward “inclusive” special education (meant, in the U.S. context, to redress the years of segregation in special education in American schools and overreliance on remedial and vocational forms of schooling for the mentally and physically disabled) is especially confusing, given that the flaw of Japanese education thus far has been “inclusion” to the point of denial and intolerance.
In a “step classroom” (suteppu gakkyū) that I observed in one elementary school, for school-refusal children, 2 h of attendance every day counts as a full day in a regular classroom.
The recently published memoir of a self-reflective day laborer in Tokyo, Ōyama Shirō, which won the Kaikō Takeshi prize for literature, occasionally offers the reader a hint as to how the author came to find himself in the position of living alone and working for an hourly wage in one of the few slums of Tokyo. It is a lifestyle that the author clearly indicates that he chose, after realizing that he would “never be able to survive in the world of ordinary adults … to go out into society and find a job, to marry a woman and raise a family….” In the conclusion of the book Ōyama (2005) mentions a cousin on his mother’s side with whom he felt close as a child (and who looked like him), who was institutionalized in his twenties and who remains confined. “I never made any direct inquiries but I can surmise that he was institutionalized for depression,” the author writes (112–113). Ōyama recalls that he looked like his cousin and identified with him as a boy. He chooses the shantytown of the day laborers as space where he can obtain a measure of stability, self-sufficiency and calm, avoiding middle-class social life and the potential of being diagnosed with a major mental disorder. To interpret Ōyama’s musings as conclusive evidence that it was depression that drove him from mainstream social life would be speculative; nor do we know whether other disenfranchised laborers share this trajectory (though Ōyama’s own story and others indicate a prevalence of alcoholism and gambling). Nonetheless, for Ōyama, the underworld of the day jobs and temporary housing quite clearly provided a haven in a society where few such alternatives exist—and the consequences for dropping out entirely can be grave.
Joao Biehl (2005) has talked about “zones of abandonment” in Brazil: spaces not on the map, in which residents appear to lack social identity—and yet spaces which speak powerfully to the social consequences of mainstream social structure (2–3). In Japan one might argue that “zones of abandonment” are not spheres of impoverishment or neglect but, rather, liminal spheres in which, for a variety of reasons, citizens who cannot accommodate the highly ordered, middle-class social life can retreat to be cared for, while at the same time sacrificing the opportunity to grow, transform and participate in society.
Opportunities for social-emotional affiliation with other human beings are still abundantly available in the family and, much more than in the past, elsewhere in Japanese society. It is noteworthy that psychiatry as private practice has almost no development in Japan, although psychiatrists are well represented in hospitals treating neurosis and psychosis and, as scientific representatives of modern medicine…. A large part of the roles of psychiatry as it operates in the U.S. is met in Japan by ties with one’s associates of daily life—family members, unrelated confidantes, co-members of the numerous social groups and the world of industry and commerce, and, for part of the nation, by membership in intimate subgroups of the new religious sects. (342)
Admissions to hospitals for “social reasons” (shakai-teki nyūin) is not uncommon—for example, admitting a patient who is dysfunctional from alcoholism, but does not fit within the medical framework of treatable disorders, or even admitting the family member of a dysfunctional or abusive individual. As such, hospitals often fill the void in care for amorphous psychological problems and needs. One close acquaintance, a middle-aged man who was depressed and had stopped working, grew disheveled and periodically abusive; his wife could no longer care for him. Under the care of a psychiatrist, he was admitted to a hospital for two months over the summer where there happened to be a bed—a hospital which specialized in care for the elderly. Clearly the intention of the stay was a manner of “rest cure”—a place to relax, to relieve the family and, perhaps, to self-reflect—but not a form of targeted psychiatric intervention.
In his study of hikikomori as a social problem, Saitō Tamaki points out that “independence” (jiritsu) is a considerably more complicated issue than simply severing social or economic dependence. For Japanese youths, historically, independence has begun with leaving the house to establish a separate residence but culminated in the care of aging parents (Saitō 2003:106, 109). Students do not typically leave home when they begin college, for example, at 18.
Munakata (1986:372) notes that previously, before public mental health care and welfare facilities came into existence, mental patients were often “left alone in a cold, dark room of the house or in a barn.”
For a thoughtful and wide-ranging discussion of the emphasis on family care as an antidote to modern society, see Lawrence Cohen’s (1998) No Aging in India, especially his section on “Gerontology as Cultural Critique” (103–106).
She had spoken earlier, warning a younger woman that working full-time could limit her emotional availability to her child (jibun no naka no yōyū ga dekite inai).
She remarked, “Just like when you hide in your house until a storm passes and it is safe to come out, I think that retreating (hikkomu) is a very natural and healthy thing to do.”
For an excellent discussion of how psychiatrists must wrestle with these kinds of decisions, and the epistemological stakes in relying on medicine over other forms of therapy, see Tanya Luhrmann’s Of Two Minds (1999), specifically, on medication (204–212, 234–238).
GlaxoSmithKline’s sales of Paxil in Japan almost tripled between 2001 and 2003, from $108 million in 2001 to $298 million in 2003 (Schulz 2004). In the United States the figure for 2001 (Paxil’s first year in Japan) was $1.8 billion (Landers 2002).
Vickery analyzes the popular television drama PsychoDoctor, its pedagogical approach to discussing mental illness and the treatment of mental illness as something even those in the mainstream (successful salarymen, housewives, etc.) may suffer from.
Applbaum’s (2006) analysis of global drug marketing and the making of biomedical universalism in marketing antidepressants in Japan focuses on the erasure of cultural particularities by shifting the emphasis from health-care providers to patients as consumers who should exercise “free choice” (100–101).
In contrast, the sales figure for 2001 in the United States, Paxil’s first year in Japan, was $1.8 billion (Landers 2002).
Breslau’s (2004) analysis of the expansion of the psychiatric diagnosis of posttraumatic stress disorder (PTSD) to wide-ranging areas that suffer from political upheaval or natural disaster is relevant to considering the future of depression in Japan. Breslau reveals the “extension of the range” of the kinds of problems that can fall into this category and the advocates for the category who accompany humanitarian interventions. He suggests that the role of the ethnographer is to continue to think through and beyond imposed categories, “to make sense of local expressive forms relating to historical traumas and individual biographies…” (123).
A private organization that reaches out to teachers and counselors.
Ideas in this article were presented at the annual meetings of the American Association of Anthropology on two panels, “Critical Therapeutics” (2006) and “The Social in the Individual: Approaches to Mental Illness, Suicide, and Suffering in Japan” (2007). The panels generated a good deal of exchange, and I would particularly like to thank the discussants for offering valuable comments: Tanya Luhrmann and Andrew Lakoff (2006) and Susan Long and John Traphagan (2007). The other members of the panels, Rebecca Lester, Joshua Breslau, Chikako Ozawa-de Silva, Ken Vickery, Junko Kitanaka and Karen Nakamura, have been—and continue to be—important interlocutors. I am indebted to colleagues and mentors in the mental health-care sector in Tokyo who facilitated my observation of support groups and counseling sessions and who shared their knowledge: Nishida Chikako, Fukazawa Satoko, Hayakawa Kazuko and Tamura Misao. Saitō Satoru has been an important mentor and interlocutor from the psychiatric standpoint. Noguchi Yūji provided valuable input from the perspective of medical sociology. Kathleen Pike and Emi Doi, both clinicians, offered valuable exchanges on the state of mental health care and the social construction of psychological issues in Japan. Research for this article was supported by an Abe Fellowship, funded by the Social Science Research Council, a Japan Foundation Short-Term Research Fellowship, and by the Princeton University Committee on Research in the Humanities and Social Sciences.