Abstract
In Japan, suicide has long been depicted as an act of free will, even aestheticized in the cultural notion suicide of resolve. Amid the record-high Japanese suicide rates since the 1990s, however, Japanese psychiatrists have been working to medicalize suicide and, in the process, confronting this deeply ingrained cultural notion. Drawing on two years of fieldwork at psychiatric institutions around Tokyo, I examine how psychiatrists try to persuade patients of the pathological nature of their suicidal intentions and how patients respond to such medicalization. I also explore psychiatrists’ ambivalent attitudes toward pathologizing suicide and how they limit their biomedical jurisdiction by treating only what they regard as biological anomaly, while carefully avoiding the psychological realm. One ironic consequence of this medicalization may be that psychiatrists are reinforcing the dichotomy between normal and pathological, “pure” and “trivial,” suicides, despite their clinical knowledge of the tenuousness of such distinctions and the ephemerality of human intentionality. Thus, while the medicalization of suicide is cultivating a conceptual space for Japanese to debate how to bring the suicidal back onto the side of life, it scarcely seems poised to supplant the cultural discourse on suicide that has elevated suicide to a moral act of self-determination.
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Notes
Japanese names are written in the order of family name followed by given name.
While the Japanese have recognized different degrees of intentionality in those who commit the act—from a reckless desire for escape from an unbearable reality to a fully premeditated act—suicide of resolve represents the ultimate expression of intentionality.
However, this idea is far from being shared beyond psychiatry. For example, the suicide statistics compiled by the Police Agency classify the reasons for suicide into the following categories: family problems, sickness, economic hardship, work-related problems, relationship problems, problems in school, alcoholism or mental disorder, other, and unclassifiable.
In one of the earliest ethnographies of medicalization, Arthur Kleinman (1986) has shown how the psychiatric discourse about “neurasthenia” gathered force in China at a particular historical moment, when people who had suffered under the Cultural Revolution began to turn to psychiatry as an emancipatory language for articulating their victimhood—even at the cost of pathologizing themselves. Atwood Gaines, who, has examined the “scientific” psychiatric discourse—best exemplified by the DSM-III—as a bundle of implicit cultural codes (Gaines 1992a), has also illustrated Christian psychiatrists’ struggles to reinterpret scientific doctrine in light of their religious beliefs (Gaines 1998). Investigating the rise of the PTSD discourse in North America, Allan Young (1995) has demonstrated how a new psychiatric regime of memory has evolved not only in scientific laboratories but also out of emotionally charged and politically contested everyday clinical encounters, where medical professionals and Vietnam War veterans confront moral questions over the nature of traumatic memory. Margaret Lock (1988) has illuminated the ways in which Japanese psychiatry has gained a public platform by virtue of being implicated is national debates about socially withdrawn children. Lock has also shown how the “socially” oriented nature of psychiatric discourse in Japan is not necessarily liberating but can be moralizing and hegemonic in the way that it overdetermines the meaning of people’s suffering (also see, Gaines 1992 b, Borovoy 2005; Lock 1986, 1987, 1991; Ozawa-de Shilva 2006).
The department was headed by Professor Higashi, a psychopathologist, who is also the grandson of a pioneering social psychiatrist. He helped create a congenial balance between its smaller, American-trained biologically oriented staff and the more dominant, European-trained psychopathologists, which contributes to an intellectually vibrant atmosphere in the department. (Psychopathology became popular in Japan in part as a response to the American brand of psychoanalysis in the 1950s, when Japanese psychiatrists turned to the existential perspectives within German psychiatry in order to develop descriptive, phenomenological, investigation into the “lifeworld of the psychotics.”) Though the psychiatrists at JP now use the DSM-IV and ICD-10 alongside more conventional nosology, the psychopathologists continue to maintain a skeptical attitude toward American psychiatry in general and occasionally critique it when articulating their own clinical perspectives. This mixture of different psychiatric cultures is reflected in the wide range of interests discussed at the weekly departmental seminars. While I was doing fieldwork, the presentations included, for instance, a lab report on serotonin syndrome by a neurobiologist, a linguistic analysis of schizophrenic delusion with a reference to Wittgenstein, and an exploration of anorexic narratives in light of the philosophy of Simone Weil. However, their apparent interest in the meanings of mental illness seems curiously confined to behind-the-scenes, intellectual discussion. In their daily clinical practices, the psychiatrists at JP emphasize a straightforward pragmatic, biological approach, which seems to differ little from those at the few other, more biologically oriented psychiatric institutions in Japan where I had done observational research. In fact, this initially struck me as one of the main features of their medicalizing suicide—that is, their emphasis on biological persuasion and their caution with psychological exploration.
Common suicide methods are by overdose, cutting the wrists, cutting the throat, evisceration, and jumping from a building, etc., as well as hanging, poison, and drowning.
Information on how to kill oneself is disseminated through Web sites on suicide, which have been mushrooming of late, and best sellers such as Kanzen jisatsu manyuaru [The Complete Manual of Suicide] (Wataru Tsurumi, 1993, Yurindo Publishing, Yokohama), which has sold more than 1,500,000 copies.
As the economic recession has dragged on, many men have taken their own lives for the sake of leaving the life insurance money for their families. This has become a social problem.
For instance, Dr. Satô cited a passage from a novel by Dazai Osamu (1936): “I was thinking about killing myself. But somebody gave me a New Year present of a piece of material for a kimono. It’s linen, with fine grey stripes. For a summer kimono. I told myself that I might just as well go on living until summertime” (also cited in Pinguet 1993, p. 267).
Translated from the Japanese translation of Feudell’s text cited by Inamura (1977, p. 61).
Though their own idea about what counts as a “true” and “pure” suicide of resolve is not a biomedical category in any sense but is, instead, a product of their cultural assumptions about what is an honorable, meaningful way to die (cf. Lock 2002).
Translated from the Japanese translation of Binswanger’s Schizophrenie.
For instance, psychiatrists are increasingly requested to consult with other medical units, to help determine to what extent a terminally ill patient’s wish to discontinue a certain treatment is a product of free will rather than an underlying depression.
Note that Japanese psychiatrists are granted the legal power to confine those who are deemed a danger to others and to themselves. While psychiatrists do not hesitate to forcefully institutionalize the first group, in the case of the latter, they can be highly indecisive about taking the same measure if being a danger to oneself means being (simply) suicidal.
References
Althusser, Louis 1971 Essays on Ideology. London and New York: Verso.
Atkinson, Paul 1995 Medical Talk and Medical Work. London: Sage.
Bakhtin, M. M., and Michael Holquist 1981 The Dialogic Imagination: Four Essays. Austin: University of Texas Press.
Barrett, Robert J. 1996 The Psychiatric Team and the Social Definition of Schizophrenia: An Anthropological Study of Person and Illness. Cambridge, UK: Cambridge University Press.
Borovoy, Amy 2005 The Too-Good Wife: Alcohol, Codependency, and the Politics of Nurturance in Postwar Japan. Berkeley: University of California Press.
Cohen, Lawrence 1998 No Aging in India: Alzheimer’s, the Bad Family, and Other Modern Things. Berkeley: University of California Press.
Corin, Ellen 1998 The Thickness of Being: Intentional Worlds, Strategies of Identity and Experience among Schizophrenics. Psychiatry 61(2):133–146.
Corin, Ellen, and Gilles Lauzon 1992 Positive Withdrawal and the Quest for Meaning: The Reconstruction of Experience among Schizophrenia. Psychiatry 55(3):266–278.
Estroff, Sue E. 1981 Making It Crazy: An Ethnography of Psychiatric Clients in an American Community. Berkeley: University of California Press.
Estroff, Sue E. 1993 Identity, Disability, and Schizophrenia: the Problem of Chronicity. In Knowledge, Power and Practice. Shirley Lindenbaum and Margaret Lock, eds. Berkeley: University of California Press.
Foucault, Michel 1973 Madness and Civilization: A History of Insanity in the Age of Reason. New York: Vintage.
Fukuoka Chihô Saibansho [Fukuoka District Court] 1982 Songai Baishô Seikyû Jiken [Appeal for Compensation for Damage] 27405686.
Gaines, Atwood D., ed. 1992a From DSM I to III-R; Voices of Self, Mastery and the Other: A Cultural Constructivist Reading of U.S. Psychiatric Classification. Social Science and Medicine 35(1): 3–24.
Gaines, Atwood D., ed. 1992b Ethnopsychiatry: The Cultural Construction of Professional and Folk Psychiatries. Albany: State University of New York Press.
Gaines, Atwood D., ed. 1998 Religion and Culture in Psychiatry: Christian and Secular Psychiatric Theory and Practice in the United States. In Handbook of Religion and Mental Health. H. G. Koenig, ed., pp. 291–320. New York: Academic Press.
Gates, Barbara T. 1988 Victorian Suicide: Mad Crimes and Sad Histories. Princeton, NJ: Princeton University Press.
Goldstein, Jan 1987 Console and Classify: The French Psychiatric Profession in the Nineteenth Century. Cambridge, UK: Cambridge University Press.
Good, Byron J. 1994 Medicine, Rationality, and Experience: An Anthropological Perspective. Cambridge, UK: Cambridge University Press.
Hendin, H., A. Lipschitz, J. T. Maltsberger, A. P. Haas, and S. Wynecoop 2000 Therapists’ Reactions to Patients’ Suicides. American Journal of Psychiatry 157(12):2022–2027.
Igarashi, Yoshio, and Kazuhiko Ishii 2000 Seishinka Byôin Deno Jisatsu no Jittai [Suicide in Psychiatric Hospitals]. Igaku no Ayumi [Journal of Clinical and Experimental Medicine] 194(6):529–533.
Inamura, Hiroshi 1977 Jisatsugaku: Sono Chiryô to Yobô no Tameni [Suicidology: Treatment and Prevention]. Tokyo: Tokyo Daigaku Shuppan.
Ishikawa, Kiyoshi 1962 Seishin Byôrigaku no Shotaikei to Ryôkai Seishin Byôrigaku Teki Hôhô [The Systems of Psychopathologies and “Versthehens”—Psychopathological Approach]. Seishin Shinkeigaku Zasshi [Journal of Psychiatry and Neurology] 64:953.
Katô, Masaaki 1953 Kattô Hannô to Shite no Jisatsu no Kisei ni Tsuite [The Mechanism of Suicide as a Response to a Conflict]. Seishin Shinkeigaku Zasshi [Journal of Psychiatry and Neurology] 55(4).
Katô, Masaaki 1976 Shakai to Seishin Byôri [Society and Psychopathology]. Tokyo: Kôbundô.
Kayama, Rika 1999 Atogaki [Afterward]. In Jisatsu [Suicide]. Yu Miri, ed. Tokyo: Bungeishunju.
Kirmayer, Laurence 1994 Improvisation and Authority in Illness Meaning. Culture, Medicine and Psychiatry 18(2):183–214.
Kirmayer, Laurence 2000 Broken Narratives: Clinical Encounters and the Poetics of Illness Experience. In Narrative and the Cultural Construction of Illness and Healing. Cheryl Mattingly and Linda C. Garro, eds. Berkeley: University of California Press.
Kitanaka, Junko 2008 Questioning the Suicide of Resolve: Disputes Regarding ‘Overwork Suicide’ in 20th Century Japan. In A History of Suicide in the Modern World: International Perspectives. John Weaver and David Wright, eds. Toronto: University of Toronto Press.
Kleinman, Arthur 1986 Social Origins of Distress and Disease: Depression, Neurasthenia, and Pain in Modern China. New Haven, CT: Yale University Press.
Kleinman, Arthur 1995 Writing at the Margin: Discourse between Anthropology and Medicine. Berkeley: University of California Press.
Kleinman, Arthur, Veena Das, and Margaret Lock, eds. 1997 Social Suffering. Berkeley: University of California Press.
Kure, Shûzô 1900 Seishin Byôsha no Jisatsu oyobi Jisatu no Kishin [Suicide and Attempted Suicide among the Mentally Ill]. Chûgai Iji Shinpô 20.
Lifton, Robert J. 1979 The Broken Connection: On Death and the Continuity of Life. New York: Simon and Schuster.
Lock, Margaret 1980 East Asian Medicine in Urban Japan. Berkeley: University of California Press.
Lock, Margaret 1982 Popular Conceptions of Mental Health in Japan. In Cultural Conceptions of Mental Health and Therapy. A. J. Marsella and G. M. White, eds. Boston, Dordrecht: D. Reidel.
Lock, Margaret 1986 Plea for Acceptance: School Refusal Syndrome in Japan. Social Sciences and Medicine 23(2):99–112.
Lock, Margaret 1987 Protests of a Good Wife and Wise Mother: the Medicalization of Distress in Japan. In Health, Illness, and Medical Care in Japan. E. Norbeck and M. Lock, eds. Honolulu: University of Hawaii Press.
Lock, Margaret 1988 A Nation at Risk: Interpretations of School Refusal in Japan. In Biomedicine Examined. Margaret Lock and Deborah R. Gordon, eds. Boston, Dordrecht: Kluwer Academic.
Lock, Margaret 1991 Flawed Jewels and National Dis/order: Narratives on Adolescent Dissent in Japan. Journal of Psychohistory 18(4):509–531.
Lock, Margaret 1993 Encounters with Aging: Mythologies of Menopause in Japan and North America. Berkeley: University of California Press.
Lock, Margaret 2002 Twice Dead: Organ Transplants and the Reinvention of Death. Berkeley: University of California Press.
Lock, Margaret, and Deborah Gordon, eds. 1988 Biomedicine Examined. Boston, Dordrecht: Kluwer Academic.
MacDonald, Michael, and Terence R. Murphy 1990 Sleepless Souls: Suicide in Early Modern England. Oxford; New York: Oxford University Press.
Marsella, Anthony 1980 Depressive Experience and Disorder Across Cultures. In Handbook of Cross-Cultural Psychology. Vol. 6. Psychopathology. J. Draguns and H. Triandis, eds., pp. 237–289. New York: Allyn & Bacon.
Miyake, Shû 1903 Seishinbyôsha ni Taisuru Kokka no Senmu [The Nation’s Tasks with Regard to the Mentally Ill]. Taiyô 9.
Nishizono, Masahisa 1986 Seishin Ryôhô [Psychotherapy]. Seishiknka Mook [Psychiatry] 13:189–198.
Ôhara, Kenshirô, ed. 1975 Jisatsu to Bunka [Suicide and Culture]. Tokyo: Shihôdô.
Ohnuki-Tierney, Emiko 1984 Health and Illness in Contemporary Japan. Cambridge, UK: Cambridge University Press.
Okada, Yasuo 1989 Seishinka Kanja no Jisatsu Jiken: I no Tachiba kara [Suicide Cases of Mentally Ill Patients: From a Medical Point of View]. Jurist Bessatsu: Iryô Kago Hanrei 100 Sen [Jurist Supplement: 100 Cases of Medical Malpractice]: 90–91.
Okajima, Yoshirô 2005 Shi o Nozomu Kanja ni Seishinkai wa Nani ga Dekiruka? [What Can Psychiatrists Do for Patients Who Want to Die?] Seishin Shinkeigaku Zasshi [Psychiatria et Neurologia Japonica] 107(9):936–946.
Osborne, Thomas 1994 Power and Persons: On Ethical Stylisation and Person-Centered Medicine. Sociology of Health and Illness 16(4):515–535.
Ozawa-de Shilva, Chikako 2002 Beyond the Body/Mind? Japanese Contemporary Thinkers on Alternative Sociologies of the Body. Body and Society 8(2):21–38.
Ozawa-de Shilva, Chikako 2006 Psychotherapy and Religion in Japan. London: Routledge.
Pinguet, Maurice 1993 Voluntary Death in Japan. Rosemary Morris, trans. Cambridge, UK: Polity Press.
Sakurai, Hirono, Kunihiko Tsutsumi, Yuko Tomita, and Mitsukuni Murasaki 1998 Sanji Kyûkyû Senta ni Hansô Sareta Seishinka Tsûinchû no Jisatsu Kito Kanja no Haikei [Research into Suicide Attempters Under Psychiatric Treatment at a Critical and Emergency Center]. Rinshô Seishinigaku [Japanese Journal of Clinical Psychiatry] 27(11):1363–1370.
Saris, A. Jamie 1995 Telling Stories: Life Histories, Illness Narratives, and Institutional Landscapes. Culture, Medicine and Psychiatry 19:39–72.
Suzuki, Hiroko 2000 Daigaku Byôin Seishinka no Jikangai Shinryô ni Okeru Jisatsukitosha no Jittai [The Realities of Attempted Suicides in a University Hospital’s Emergency Unit]. Igaku no Ayumi [Journal of Clinical and Experimental Medicine] 194(6):541–544.
Takahashi, Takao 2003 Anrakushi ni Tsuite: Nihonteki Seishikan Kara Toinaosu [On Euthanesia: Reexamining It in Light of Japanese Views on Death and Life]. In Yoki Shi no Sahô [Manners of Good Death]. Takao Takahashi and Hiroaki Taguchi, eds. Fukuoka: Syûshû Daigaku Shuppan.
Takahashi, Yoshitomo 1994 Jisatsu Keikô [Suicidal Tendencies]. Rinshô Seishin Igaku [Journal of Clinical Psychiatry] 23(1):55–63.
Takemura, Kenji, and Hiroshi Shimura 1977 Kaihô Ryôhô no Jissen no Moto De Okita Jisatsu no Keiken [Experience of Suicide Cases That Occurred Under the Open-Ward Therapy]. In Seishin Byôin ni Okeru Jisatsu [Suicides in Mental Hospitals]. Seishin Byôin Kyôkai [Association of Mental Hospitals]. Tokyo: Makino Shuppan.
Takemura, Kenji, and Hiroshi Shimura 1987 Jisatsu no Sain [Signs of Suicide]. Osaka: Shinryô Shinsha.
Taussig, Michael 1980 Reification and the Consciousness of the Patient. Social Science and Medicine 14B:3–13.
Young, Allan 1982a The Anthropologies of Illness and Sickness. Annual Review of Anthropology 11:257–285.
Young, Allan 1982b Rational Men and the Explanatory Model Approach. Culture, Medicine and Psychiatry 6:21–34.
Young, Allan 1995 The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press.
Acknowledgments
I would like to thank Professors Margaret Lock, Allan Young, Ellen Corin, Laurence Kirmayer, Kato Satoshi, Takahashi Yoshitomo, Eguchi Shigeyuki, Kobayashi Kayo, and Suzuki Akihito for their inspiring comments on earlier versions of this paper. Special thanks go to Chris Oliver and Dominique Béhague for wonderful dialogues over the years and for their many insights into my work. The dissertation research on which this paper is based was generously funded by McGill University, the Wenner-Gren Foundation for Anthropological Research (Grant 6682), and the Japan Foundation.
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Appendix: On Ethical Considerations
Appendix: On Ethical Considerations
After obtaining formal ethical approval for my doctoral dissertation research (on which this paper is based) from McGill University, I also presented my research plan and obtained official approvals for my research from the ethics committee of the university hospital where I conducted most of my fieldwork. To all patients I formally interviewed, I first explained the aim of my research, the measures I was to take in order to protect their privacy, the form of publication it would result in and that they had the right to withdraw their participation any time they wished. Only then did I obtain their written informed consent. Patients’ health and well-being are always a concern that must be given top priority, thus I avoided seeking any interviews with people who were under severe distress, and consulted closely with psychiatrists before asking any patient for an interview. Any information that might reveal patients’ identities (including their names and, sometimes, their occupations) has been changed to protect their privacy. In addition, all the psychiatrists who appear in this paper are given pseudonyms.
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Kitanaka, J. Diagnosing Suicides of Resolve: Psychiatric Practice in Contemporary Japan. Cult Med Psychiatry 32, 152–176 (2008). https://doi.org/10.1007/s11013-008-9087-1
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DOI: https://doi.org/10.1007/s11013-008-9087-1