If you’ve been reading my pieces up until now, you’ll probably notice that I like to weave concepts of psychology into the understanding of Japanese society.
I do this for a number of reasons. One is because I’m fascinated by psychology as much as Japan; two, what better way to understand human behavior than gaining insight through the social sciences; and, three, Japan (like many countries) is in the midst of a mental health crisis.
Understanding Japan from the perspective of the social sciences is nothing novel, of course. Prior to coming to Japan, one of the first books I read was the late Takeo Doi’s “Anatomy of Dependence,” a study of “amae” – which, traditionally speaking, forms the basic core of almost all Japanese relationships. It relates to the need to care for someone and a need to be cared for in a hierarchical society of "senpai" and "kohai."
But this article is not about "amae." It's about "honne" and "tatemae." "Honne" is a person’s true feelings and desires. Ideally, they are to be kept hidden, and only revealed in the most appropriate social circumstances. Instead, "tatemae" comes into play. "Tatemae" is a person’s façade and is related to the behavior and opinions that are to be displayed in public.
When I think about “honne” and “tatemae,” I’m reminded of a famous tune by the jazz hipster poet, Oscar Brown Jr.
“I always live by the golden rule, Whatever happens, don’t blow your cool! You gotta have nerves of steel, And never show folks how you honestly feel!”
The verses of the tune offer examples of this, but in each situation, the poor fellow ends up suffering a nervous breakdown and begins howling and screaming ... then suddenly on the break says,
“But I was cool!”
You might argue that the tune is an example of "honne/tatemae" (Actually, it's more about social grace than machismo, but I digress.)
Whether it is or it isn’t, a misunderstanding of "honne/tatemae" often leads foreigners into trouble in Japan. Take the English teacher who can swear a lesson with a student went perfectly ... then gets called into the office by the manager with that ominous, “We’ve had a complaint…” lecture.
Thinking about this, I began to wonder, if Japanese people are limited in how they can express themselves with strangers, might it be part of the reason that counseling and treatment of mental illness is so far behind the times? Perhaps “opening up” is simply alien to the culture, and psychotherapy itself is intrinsically “Western” in nature?
I spoke again to Dr Shibata, a psychiatrist at Kawaguchi Hospital. I was wondering how much of a problem it was and whether Japanese people had to be assessed differently in psychiatric situations as a result.
To my surprise, he dismissed the idea.
“Actually there is 'honne and tatemae' in Japan, but patients with depression usually don’t use them. Because the patients come to the clinic wanting to improve their symptoms, they understand if they use 'honne and tatemae' in the consultation, the clinician can’t assess their state properly and they won’t be able to get treatment.”
On the other hand, Dr Shibata brought out a point I found interesting. “In Japan, patients don’t complain about sexual dysfunction so often, which may be different from Westerners. This is because Japanese people tend not to talk about sexual matters openly.”
I chuckled to myself thinking about the many times even I’ve felt prudish sitting in izakaya and listening to drunken men discuss matters many Westerners might take issue to discussing in mixed company. But that’s an izakaya, and a situation where people, to a great deal, have license to be themselves.
Still, what about Japan, and the fact that there is such a stigma and public non-acceptance of counseling and psychotherapy? This is definitely not a nation of young hip era Woody Allens who brag about their analyst… or even Oprah aficionados.
Dr Shibata pointed out a serious challenge for psychiatrists. A major part of his job is to adjust medicine according to the patient’s condition and requirements. He said that verbal approaches are indispensable, but there are few psychiatrists compared with the amount of patients, so time tends to be spent dealing with pharmacotherapy rather than verbal intervention. In his case, he sees more than 10 patients an hour.
“In Japan, psychotherapy is usually administered by a psychiatrist or psychologist. When administered by a psychiatrist, it's covered by health insurance and the fee is set at 3,300 yen (5-29 minutes) or 4,000 yen (more than 30 minutes) by the government. If the patients use health insurance, they pay 30% of the cost and that is not a significant burden. But there are few psychiatrists who administer psychotherapy as a main treatment for the reasons mentioned above, and in most cases health insurance is not available.”
At 5,000-20,000 yen a session, private counseling simply isn’t so affordable.
One might assume that clinical psychologists would be fighting for this to change by allowing their services to be covered by national health insurance.
Dr Shibata disagreed. “The Foundation of the Japanese Certification Board for Clinical Psychologists opposes admitting counseling as medical care. One reason is that if counseling were to be admitted as medical care, psychologists couldn’t administer counseling without the doctor’s instruction. The board worries that psychologists would lose their autonomy as a result.”
But with problems such as "hikikomori," train “chikan,” “ijime,” PTSD and suicide being such major social issues, aren’t any changes being forced on the field?
Dr Shibata doesn’t think so. “Maybe the government can’t focus on problems beyond suicide prevention. There are few mental health experts for such problems.”
In the end, it seems, although there is a stigma surrounding getting help in Japan, it isn’t purely about “nihonjinron” or opening up to therapists being “un-Japanese.” Rather it is a more universal problem -- a mixture of affordability and the availability of professionals.© Japan Today