Japan Today



'Getting help' is not un-Japanese; it's expensive


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

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“Maybe the government can’t focus on problems beyond suicide prevention. There are few mental health experts for such problems.” This is the problem, not money. It is the attitude that there isn't enough help out there and there is no government support to increase the numbers. Clearly there is a need but lack of care and funding. "Help" back home is also expensive but you see a lot more people going and getting the help they need.

I find that as a foreigner people are faaaaar too open with me when it comes to their problems - be it DV, sexual assault, depression... I have asked people why they tell me this and not other. Their reply? As a foreigner they think I won't judge them. I think this is also a major part of the problem. They think they'll be judged by those they seek help from - and they are right. I know more than a few couples who actually have gone for help and they've basically put ALL the blame one person - the wife.

The honne/tatemae thing is not related in my opinion. I don't get it and is one of the most confusing things I find about the people here. It is blatant lying with a cultural excuse so they can "get away" with it. It gets used all the time as to why us foreigners just don't "understand" things. Perhaps we would if people wouldn't bare face lie? Tend to think this issues leads to so many of the problems this country faces. No honesty? Certainly helps explain the government.

-2 ( +4 / -6 )

Also, I've been told that admitting you have a disease, such as cancer or even asthma, will result in 'friends' shunning you because they don't want to catch it, too. Imagine if you admit to a psychological problem like depression. You'd be shunned by everyone but the NHK bill collector.

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Don't forget that sometimes doctors here don't tell someone they are sick but will tell their family!

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There are mental health experts in Japan, just not enough good ones. The psychiatrists just wanna prescribe away the patients' problem(s). And since anyone can call him or herself a counselor, who knows what kind of advice a patient is getting?

Lastly, Dr Shibata's quote:

“Maybe the government can’t focus on problems beyond suicide prevention."

is laughable as we all know the suicide rate in Japan has been very high for many years. Think making it harder to jump in front of a train would be more effective than what the Ministry of Health has in mind.

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And since anyone can call him or herself a counselor, who knows what kind of advice a patient is getting?

Actually, under the new rule, counselors have to undergo 2 years of supervised training to get licensed. I'm not sure if not having a license rules out a license to practice though.

If train companies offered free counseling clinics, I wonder how much money they'd save a year?

2 ( +2 / -0 )

There's a new rule, Johnny? Didn't know that. As my better-half has been a counselor for over 15 years here in Japan (she trained in America, though) I wonder if this will affect her?

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Godan, the two main certifications are JSCCP and JFP. Actually, the word "license" is probably a poor choice of words. "certification" would be better... but I'm not sure. http://tokyocounseling.com/english/column/tcsstandardsmental.html

3 ( +3 / -0 )

>I know more than a few couples who actually have gone for help and they've basically put ALL the blame one person - the wife.

Sounds a bit like the disgruntled CharismaMen with Japanese exs we meet on JT.....

4 ( +8 / -4 )

johnnygogogoJan. 08, 2012 - 11:47AM JST

Actually, under the new rule, counselors have to undergo 2 years of supervised training to get licensed. I'm not sure if not having a license rules out a license to practice though.

At the end of the day the only thing that not being certified by the Japanese Certification Board for Clinical Psychologists means is that you have to organise private malpractice insurance. There's little or no impediment to anyone putting up a sign saying "Psychologist". Of course the big problem with qualified psychologists from overseas getting certified in Japan is that the entire Japanese Certification process is... drumroll in Japanese, with no compromises available for foreign psychologists who wish to give counselling in English. So you have the ridiculous situation where a Japanese psychologist is "certified" to counsel English-speaking expats, despite the fact that in most cases they have no clue about the culture, language, etc, and will botch the job completely. I equally have a problem with foreigners who aren't fluent Japanese speakers with extensive Japanese cultural experience trying to counsel Japanese people, for the same reason, psychology deals with nuances and you simply can't effectively counsel a patient who you don't understand.

-1 ( +0 / -1 )

If train companies offered free counseling clinics, I wonder how much money they'd save a year?

Why should train companies offer this? Wouldn't it be better if health insurance we pay for did?? Charge the grannies and geezers who visit the clinics for a cold more and use the money to help with mental health issues!

Cleo, don't get me wrong, in some cases the wife IS the main problem but yes, takes two and no one is ever not at fault. I have been disgusted by some of the stories I have heard - from my understanding as well, most offering the help are men so... not surprising the women get blamed.

-1 ( +0 / -1 )

If you look at the fee schedule, it discourages intensive verbal interaction. It is very obvious that a professional who is given the opportunity to charge over ¥19,000 an hour or ¥4,000 per hour, you are not going to be very open to talking with a patient for an hour. As the doctor in this article takes 10 patients an hour, he is obviously not doing much in the way of proper counseling. Patient: "I hate my life. I want to kill myself. My mom and dad ignore me and I can never seem to get good grades in school because I am always so tired from staying up late ganbarre-ing. What should I do?" Shrink: "So, you are considering jumping in front of a train? Too much pressure at school and home? Well, I think that this drug who should help. It will take me a few minutes to write the prescription and explain to you how to take it and the possible side effects...Ganbatte kudasai!" Shrink: "Next, please..."

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Oops...new iPad so I added the 'who' in there...

-1 ( +0 / -1 )

GD, if you have a problem with too many meds, what do you think about western countries? Japan is actually pretty good at limiting drugs - be it for depression, ADD, ADHD... compared to western counterparts. I agree that 10 mins is a joke but think you are off based about the drugs. Just think the mentality is a) the most people they see the more money they get and b) seeing more is better than seeing fewer when it comes to possibly helping people.

-1 ( +0 / -1 )

Sir, The people in the city are scared of "getting help". This holds good in almost all the countries. Especially in India, most of those who live in rich urban centres seek neither help nor come forward to help others due to various reasons. But in rural areas, people are more homely and very helpful and it comes natural to them to help others without making others feeling "getting help". No one in independent. All of us are interdependent. We need to learn to live for others and for all of us. All of us are human beings basically, even though we speak different languages. Our problems are same, our limitation are not different and our goals in life are same.

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Hire a private English tutor. Much cheaper, and more sympathetic. Just my Y2.

1 ( +1 / -0 )

Im with you tmarie - I came expecting to be an English teacher and found myself being a psychologist/therapist/counsellor. Still do. Now it is not just students, but kindergarten mothers too, and I really wish Japanese would learn to start opening up to each other because they invariably come to me with very similar stories and problems.

Japan is good at limiting drugs, but there are times when they really shouldnt. Like the womens doctor who prescribed one weeks worth of SSRI meds. They take 8 weeks to even start having a full effect!

1 ( +2 / -1 )

Interesting article. Thank you Eddie!

he sees more than 10 patients an hour. that's quite a lot. Admittedly 10 minutes would be the minimum, he probably sees many couples or something?

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This is fascinating. I have a friend whose father is evidently paranoid or delusional, and a sibling who suffered from similar issues, and yet, it doesnt seem any are treated or seen by professionals. The adult parent even stabbed his wife, at one point, and still he isnt treated. He basically got away with it because the wife lied, as suggested by his in-laws...an obvious problem.

I have several Japanese friends who seem to want counseling, and need it, but they just cant get to do it. Even though they now live in the west, where its perfectly normal to resolve issues via counseling. Another friend recently asked me to speak to another Japanese man, who was having issues with his girlfriend. I of course said no, because I dont know the guy at all, and they should, together, go for counseling to preserve or resolve relationship problems. Bizarre.

Sadly, it seems as though many Japanese are just victims of their own upbringing, who clearly suffer from issues that need to be treated, and yet they are unwilling to do so. It is no wonder that alcoholism is such a severe issue, in Japan.
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