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Mental health and counseling in Japan: a path toward societal transformation.

The collectivist Japanese culture has been influenced by Westernization and internationalization. Today's Japanese mental health problems reflect the confUsion among Japanese individuals who live in an unstable period between enduring interdependent cultural values and emerging Western values of independence. This article underscores the importance of mental health counselors working congruently within Japanese society by incorporating the social justice perspective. A conceptual framework for optimal societal adaptation is presented. The proposed model consists of action-oriented outreach and advocacy designed to create societal transformation to foster psychological well-being and reduce existing stigma about psychosocial problems and treatment. Mental health issues in the changing climate of contemporary Japan are illustrated. Emphasis is placed on culturally specific trends and resources in order to prevent conflicts and to maintain harmony among individuals within the changing societal systems.

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A recognition of the need for counseling has become much more apparent among the Japanese public since the economic crash of 1992. A bubble economy that made Japan the world's second largest economy in the late 1980s ended in great financial disruption and the worst Japanese recession in history (Kinugawa, 2002). This drastic period brought about many personal and social problems that increased the need and demand for mental health treatment. As the Japanese perception of counseling services changed, the number of mental health professionals increased. Western practitioners have been invited as guest speakers and trainers at universities and professional conferences as seen at the 2004 World Congress of Behavioral and Cognitive Therapies held in Kobe, Japan. Many Japanese graduate schools use non-translated American textbooks and periodicals to deliver the latest theory, practice, and research.

A major challenge remains for Japanese professionals to identify and implement culturally relevant and effective services. In Japan, the modification of traditional Western counseling approaches, however, seems to be minimally effective as the individualistic/independent and Eastern collectivistic/interdependent cultures collide. According to Markus and Kitayama (1991), Japanese people, and other Asians, hold an interdependent construal of the self, which is clearly different from an independent construal of self as seen in many Western cultures. An interdependent-self construal has a strong orientation to relational and other environmental contexts, both of which are important factors for defining the self in Japan. The Western independent self, on the other hand, is relatively firm and separated from social context and uses a perceived relationship with others to compare and evaluate the self.

Because the interdependent self consists of a strong orientation to the social environment and relational factors, mental health counselors of Asian clients must take into account and carefully explore the surrounding context in which clients' problems are perceived and presented. In the context of multicultural counseling, Yeh and Hwang (2000) asserted the importance of the contextual examinations as follows:
 Specifically, a client's self and particular concerns, such as
 relationships with friends, family, and partners; personal and
 professional decision making and choice gender role; and racial
 identity. These concerns should not be addressed solely as
 intrapsychic phenomena contingent on deficient internal attributes
 and processes. Rather, an interdependent perspective proposes that
 the counselor address the client's concerns by examining the
 surrounding context that shapes the client's experience,
 interactions, and sense of self. (p. 425)


By using a case illustration, these scholars delineated the ethnic identity formation of a Chinese American and suggested interpersonally oriented goals to assist the client in integrating the two different cultural orientations. Although their overall counseling implications are valuable, the counseling that they describe still rests within the concept of individual counseling as opposed to interventions involving a client's social context.

Conventional mental health counselor-client activities and service modes (i.e., individual, couple, family, and group) for minorities in the United States recently have been criticized by scholars (e.g., Ivey & Collins, 2003; Prilleltensky, 1997; Ridley, Baker, & Hill, 2001: Vera & Speight, 2003). They argue that effective intervention must go beyond the scope of traditional counseling practices: multicultural counselors must work within the community, institutional, political, and related social systems and address social injustices that exist in the United States. In the Japanese context, a social justice perspective is vital for generating a healthy social environment for all Japanese individuals.

In this article, the author first addresses the need for professionals to work with and within society by illustrating major mental health problems in contemporary Japan. In the second part of the article, the author presents a conceptual framework for optimal adaptation to recent societal changes by incorporating a social justice perspective into the notion of the interdependent Japanese culture. This framework emphasizes broad, system-wide intervention to create a social transformation that could, in turn, provide a sufficient social context in which the interdependent self of the Japanese culture might thrive.

MENTAL HEALTH PROBLEMS TODAY: FOCUSING ON SOCIETAL CHANGE

Westernization in Japan began with the U.S. occupation after World War II. Economic and political restructuring led to stability and eventually a democratic process. While Japan was gaining world economic power, internationalization was encouraged across social systems. Today, even more Western influences on its culture can be seen as Japan recovers from a long recession. Drastic changes have occurred in Japanese social systems (e.g., family, school, workplace, and community). Within these systems, the interdependent-self perception of the Japanese people is clearly reflected. Hierarchical social orders based on status, gender, and seniority are not as firm in Japan as they once were. Members of a given system can be asked or required to perform nontraditional roles and tasks in today's Japanese society. In the three following subsections, major mental health issues that affect work, family, and education are illustrated with examples of change in Japanese society.

Work

Traditionally, Japanese workers stayed with a company and climbed the career ladder. A clear hierarchical relationship between superiors, or joshi, and subordinates, or buka, was maintained in and out of the workplace. Seniority and good relationships with superiors were major factors in determining one's position. Until recently, most workers were rewarded with traditional job security and retirement plans to acknowledge their devotion and loyalty. Today's Japanese work environment is much different as Japan is still recovering from its worst recession. An inflationary trend has aggravated a drastic increase in unemployment, bankruptcies, and incidences of excessive personal debt (Japanese Statistics, 2002). A high suicide rate since 1998 and increased homelessness are by-products of the economic crash (Japanese Statistics). In Japanese culture, suicide can be seen as a way to show responsibility and "apologize" for socially inappropriate or shameful behavior.

Using Markus and Kitayama's (1991) concept of an interdependent value orientation, it becomes easier to understand why an individual has sacrificed his or her life when a partner in a shared membership has failed. To survive the economic crisis, many companies were forced to merge or include American-style approaches such as layoffs, productivity-based promotion, and job compartmentalization. For instance, Nissan hired an American chief executive officer, closed five plants, and introduced new Western concepts to recover from the company's crisis (Nissan Keizai, 2003). As Western-style management began turning business practices and the fundamental view of the self upside down, the question of "Who am I?" became a challenge for many Japanese workers amid workplace and social upheaval.

In Japan's changing society, female and younger workers have seen more fairness in competition and advancement. Some women have entered male-oriented jobs such as construction, transportation, and politics. Yet, changes in the workplace are slow due to lingering gender and age discrimination. Nonetheless, harmonious teamwork is giving way to individual competition as consensus leadership is slowly replaced with top-down directives. It is a time when being unique and other Western independent-oriented postures are being taught instead of the traditional Japanese value, derukugi wa utareru, "the nail that stands out gets pounded down." Japanese people often feel uncomfortable at work today (Kato, 2003) as profit-based and individualistic approaches have created a highly competitive and unpleasant workplace. Many concerns expressed by workers must be seen within this context of a changing work environment.

Family

Democracy and the economic bubble of the 1980s brought a materialistic value to Japan. This new materialistic interest, in addition to the Japanese traditional work ethic, has occurred at the expense of strong family ties. Many married males have focused on their careers and failed to make time for their wives and children, while many wives have become overly involved in their children's academic success (Kato, 2003). Private tutoring schools and cram classes add to many busy children's regular school load. A goal for children, often their parents' goal, is to enter a prestigious university, which is often believed to be the key for success in life.

Many married females hold part-time or full-time employment to replace the loss of family income due to layoffs, salary cuts, or divorces. They often enjoy the time spent working outside the home as they discover new talents and different interests. Conflicts arise, however, in many families due to the recent structural changes in the family. Roles and responsibilities for performing occupational duties, household chores, child rearing, and community responsibilities must be reworked.

There have been significant changes in marriage and divorce. Men and women remain single longer than before. The average age for a woman's first marriage increased from 24.2 in 1972 to 27.4 in 2002, and the average age of first-time marriage for men increased from 26.7 to 29.1 in the same period (Ministry of Health, Labor, and Welfare, 2002). Divorce also became common in Japan. In 2002, 23% of marriages ended in divorce contrasted with 10.2% in 1972 (Gifu Prefecture, 2003). Although some couples officially end their marriage, other couples remain married because of children, financial strains, or the stigma of divorce. This phenomenon is known as kateinai rikon, or in-home divorce. Domestic violence, wife battery, and child abuse are reported in the media today Other common problems are alcoholism, gambling addiction, and caregiving for aged parents.

Education

The Japanese cultural value of education, once a vital element of Japan's economic development, appears increasingly problematic due to a strong emphasis on grades and test scores, which often are accomplished through rote memorization rather than meaningful acquisition of knowledge, critical thinking, and creativity The achievement of academic success in today's Japanese society often is given a higher priority than the fostering of interpersonal relationship skills and emotional development. Many children are busy preparing for tough higher-education entrance exams. About 25% of elementary school children and 60% of secondary students attend cram schools (Noguchi, 1997). Some high school students and those trying a second time to pass entrance exams often attend special preparatory schools. These schools offer special training sessions on weekends, at night, and during school breaks. Very little time is left for Japanese children and adolescents to play with their friends and develop personal interests. Moreover, they often are evaluated solely on their academic performance, particularly on hensachi, or T-score (i.e., the number of standard deviations from the mean on a t-distribution), by school, parents, and society Japanese parents are very enthusiastic about their children's academic success, but many children feel pressured, vulnerable, and isolated (LeTendre, 1996). The lives of modern Japanese children and adolescents are so strenuous that this phenomenon often is called juken jigoku, or the examination hell.

Stress from competition often relates to bullying, violence, and school phobias resulting in long school absences. A large-scale survey was conducted by the Management and Coordination Agency Administrative Inspection Bureau (1998) in 1997 to study bullying, truancy, and violence in Japan. Among 16,824 student respondents (4th through 9th grades), about 30% reported that they had been victims of bullying. About 40% of the bullying victims reported that they did not tell anyone and held in the bitter experience. Approximately half of the older students in this study reported that they did not help the victims--the so-called bystander effect. Almost 90% of the 785 teachers in this study reported that they had students who met the criteria of Japanese truancy--more than 30 days of school absences in a school year. Depression, social isolation, and delay in academic achievement are common among victims of bullying and school violence. In some extreme cases, the victims commit suicide.

FRAMEWORK FOR OPTIMAL SOCIETAL ADAPTATION: WORKING WITH SOCIETY

The culturally relevant counseling practice must actively and collaboratively work within a Japanese society that is increasingly adapting to Western influence. Although current counseling work in Japan consists mainly of remediation at a micro level (i.e., mostly individual level), a different approach is needed to fit the uniqueness of Japan's culture. In this section, conceptual assumptions supporting a framework for optimal societal adaptation are presented. Implementation of these ideas is discussed in terms of culturally relevant outreach and advocacy.

Conceptual Assumptions for Optimal Societal Adaptation

The conceptual framework for optimal societal adaptation in Japan rests upon five assumptions: (a) self-satisfaction, (b) professional competency, (c) self-stigma and social stigma, (d) interdependent cultural communication, and (e) collectivistic harmony. The first assumption is that a Western-style concept of self-esteem is not as active and central in the present Japanese society. Markus and Kitayama (1991) pointed out that self-esteem is an independent-self type of value and should be replaced with a different term, self-satisfaction, within an interdependent culture. Self-satisfaction is attained by adapting one's internal attributes (e.g., cognition, emotions, and motivation) across different contexts and feeling satisfied by fulfilling one's culturally mandated tasks. This concept of self-satisfaction for the Japanese interdependent self is viewed in contrast to the Western independent self, which strives for higher self-esteem by improving one's ability to express and validate one's internal attributes.

Although Westernization has introduced the concept of self-esteem into the Japanese interdependent culture, the traditional value of self-satisfaction still endures. Optimal psychological functioning of a Japanese individual would be determined by the degree of successful interaction with others and adaptation to society. Due to the strong connection with others within the societal context, one can function better if his or her surrounding social environment shows healthy adaptation to various social changes in Japanese society.

The second assumption is that the application of traditional Western theories of personality, counseling, and psychotherapy in Japan could be harmful to an individual unless the changes are compatible with the social context in which the individual must function. For instance, in a counseling session, a Japanese female client might be encouraged to assert her individual right to maternity leave in a small company. Yet, despite her success in achieving that goal, upon return, she may experience indirect and subtle mistreatment (e.g., being given unimportant tasks). Thus, she may feel isolated and rejected in a work environment that supports a traditional Japanese work ethic such as giving up one's own personal time to meet team goals. Undesirable consequences such as this may occur because a mental health counselor inappropriately applied Western assertiveness training techniques and/or individual problem-solving techniques. Needless to say, traditional Western theories of counseling and psychotherapy were developed to support the independent self promoting individual autonomy, self-determination, and self-actualization.

The third assumption is that conventional counseling practices can reinforce both the existing self-stigma and social stigma. In traditional counseling settings, clients, important others, and even mental health counselors themselves may unintentionally fortify the idea that clients must alter their internal attributes and behaviors because they are solely responsible for the problems. Even in a situation in which obvious environmental barriers and obstacles exist, clients are more likely to be blamed or feel guilty about family disgrace and shame because it is assumed that they somehow failed to manage internal conflicts or promote system harmony.

In a recent study of self-stigma among patients with depressive disorders in Japan, it was found that those experiencing higher levels of self-stigma are less likely to continue psychiatric treatment (Shimotsu et al., 2004). More importantly, these researchers found that the main reason for refusing participation in the study was a denial of a need for psychiatric treatment. Thus, without lessening the existing stigma, the current remedial work in Japan appears to have only a minimal effect because of the avoidance of available treatment. If mental health counselors can promote the importance of psychological well-being to the general public, more Japanese individuals might pay attention to the potential value of psychological care. Such efforts on the part of the professional community would function as preventive care, and as a result, there would be less severe cases. Furthermore, there would be a lower incidence of self-stigma and social stigma within society.

Within the social justice framework, Prilleltensky (1997) criticized the traditional and passive U.S. practice of focusing on individual problems in isolation and not addressing the environmental issues in which various forms of oppression exit in a multicultural setting. Furthermore, some U.S. counseling psychologists challenged the application of current remediation for minorities by pointing out the uniqueness of their profession, that is, being social change agents who are trained in understanding developmental, educational, and preventive loci (Albee, 2000; Fox, 2003; Hage, 2003; Vera & Speight, 2003). In Japanese culture, social-contextual counseling interventions should be encouraged for all mental health professionals. Such intervention may serve to reduce resistant stigma in order to help change agents approach those who are severely ill and to promote social support for those with psychological distress.

The fourth assumption is that an indirect approach to communications will be a culturally suitable tactic. Compared to the Western value of being direct, Japanese communications are not straightforward and are also other-focused: "Say what's on your mind" vs. "Read other's mind" (Markus & Kitayama, 1991). In Japanese culture, an important message often is delivered indirectly over time, which can create frustration and misunderstanding among foreigners. The unique interdependent-oriented style would be applicable in creating a societal transformation because of the long Japanese tradition. Shifting the focus from mental illness to optimal functioning, from individuals to society, and from remediation to prevention is assumed to be a key to indirectly attacking the existing psychological stigma and avoiding major psychological problems before they occur.

The fifth assumption is that effective interventions are generated and disseminated in a culturally relevant manner so that collaborative work and harmony are maintained. The aim is not to change Japanese society into an independent-self-oriented culture. Rather, the aim is the development of optimal adaptation skills within the unique culture without giving up its traditional strength of unity and social sensitivity. The key concept is collective harmony that has long been valued in Japan.Thus, instead of rejecting its own uniqueness, those resources and trends that exist in today's Japanese culture should be acknowledged and applied in counseling interventions.

In terms of the Japanese mental health field, counseling/psychotherapy is currently provided by mental health professionals with certifications from various organizations. Unlike in the United States, clear boundaries and specializations have not yet been established between certified clinical psychologists and mental health counselors. The current qualifications for certification in Japan are not specific. The certification procedure currently allows academic degrees of any level (e.g., bachelor's, master's, doctoral) or academic discipline (e.g., psychology, education, sociology, medicine) to qualify for certification. However, counselors are required to complete a certain length of clinical experience to be certified (Japanese Association of Counseling Science, 2001; Japanese Certification Board for Clinical Psychologist, n.d.). The variability and the flexibility of professional value orientations among professionals can create rich resources when collaborative work is necessary. These procedures will soon be undergoing change as Japan adapts a more American-style system of certification and accreditation.

Culturally Relevant Outreach and Advocacy

For the purpose of this article, outreach and advocacy are core elements through which Japanese mental health counselors can effect optimal societal adaptation. These activities and prevention work were recommended by Vera and Speight (2003), who reexamined and redefined present multicultural counseling competencies in the United States by using a social justice perspective. Similar activities are needed to promote optimal societal adaptation in Japan as the goal for both cultures is to promote optimal development for individuals, groups, and systems (Hage, 2003; Meara et al., 1998). Outreach work is the primary and central focal point in the present framework for the optimal societal transformation in Japan. Being involved in community education projects should be one of the requirements for accreditation or certification and also should be accorded continuing education credits. Outreach should be practiced based on the concept of universal prevention, that is, targeting the entire population (e.g., nation, local community, school, corporations) without preliminary discriminatory screening for any risk status (Gordon, 1987).

The stigma associated with psychological problems and treatment can be overcome with public education. The Bridge Program, an outreach effort, was developed for Asians in New York City as a way of reducing the stigma associated with counseling and increasing overall accessibility to mental health care (Chen, Kramer, & Chen, 2003). The community education component of this program promotes the awareness of mental health problems and available services via radio and community forums. It was reported that the testimony from consumers and their families of mental health services was one of the most effective mechanisms of the public education component for the Bridge Program. A different approach, however, may be needed in Japan. Finding families or consumers who are not embarrassed and who are willing to share publicly their experience with psychological illnesses is a more difficult challenge in Japan. Although the same act of self-disclosure requires substantial courage for Asians in the United States, the powerful host culture (i.e., the United States) supports such acts. The context of Japanese society is different wherein such an act might create or be seen as a much greater stigma and result in a devastating outcome (e.g., isolation from the group or society).

In Japan, the content of public education should be carefully worded so that it creates a positive impression, curiosity, and interest. For example, the term seishin eisei, or mental health, can have a negative impact since the words are similar to seishin biyou, or mental illness. Instead of seishin eisei, which sounds too official, the phrase kokoro no care might sound more people-friendly due to the relationship of a "heart-to-heart" meaning or the appeal to "one's spirit." Other strategies would be to use a phrase such as "mind-body-spirit" or "stress management" to promote an Asian holistic view of health or hope. The message should be tailored to a given population with a positively worded title (e.g., "skills for successful leadership" at a corporation, "harmonious family communication" at a neighborhood facility).

Information and skills to prevent psychological illness and promote psychological health need to be disseminated to the Japanese public in multiple ways. One way to reach the general public is through community outreach programs. The diversity seen in the background of mental health counselors and psychologists should be used to good advantage in the outreach effort. In particular, various types of academic occupational backgrounds can be used to build specific bridges to the community and to more readily attract stakeholders in a given social system (e.g., schools, public-health facilities, corporations). Moreover, this uniqueness of the Japanese profession can create a true interdisciplinary team to develop comprehensive outreach programs and services. Perhaps the most Japanese-specific manner in which to disseminate services might be the effective use of media. Unique ads in public transportation vehicles can be effective communication methods to reach people of all ages because Japan uniformly employs nationwide public transportation. An actual example is a recently implemented electronic advertising device that has received much attention from train passengers. A television-like monitor delivers a message (e.g., teaching English phrases) while promoting the name of products and manufacturers. A similar method can be used to teach psychological health.

In addition, newspaper columns, magazine articles, quiz shows, radio programs, and even television dramas can be powerful ways to communicate with the public in Japan. The media often create a public fever for a certain item or phenomenon (e.g., foreign merchandise, hair coloring) within the Japanese culture of conformity. By working with other professions and the media, mental health counselors could spur a societal transformation of perceptions toward psychological care issues. In his writing on action-oriented social justice, Fox (2003) criticized the tendency of psychologists to "divine human expertise into arbitrary segments" and suggested that psychologists "go beyond intellectual awareness and comforting rhetoric" (pp. 301-302). Thus, incorporating strategies and methods from outside the mental health profession could help promote the well-being of an entire society.

Advocacy can help protect both mental health service consumers and providers. The 2002 revision of the Japanese translation of schizophrenia from Seishin-bunretsu-byou, a disease of split spirit, to Togo-shutyo-shou, a disease of loosened association, is an excellent example of consumer advocacy. A number of scholars examined the effect of labeling of schizophrenia on the degree of stigma found in their own group and among the general public in Japan (e.g., Higuchi, 1998; Iwadate et al., 1996; Sugita, Sakamoto, Tanaka, Tomoda, & Kitamura, 2001). By using a public survey, Zenkaren, the National Federation of Families for the Mentally Ill in Japan along with other professionals worked closely to find a less stigmatized name for schizophrenia. The entire process was conducted among patients, families, professionals, and all those affected by the outcome.

There are also other areas of advocacy that would benefit from the use of critical evaluation, consumer research, and interpersonal collaboration. Currently, counseling services are not covered by Japanese health insurance. Individuals who would like to receive services must either pay privately or schedule appointments according to the availability of publicly funded services. Therefore, another major issue that mental health counselors should advocate, for the benefit of the public and their own profession, is appropriate access to adequate mental health care including preventive work.

Counseling and consultation services at public places often have a long waiting list due to infrequent service delivery. Because of the limited availability of services, 4 to 6 weeks of waiting is common at public health facilities and public schools. In public schools, the Ministry of Education approved only 280 hours of school counseling services per year per school (Murakami, n.d.). Schools typically include 300 children, which would allow approximately 1 hour per child per year. Due to the government regulation, many school counselors, who are certified clinical psychologists, must find multiple work sites to be able to financially support themselves.

Empowering an individual can be self-defeating in an interdependent culture. The current situation in Japan could be improved if all mental health counselors would combine their efforts into a collective voice and help to educate the public through community outreach programs. In fact, all mental health professionals should advocate collective empowerment and promote the positive aspects of psychology in order to activate policy changes. Consultation skills should be used for policy change to find a way to encourage administrators to share their power (Helms, 2003). Building close relationships with policy makers is crucial; mental health counselors could teach management skills and leadership through outreach efforts. A central professional advocacy committee could be formed and branch teams set up wherein broad counseling activities and initiatives could take place. The committee should work closely with the leader of each system as individual mental health counselors seek to find a collective solution for the best interest of all.

CONCLUSION

Japanese mental health practitioners have been enthusiastic to learn and to apply the Western approach to psychological restoration that is known as counseling. Cultural differences between the East and the West remain as an ongoing impediment in the application of major counseling theories and techniques in Japan. Integrating East and West is an enormous challenge that can be approached within a social context. Acknowledgment of the uniqueness of an interdependent self-concept and the dynamic interaction between the self and its sociocultural context creates a path to systemic intervention from a social justice perspective. For systemic work, both traditions and newer trends are critical to make a smooth societal transition to create an optimal adaptation to change. Active participation within society is indeed a culturally relevant approach in which mental health counselors can assist all individuals in the Japanese society.

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Michiko Iwasaki, M.A., is with the Department of Counseling Psychology and Guidance Services, Ball State University, Muncie, IN. E-mail: miwasaki@bsu.edu
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