Mentally ill shunted
behind locked doors

By William Wetherall

A version of this article appeared in
Far Eastern Economic Review, 137(33), 13 August 1987, pages 36-37

Japan plans to free its hospitalised mental patients in the same way that it has tried to better its treatment of aliens: symbolically. Two years ago, the Ministry of Justice sought to offer relief to foreign residents who dislike fingerprinting by changing from black to colourless ink. Now the Ministry of Health and Welfare wants to give mental patients the illusion that they are part of the world, by letting them see more of it.

The government has decided that the iron bars should come off the windows of mental hospitals. The scheme to replace the iron window gratings with reinforced glass on the locked wards of all public and private mental hospitals is part of a government spending package to stimulate the domestic economy. It is also aimed at brightening the gloomy image of Japan's mental institutions, especially in the eyes of foreign critics such as the International Commission of Jurists (ICJ).

In May 1985, three specialists representing ICJ and the International Commission of Health Professionals investigated Japan's mental hospitals, in response to a request made by Japanese lawyer Etsuro Totsuka on behalf of the Japanese Fund for Mental Health and Human rights. The Japanese group had formally appealed to ICJ in September 1984, at the height of a scandal of Orwellian proportions at Hotokukai Utsunomiya Hospital, a private institution in Tochigi prefecture two hours by train north of Tokyo.

Japanese human rights advocates made the appeal to pressure the government into action. In May 1984, ICJ had written to Prime Minister Yasuhiro Nakasone to suggest that he appoint an independent group to study the treatment of mental patients and related laws. Nakasone did not reply, implying that how Japan treated its mentally ill was its own business.

ICJ recognises that local conditions like culture affect how a country will care for its mentally ill. But in Human rights and Mental Patients in Japan, its September 1986 report on the findings of the joint mission, ICJ maintained that "common human needs and fundamental aspects of human rights transcend cultural factors" in a country like Japan, which has the economic resources to end discrimination.

The Hotokukai scandal exposed one of Japan's biggest government-sponsored rackets. Japanese laws allow families and society to hospitalise anyone alleged to be mentally ill. Vague definitions of "mental disorder" facilitate medical pretexts for incarcerating "embarrassing" or "troublesome" members. The law gives mental patients less protection from arbitrary detention and less opportunity for legal redress than criminal suspects. And further abuse of patient rights is underwritten by a health insurance scheme which rewards remotely located hospitals that accept as many patients as possible, and keeps them as long as possible.

The Hotokukai scandal revolved around reports of violence. It all began with suspicions over the hospital's high death rate. At least two patients had died from disciplinary beatings by male nurses using steel pipes. The causes of death were obscured by false statements on death certificates. Other patients had been forced to do work that was supposed to be performed by licensed medical technicians and nurses. The hospital had made fraudulent claims for health insurance compensation, operated facilities without permission, sold rice produced by patients on the black market and hid evidence. Staff nurses had illegally dissected patient bodies to remove brains for study by University of Tokyo medical school doctors who reciprocated by referring patients to the hospital.

Most Japanese mental hospitals are far from being such chambers of horror. But even the best share the traits that foreign and domestic critics alike have attacked: high rates of involuntary admission (80 percent), high rates of detention in locked wards (70 percent), and long periods of incarceration.

Japan's 1,605 mental hospitals are filled with 340,000 patients. According to figures which include 90 percent of the mental hospitals, about 70 percent of all mental patients are confined to locked wards. About 85 percent of the beds are in private mental institutions. In addition, about I million people are being treated for mental disorders as outpatients, so about 1 percent of Japan's 121 million population is officially mentally ill.

About 80 percent of all patients are hospitalised involuntarily--70 percent by the consent of their legal guardians, and 10 percent by order of a prefectural governor. Inside mental hospitals, patients are often not allowed to make phone calls or write letters. Outside, they are legally barred from public baths, and jobs like teaching and truck driving.

Japan has been locking up more mentally ill people, and keeping . them locked away longer, at a time when most industrialised countries have been revamping the treatment of those with mental illnesses. Between 1955 and 1980, the number of hospitalised mental patients, calculated as a rate per every 10,000 people, in the US dropped five-fold from 34.4 to 7, while Japan's rate rose five-fold from 5.5 to 26.7.

The US hospitalisation rate rapidly fell because of federal and state programmes to discharge as many patients as possible. This policy, known as deinstitutionalisation, has not had a good track record. Thousands of mental patients were released into communities that lacked adequate mental-health facilities. Discharged patients with no families to support them ended up on the streets with the homeless.

A Japanese newspaper reported that the US has about 2.5 million homeless people, 40 percent of whom may be mentally ill. In the US, these figures vary widely. Estimates of the homeless range from 300,000 to 3 million. Most estimates figure about 30 percent of the homeless are mentally ill.

Yet Japan, like other countries, has homeless people who prefer their impoverished freedom to the confinement of an asylum. In Tokyo alone, hundreds of homeless men live in subway stations and parks, and some of them are mentally ill. Generally they bother no one, but in August 1980, a deranged homeless man ignited a bucket of gasoline he had thrown into a bus in front of Shinjuku station, killing five and badly burning 18 others.

It was not until the next year that violent crimes by the mentally ill began to stir fears about public safety. In June 1981, a knife-wielding man went berserk on a Tokyo street, killing four passersby and injuring two others, then holding a woman hostage for seven hours before he was arrested. The man had been mentally ill and was taking stimulant drugs. A wave of such crimes by men with a history of mental illness and drug abuse moved the government to study measures to prevent indiscriminate killings.

By 1983, the Ministry of Justice had started to draft a new Penal Code with a "security-detention" provision that would allow the police to hold any person thought to be temporarily suffering from an impairment of their mental faculties, or judged mentally incapable. The provision was aimed at released murderers, arsonists, rapists and other felons who the authorities feared might repeat their crimes. The ministry also considered a plan to establish its own mental hospitals where those subject to security detention could be committed.

The government has argued that the police need stronger holding powers to keep Japan's streets safer than those of other countries. Public reaction to cases of indiscriminate violence has been to demand more protection in the belief that real or possible victims have a higher claim to human rights than actual or potential criminals. But the Japan Federation of Bar Associations has strongly opposed all legislation that would give the police more arbitrary power.

Media coverage of violent crimes by the mentally ill has created the impression that mental illness constitutes a major. public hazard. But a white paper on crime reported that in 1983, only 2,461 (0.56 percent) of 438,705 suspects arraigned on criminal charges--excluding traffic accidents--were thought to be suffering from mental disorders. If so, then the crime rate among Japan's mentally-ill is only about half the 0.4 percent rate for the nominally healthy part of the population.

This does not mean that a neighbourhood of mentally-ill people would be twice as safe as one with only supposedly healthy citizens, for the rates for murder and arson by the mentally-ill are relatively high. But it means that mental illness is not tantamount to danger. Yet the equation of mental illness with danger makes it difficult for people with a history of mental illness to live ordinary lives.

In 1982, a man thought that he had been fired from his job because his employer had learned that he had once been in a mental hospital. The man went to the hospital for a certificate of sanity, but the superintendent forcibly admitted him with the help of some orderlies. In 1985, with the help of the Second Tokyo Bar Association, he sued both the city whose mayor approved of his involuntary detention, and the state of Japan which is responsible for the arbitrariness in the law. The man reportedly negotiated a cash settlement with the hospital and is working again.

The ICJ report concluded that one of the most serious defects of Japan's Mental Health Law (MHL) is the absence of a specific provision allowing for an individual to request admission on a voluntary basis. The MHL has noble goals: to provide medical treatment for the mentally ill and to prevent mental illness, in order to preserve and improve the mental health of the people. But ICJ found that this purpose "was being undermined by a policy whereby the law was being used primarily as a police or social control mechanism" in violation of the UN Convenant on Civil and Political rights which Japan ratified in 1979, and even the Japanese Constitution.

Moreover, "the method of reimbursement itself discourages voluntary admissions and encourages forced hospitalisation." So even when a person with a mental illness is willing to be hospitalised, doctors commonly recommend that the involuntary or compulsory provisions of the law be used. The hospitals make more money this way.

A limited government survey in 1983-84 showed that about half of all hospitalised mental patients could have avoided hospitalisation if their families had helped them, while half could be discharged if their families would accept them. But a 1986 poll by the National Federation of Associations of Families of Mentally-Ill Persons found that two thirds of the families were not willing to look after them at home.

The Ministry of Health and Welfare, in response to both the ICJ report and domestic opinion, has drafted a bill to revise the MHL. Approved by the cabinet in March this year for submission to parliament, the bill encourages voluntary admission and greatly stiffens medical criteria for involuntary detention. In theory a hospital would have to obtain the written consent of the patients it admits, inform them of their right to request release and release them upon request. But in practice the status quo could continue.

Patient rights activist Totsuka, also a member of the Committee on Human rights of the Second Tokyo Bar Association, welcomes the bill's promotion of voluntary admission. But he criticises the Ministry of Health for not setting specific targets, like a voluntary admission rate of 95 percent within 10 years. And While he accepts the bill's emergency holding powers, he faults its failure to guarantee patient rights to a fully independent diagnosis and redress, as stipulated in the UN covenants and as recommended by ICJ.

The MHL bill proposes to rename the law--from Mental Hygiene Law to Mental Health Law. A Japan Times editorial, seeing a "major social reform" behind this change, stated that "The [reinforced] glass may effectively serve the same purpose [as the iron window gratings, but it is important that it does not convey the weighty meaning that the bars do."

Such stress on form over content is typical of attitudes towards legislation in Japan, where laws are seldom taken seriously as instruments of social reform even by law makers.

"We are behind Europe and the US, but though we have much to learn from them, we also want to avoid their mistakes," a Ministry of Health official was recently quoted to have said about the MHL bill. "We are not going to start from a blank sheet of paper, but rather revise the law in line with the legitimate rights of patients and the cultural and ethical background of Japanese society."