Article Highlight: Vol 40 Issue 4, Social Withdrawal in Japan

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The December 2016 issue of Culture, Medicine & Psychiatry is now available here. In this series of article highlights, we will explore publications included in the latest issue. This week, we present a highlight on Ellen Rubinstein’s article “Emplotting Hikikomori: Japanese Parents’ Narratives of Social Withdrawal” (which you can access here.) Rubinstein observes that there has been a flurry of public attention to hikikomori, a socio-medical condition typically experienced by young people that is characterized by increasing, marked social withdrawal.

Rubinstein notes that though there is a perception of hikikomori as a condition of isolation, parents of “hikikomori children” often crafted narratives about their children’s illness that suggested it had discernible stages, signs of progress, and possibility of recovery. These narratives engaged parents in the present, facilitating connectedness between hikikomori children and their families, and thus challenging the assumption that hikikomori is a condition of perpetual or crippling isolation. For instance, some parents at a support group for hikikomori children and their families stated that their children were more mature than others, as their time away from other people encouraged them to be meditative and thoughtful.

One mother, named Kawano-san, first described her son’s hikimori as a process of productive, but not permanent, isolation in an interview with Rubinstein. Kawano-san said that her son’s withdrawal might lend him an opportunity to step away from the social world, assess his future, and prepare for college after initially failing to pass university entrance exams. She felt certain that this period would be one of reflection and reassessment, before the son eventually entered university. Kawano-san also criticized the expectation amongst many Japanese families that children should be extroverted and talkative, instead saying that her son was not pathologically isolated but simply different. Eight months after this initial interview, Kawano-san was interviewed for the second time about her son’s condition. The son had not entered college as Kawano-san expected, but the mother had readjusted her narrative such that she began to acknowledge that path might not be viable for her son. She instead noted that her son could have a disability, or that he simply needed more time to process his feelings. Kawano-san ultimately accepted that her initial expectations did not match her son’s experience, and began to try new approaches to her son’s condition: like encouraging her husband and daughter to write birthday messages to him that might make him feel more welcomed and included in their family unit.

Rubinstein examines similar cases to Kawano-san and her son, finding that many families engaged in a process of narrative emplotment and un-emplotment of their children’s hikikomori. Their narratives thereby gave order or meaning to what otherwise seemed like an ongoing and static psychological condition. Alternatively, they situated their children’s experiences in other contexts: such as expected developmental and social growth, and the efficacy of biomedical interventions or support groups for the condition. Parents of hikikomori children were not inactive bystanders, but rather active interpreters of their children’s experiences and advocates of their unique individual needs. The parents learned to read their children’s condition and support them accordingly, complicating the notion that hikikomori is solely about individual isolation or inaction.

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From the Archive: Revisiting Neurasthenia in Japan

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In 1989, our June special issue centered on the theme of neurasthenia: an illness category made most recognizable in current medical anthropology by Arthur Kleinman in his book Social Origins of Stress and Disease: Depression, Neurasthenia, and Pain in Modern China (1988.) Neurasthenia is a flexible diagnosis that encompasses a set of broad psychosomatic symptoms: fatigue, emotional unease, irritability, and bodily pains. It has fallen in and out of favor throughout history, yet in China and other Asian countries, it continues to be used to describe psychiatric distress. The special issue was published during the final year of Kleinman’s tenure as the editor-in-chief of Culture, Medicine & Psychiatry, and represents the culmination of research carried out throughout Asia on the diagnosis and treatment of the illness. You can access the full issue here.


 

The focus of this From the Archive feature is Tomonori Suzuki’s article on the diagnosis and treatment of neurasthenia in Japan. Unlike China, where neurasthenia continued to be clinically relevant through Kleinman’s research in the 1980s-1990s, the disease category fell out of its original use in Japan following World War II. Suzuki writes that this shift was not directly due to changes in Western psychiatry, in which European and American physicians replaced ‘neurasthenia’ with new categories under the umbrellas of neuroses, depression, or anxiety. These shifts may have influenced psychiatric disease models elsewhere, but in Japan, neurasthenia was instead rebranded and treated via a different historical pathway.

Morita, a renowned Japanese psychiatrist who lived in the late nineteenth and early twentieth centuries, was the first to suggest that neurasthenia was not exogenous: in other words, it did not stem from social disorder on the outside, but from psychological unrest within the mind. His therapeutic regimen for this newly-conceived “neurasthenia” became widely adopted, even into the contemporary age. Thus neurasthenia– while formally removed from the diagnostic lexicon– took a new form with an accompanying treatment as proposed by Morita.

Following WWII, when Japanese medical practitioners did begin to employ American principles of psychiatry, clinicians began to replace “neurasthenia” with the new category “neurosis.” Although this aligned with shifts in the nature of treatment that occurred in other places where biomedicine was practiced, Japan was unique in that many patients labeled as neurotic nevertheless sought out Morita therapy: a treatment initially designed to ameliorate an illness closer to the original form of neurasthenia. Some patients also opted for Naikan therapy, another indigenous psychotherapy based on Buddhist principles similar to those woven into the practice of Morita therapies. While the importation of “Western” diagnoses of neurosis brought with it accompanying forms of therapy native to Europe and North American, Morita and Naikan proved to be durable therapies equipped to treat Japanese patients with illnesses somewhere within the neuroses-neurasthenia spectrum.

Although the author notes that the use of these therapies (in the 1980s) could decline as Western models of psychotherapy continue to spread, Suzuki’s research into Japanese psychiatry practice revealed that many patients continued to seek out indigenous Morita and Naikan therapies. The two treatments’ focus on inner self-mastery, connectedness to the social and physical worlds, and the minimization rather than elimination of symptoms echo native Japanese spiritual beliefs, making these therapies legitimate alternatives to imported models of treatment. In sum, though the category for neurasthenia changed across time, foreign models for the conceptualization of mental illness did not always neatly correspond to foreign models for treatment. For the Japanese, local therapies such as Morita and Naikan proved to be quite resilient, as the therapies adapted to address psychiatric disorders despite the repackaging of mental illness into new forms.

 

From the Archive: Eating Disorders Amongst Japanese Women

In our “From the Archive” series, we revisit an article published in past issues of Culture, Medicine & Psychiatry. This week, we’re highlighting a piece on eating disorders in Japan, originally featured in our December 2004 issue.

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Kathleen Pike and Amy Borovoy’s article “The Rise of Eating Disorders in Japan: Issues of Culture and Limitations of the Model of ‘Westernization'” makes a poignant case for the importance of context when examining eating disorders across the world. In this piece, they argue that studies of eating disorders abroad have often attributed the etiology of these illnesses to an increasing visibility and presence of Western beauty standards that accompany the spread of new technologies, medias, and communication tools. While Western beauty ideals have been problematically exported to the non-Western and developing worlds in other cases, Pike and Borovoy suggest that this model does not account for the experience of eating disorders in Japan.

Westernization and modernization, they note, are two distinct processes: and Japan, which has developed economically but retained many of its traditional social roles, exemplifies this difference. Modernization is the process of economic and technological development as a nation shifts from traditional to modern (often, mechanized). Westernization may be defined as the process of integrating the lifestyle, values, and experiences of Western cultures into the fabric of society, especially during periods of modernization and economic change.

Despite the drive for modernization, Japanese women are still expected to be homemakers and mothers rather than career women in the new economy. The Japanese have not adopted the individualistic and feministic sensibilities of the Western world, and the domestic burden– both caring for the home and children, and tending to older family members– squarely falls upon wives and mothers. This creates enormous stress for young women, who wish to extend their adolescent years and savor the freedom between childhood and their adult lives, as defined by marrying and becoming a homemaker. Modernization allows young Japanese women to obtain jobs, travel widely, and earn an education, but traditional social roles do not create a space for women to enjoy such a designated period of freedom without familial commitment. The inevitability of domestic life, then, is ever-present in the lives of women who yearn for fewer responsibilities– even if just for a time. This creates feelings of distress, unease, or unhappiness in many young women.

Pike and Borovoy observe that Japanese women do not reject food (anorexic behavior) or induce vomiting (bulimic behavior) out of a desire for thinness or due to fat phobia, as women with eating disorders almost universally experience in Western nations. Rather, Japanese women stress that they reject food because it worsens their digestive complaints, which are connected to the anxiety and stress they feel out of dissatisfaction with their social role (or lack thereof.) The tension between women’s expected social functions, and their desire to live and work in some other way, therefore spurs disordered eating within this broader frame of mental distress.

As we see, women’s experiences of Japanese eating disorders are entwined in the fabric of traditional social life, and not rooted exclusively in imported ideas of the body, independence, and individualism per the Western way of life. Indeed, the non-fat phobic symptomatology of eating disorders reflects the essential differences between Japanese women with eating disorders and their peers in Western nations. The study highlights the centrality of culture in studies of mental illness, and the way that these conditions emerge out of a local social world.


To find the full article online, click here: http://link.springer.com/article/10.1007/s11013-004-1066-6