2003 Symposium of the Japan Society for Traumatic Stress Studies (JSTSS) Kobe Japan

The 2003 Symposium of the JSTSS was held in Kobe on 14th and 15th of March. This symposium was attended by a wide range of mental health care professionals including nurses, social workers, doctors, psychiatrists, clinical psychologists, psychotherapists, psychiatric social workers, art and dance therapists.

At the symposium there were many interesting presentations and open panel discussions, including the introductory keynote presentation by Dr Asukai, the current president of the Japan Society for Traumatic Stress Studies and including guest presentations from Dr Charles Marmar University of California, San Francisco (”Dynamic Psychotherapy for Acute and Chronic PTSD”) and Dr Randall D. Marshall of the New York State Psychiatric Institute (”If We Had Known Then What We Know Now: Learning from 9/11″).

The presentation by Dr Asukai focused on the wide range of psychotherapies and medical treatment available for people who suffer from PTSD (Post Traumatic Stress Disorder) and the need for careful consideration in assessing the condition of people who have experienced traumatic events. Dr Asukai emphasized three key points to keep in mind when treating people who have experienced traumatic events:

1. No one-size-fits-all therapy
2. First, do no harm
3. Natural recovery process

Doctor Patch Adams Japan Lecture Tour: Tokyo Presentation September 2002

Community Mental Health Care in Cambodia and Taiwan In a remarkable and deeply impressive presentations given by Cambodian psychiatrist Doctor Sotheara Chhim (”Community Mental Health Service in Cambodia”) and Mr. Yoshimasa Tebayashi, a Japanese Clinical Psychologist (”Six Years Experience of Mental Health Support Activities in Cambodia”), the following information was included: mental health cambodia During the Pol Pot period from 1975 to 1979 it is estimated that 1.7 million people were killed or died in captivity. The two psychiatrists practicing in Cambodia when the Khmer Rouge took power in 1975 were sent to do farm labour disappeared without trace. The only Mental Health Hospital, built in 1960’s, was closed. Psychiatric patients were killed or sent to work in the fields. Now in 2002 in Cambodia serving a population of about 12 million people there are approximately only 350 mental health care providers including 20 psychiatrists, 20 psychiatric nurses and 215 psychiatric clinical psychologists. Through the incredible efforts of people like these individual psychiatric practice and individual and group counseling programs have been established in Phnom Pen and some of the provinces of Cambodia. For anyone interested in learning more and who are in a position to offer tangible support a good place to start is through the Japanese NGO, the SUMH Network: Supporters Mental Health Website in Japanese Taiwan: Dr Chien is a Taiwanese psychiatrist who has been working within and a leading figure in the development of mental care system in Taiwan. In flawless Japanese he gave an insightful and highly informative presentation on both the way people suffering mental illness had been traditionally been regarded and the current mental health care provision in modern Taiwan, with particular regard to the development of mental health care training and services since the mid 1980’s. Taiwan psychiatrist These presentations by Dr Chien, Dr Chhim and Mr. Takebayashi were jointly sponsored by the Japan Association of Psychiatric Clinics and the Tokyo Association of Psychiatric Clinics and were chaired by Dr Kubota, the President of the TAPC. Dr. Kubota, in his concluding statement, said that he is hoping to develop cooperation with other Asian countries and develop community care services such as psychiatric clinics rather than inpatient facilities.

Held in Tokyo on 2nd and 3rd of March this inaugural symposium was well attended by health care professionals from many fields including nurses, social workers, doctors, psychiatrists, clinical psychologists, community workers and educators.

Do you find it is easier for Japanese to talk about their problems in English rather than Japanese?

Yes, sometimes. This can be the case even with people of varying levels of fluency if they are given sufficient time to formulate what they want to express in their minds before responding verbally and providing that the counselor or group facilitator can speak Japanese.

When speaking in Japanese people may ‘hesitate’ to express personal feelings and emotions verbally. Even as very young children people here have been ‘trained’ to suppress, in public and even at times in private, expression of their emotions and individual opinions when they differ from the group view or the views or their elders in order to maintain an impression of social harmony and agreement. (In fact the suppression of personal emotion in front of other people outside one’s social or business group may still be considered by some more traditionally minded Japanese to be the hallmark of a sophisticated and mature member of society.) In contrast to this English is thought by many people here to be a more ‘direct’ language. In Japanese the expression of material and emotional desires, of hopes and also of expectations of others are often expressed indirectly using hints or innuendo in speech or by simply depending on others to guess one’s “true feeling” or “honne” without verbal explanation.

Both in individual counseling and group therapy situations many people here have said on occasion that is it easier for them to freely express their emotions and talk about their worries or problems in English and also, in some cases, that talking in English helped them to become aware of feelings they had never experienced in Japanese. Also I think that it can be easier for younger Japanese to talk freely about themselves with a counselor who is not Japanese because of the belief that it is somehow more ‘permitted’ to do so in other cultures.

Is bullying still quite common and is it seen in college age population as well?

Yes, it is still very common throughout Japanese society as a whole. Cases of suicide among high school age teenagers linked to bullying tend to get more media coverage here as well as abroad but what is less publicized is the fact that bullying by one’s elders and people in a position of authority can be found in many areas of adult society including both the academic and corporate worlds. Colleges here are more authoritarian than in western cultures and the traditional hierarchical (and largely male dominated) Japanese social structure is still strongly in evidence and it is not unusual to hear college students say they are afraid of their professors because they are so “kibishii” which means “strict”. One women’s university here has the reputation of, to quote a teacher I know who used to work there, “protecting students very strictly” and there are apparently rules regarding the use of make-up, restrictions on wearing jeans on campus and that students are not allowed to be seen in certain areas in Tokyo fashionable among teenagers and young adults after 9 p.m.. The pressures to conform to college, family and social expectations of them can often conflict with the “true feelings” of college age people, especially those with less traditional and more progressive attitudes.

I was a drug and alcohol counselor in USA. Do they provide that counseling in Japan? How does counseling differ?

In comparative terms drug abuse is not as big a problem here as in other countries but alcohol abuse is certainly a problem, especially as heavy drinking is considered by some people to be a socially necessary or unavoidable part of both doing business on a personal level and and also as a way of relieving stress. There are psychiatrists here specializing in alcohol abuse who have their own clinics and rehabilitation day care centers. But counseling here tends to be more generic in the sense that counselors have to assist people with a wide range of social, emotional and mental issues. Not surprising I think considering there are at present around 11,000 JSCCP Clinical Psychologists providing psychological counseling within a population of about 126,000,000 people. In other words the level of expertise of counselors qualified here in Japan is very good and there are very hardworking, and highly dedicated professionals counseling here trained, experienced and skilled in assisting clients with a broad range of emotional and psychological problems.

…. Also how is it treated there?

As in any country treatment varies considerably depending on the psychiatrist providing that treatment. Perhaps I should first explain that some psychiatrists here may still regard mental health care and other psychological support services to be solely within their ‘domain’ and simply don’t see or understand the need for counseling from other health care providers as an integral part of the treatment of anorexia or any other kinds of psychological disorders. They tend to take a completely pharmacological approach to treatment, in some cases sometimes seeing the client for several minutes only, prescribing medication and offering very little in the way of counseling or other forms of psychological support. However I think it’s fair to say that among the majority of psychiatrists here there are many very gifted and skilled doctors who place a stronger emphasis on a teamwork approach to psychiatric care and counseling and who would favor combining their own psychiatric and diagnostic skills with individual and family counseling at independent counseling centers, university student counseling centers or by referring to other medical specialists.

What’s the difference between a psychologist and a psychiatrist here?

Basically a psychologist is a trained counseling and group therapy mental health care provider providing psychological and social support services. A psychiatrist is a medical doctor who is also a trained mental health care provider but who, as a medical doctor, is licensed in Japan (’kokkashikaku’) by the Ministry of Health and Welfare to diagnose, prescribe medication and provide treatment. Some people find it easier to have counseling with a registered mental health counselor (clinical psychologist or psychotherapist) rather than a psychiatrist. But of course counselors, psychotherapists and psychiatrists are concerned with the same fundamental aim: to help the client find a solution to their problem whether it is mainly a social, emotional or mental problem.

It is worth mentioning that the situation at present in Japan is that only medical doctors are legally nationally qualified and licensed (kokkashikaku) by the Ministry of Health and Welfare to diagnose, provide treatment and/or prescribe medication. C.P.s here are board certified by the Japan Society of Certified Clinical Psychologists to provide counseling services in the form of client centered psychological and support services. It is neither ethical nor legal for anyone other than a medical doctor licensed by the Japanese Ministry of Health and Welfare, regardless of whether they may be qualified or licensed to do so in states or countries abroad, to be offering diagnosis (”shindan”) or treatment (”iryou”) as part of their counseling services in Japan.

Are people in Japan still reluctant to seek counseling in your experience?

Yes, compared to the situation in some other countries some people here may still be reluctant to seek counseling, although overall I would say that overall counseling has gained greater social acceptance, especially over recent years.

One reason for this is that there is still quite considerable prejudice against people facing emotional and psychological issues in some quarters of Japanese society and some people here consider mental illness within the family could be seen as being cause for a sense of “social shame” known as “haji”. For this reason, in some cases, people receiving counseling may try to conceal the fact from their families and in other cases it can be difficult to convince parents of the need for psychiatric treatment for their children.

However recently social attitudes are beginning to change a lot and younger people in particular are becoming more positive in their attitude towards counseling and so it is gaining a greater degree of social acceptance. Also it appears to be the case that men here have a better understanding and are more willing to accept the benefits of counseling services, particular with regards to stress management and family counseling, than was the case several years ago.

Whether you are presently living or studying here or abroad start your job search well before you graduate and return to Japan. I have had several emails from people living in various parts of Japan who waited until they graduated and/or returned home before starting their job search and are still trying to get into counseling related work many months later.

If you are not already qualified and certified to offer counseling services here as a Clinical Psychologist by the Foundation of the Japanese Certification Board for Clinical Psychologists (Nihonrinshoushinrininteikyoukai) then please take steps to do so. Over 95% of university graduates from masters courses in psychology in 1999 went on to gain further experience and study for the JSCCP exam to become JSCCP board certified CP’s. You can find out more about how to qualify here as a clinical psychologist in the “Counseling and counselors” section above.

If you have a BA in Psychology or other relevant first degree that’s a good first step but if you are seriously considering becoming a counselor/psychotherapist in Japan you will have to go on to graduate with a master’s degree. Since April 1996 only MA and Ph.D. level candidates are now eligible to apply for qualification as a clinical psychologist.

Sounds obvious but……

Do keyword searches using Japanese search engines and directories in Japanese. For example, entering “Japan clinical psychology” in Japanese will produce 100 times more useful results than searching for “Japan clinical psychology” in English.

May sound even more obvious but…..

Whether you are Japanese or not it may not create the impression you want to if you write saying you are looking for a job as a “bilingual counselor”. Japan like any other country has good mental health who want to assist ALL people regardless of the clients’ nationality and the language they speak. Being able to speak English or other languages can be a useful skill at times but is perhaps best not regarded as a way to avoid (re)adjustment into Japanese society.

In a country where until relatively recently there were not as many opportunities to gain experience through official ‘internship programs’ as in other countries even qualified therapists often find career opportunities initially through volunteering at counseling centers and community organizations.

If you are not Japanese and do not yet have the JSCCP or PSW (Psychiatric Social Worker) qualifications and are seriously considering working here as a useful and effective mental health counselor or JFP (Japanese Federation for Psychotherapy) psychotherapist within the mental health professional community here in Japan you should:

1. learn to speak and understand Japanese.

2. gain a good working knowledge of Japanese society, culture and values.

3. not consider working with Japanese or clients of any other nationality in English unless you understand Japanese too.

4. be prepared to be patient. It takes longer to become established and respected here. If you simply are looking for a relatively more relaxing and financially rewarding way to experience a year or two living and experiencing life in Japan and have more vacation time to enjoy it you could probably achieve this in less demanding occupations.

5. be prepared to study at least to masters level in order to become fully qualified to work as a mental health care professional in Japan.

6. make contact with and establish an effective working relationship within a Japanese hospital/clinic which has psychiatrists on staff who are nationally licensed in Japan to provide treatment and diagnosis, or find a position within an established counseling center which also has the resources, connections and an effective working relationship with a Japanese hospital/clinic with psychiatrists on staff who can support your clients in situations where they are in need of immediate recommendation to an established medical institution for medical support or hospitalization.

7. Finally I would also clearly advise against thinking about seeing clients in you own apartment and giving out your personal phone number. There are many social, cultural, professional and ethical reasons for not doing so in Japan. At the least you could find yourself feeling unsupported, vulnerable and socially isolated. It could also lead to unforeseen problems for both your clients and for yourself to do so.