David LeCount Report

Primary Premise

The primary premise of this report is that Japan has been able to build a hospital-based system in a relatively short period of time that provides access and availability for a large number of people. There exists a tremendous work ethic, dedication, and attention to detail, that is manifested throughout Japan, also exemplified within the mental health system. The same culture that created this system has the potential to develop the infrastructure and services for one of the finest community oriented mental health systems in the world. This will require a paradigm shift away from the hospital as the focal point of treatment, to the community as the focal point of treatment. There is much promise in this message for the future.

Background

This report is based on a two-week mental health consultation; lectures, seminars, and site visits in Japan, September 10 - 24,th 2000. During this time seven cities in Japan were visited; from Obihiro to Osaka and Kobe, with Tokyo being the landing, departure and in-between setting. It was a wonderful comparative experience in which information was gathered and exchanged in a variety of informal communications such as in-patient and community mental health program site visits, as well as through more formal mediums such as lectures, seminars, and workshops. All of the formal presentations were well attended. Participants consisted of mental health professionals, students, and some consumers, with questions and answer time affording excellent participation.

Madison Model Presentation

My advance prepared PowerPoint presentation entitled: The Madison Model - Keeping the Focus of Treatment in the Community was the primary tool used to explain our comprehensive system of care in Madison, Wisconsin, USA. This presentation was prepared specifically for a keynote address at the National Psychiatric Social Workers Conference in Obihio and then was used during all other sites visited. The Madison Model presentation established a foundation for discussion about community mental health services and principles based on the past quarter century of experiences in building a comprehensive system of care in Madison, Wisconsin. This presentation served as the focal point for discussion in each of the sites visited, to share ideas, and promote further interest towards community services. I will be using information from the presentation throughout this report and there will be a specific section explaining community mental health principles, many of which were briefly explained in my presentation. The text of this presentation is available on the web site listed below.

Reactions

As a part of the PowerPoint presentation, further background information was placed on the following web site: http://userpages.chorus.net/lecount/. Since my return to the United States, there have been more than 100 hits from Japan on this site. I also disseminated my e-mail address: LeCount@chorus.net.I have received numerous e-mail communications and requests for on-site visitations to our system in Madison, including one group from Japan who visited here upon my return. The Program of Assertive Community Treatment (PACT), the pioneer program started in Madison in 1972, which originally demonstrated the efficacy of community-based treatment, is currently in the process of having their manual translated into Japanese at this time. While PACT is a part of the Madison Model, it should be noted that this effort is independent from my responsibilities, but very much relevant to our ongoing information exchanges.

Contextual References

In writing this report, I will be making many comparatives between our respective countries. In doing so, it is not my intention to be ethnocentric, or to emphasize one approach is better than another. Rather, the intent is to look at patterns and trends, and incorporate my impressions that will invariably be fraught with my personal experiences and bias. In this regard, I want to make it clear that my bias is towards community-based treatment. I am not anti-hospitalization, rather I believe it should be viewed in the context of one treatment approach within a community-based treatment network, and that it should primarily be used for short periods of time for the highest levels of acuity. I am aware there are many differences between us in terms of culture and the way social, legal, political, economic, and governmental systems operate. Certainly, universal human values will be highlighted and accentuated throughout this report. I am very conscious of the fact that I am presenting this information from my perspective and my culture. I am very respectful of the Japanese culture, and in no way intend for the reader to assume that I can fully understand the culture, or that I am making any value judgements predicated on my lack of knowledge. Just as each person in the mental health system should be empowered to be responsible for their own change and growth processes, likewise, each system of care has to define for itself how to best make changes possible within the context of their respective governmental-political-social systems and culture. Hopefully, we can all build on our strengths and accomplish our goals in the context of best practices and efficiencies. The only other caveat I would offer is this process was conducted largely through the intermediary of translation. Therefore, it is possible that misunderstandings and subtle language differences may account for some inaccuracies in the information I am including in this report. To the extent this may have happened I am apologetic and hope that any factual inaccuracies will be weighed critically in that context. There are also some areas where I received conflicting information, such as the historic numbers of people in psychiatric in-patient settings and the cost for services, for which I therefore remain confused. This confusion is presented in the context of promoting a dialogue that hopefully can lead to the necessary clarification and arrival at more accurate information.