David LeCount Report

Itinerary

The dates, places, and events in which these experiences occurred are as follows:

Obihiro

1. 9-11-2000: Obihiro: Comparative seminar presentations were made between mental health services in the Hokkaido prefecture and Madison, Wisconsin.
   
2. 9-13-2000: Meeting with the mayor of Obihiro, the Honorable Mr. Toshifumi Sunagawa.
   
3. 9-14-2000: Workshop on Interdisciplinary Teams conducted at the National Psychiatric Social Workers Conference in Obihiro.
   
4. 9-14-2000: PowerPoint presentation of the Madison Model made at the National Psychiatric Social Workers Conference in Obihio.
   
5. 9-15-2000: Site visits including community mental health services in Obihiro; a private psychiatric hospital in Obihiro, the Hokkaido National Hospital, observed work sites and living arrangements, and ended with a wrap-up session at the Obihiro Care Center.

Osaka

1. 9-16-2000: Visitation at Parappa Workshop in Osaka.
   9-16-2000: PowerPoint presentation at Osaka College of Health & Welfare, along with question and answers.

Kobe

1. 9-17-2000: Kobe Seminar.

Tokyo

1. 9-18-2000: Tokyo Seminar.

Nagoya

1. 9-19-2000: Nagoya PowerPoint presentation, including question and answer session.
   
2. 9-19-2000: Nagoya site visits included 3 workshops, Danshu-Kai (a self-help group for alcoholics), and a private psychiatric hospital.

Kawaski

1. 9-21-2000: Site visits in Kawaski including a large Psychiatric Rehabilitation Center. Visited three workshops and a public health department.
   
2. 9-21-2000: Dr. Kimura delivered the PowerPoint presentation, local people made presentations, and I critiqued my observations of the Kawaski service delivery system and answered questions.

Saitama/Omiya

1. 9-22-2000: Site visit at Saitama Comprehensive Mental Health Center in Saitama.
   
2. 9-22-2000: Site visits at the Yadokarinosato in Omiya. Dr. Kimura delivered the PowerPoint presentation and facilitated question and answer session.

General Impressions

All of the participating communities were enthusiastic and receptive to the Madison Model presentation and moving in the direction of community-based treatment. I was impressed with the graciousness, generosity, and eagerness of the hosts to showcase their services and share their experiences. It is apparent there has been uniformity throughout Japan in the development of the hospital-based approach, which had its primary development in the 1960s. It is somewhat ironic that this development occurred at the same time the United States was moving in the opposite direction of down sizing hospitals, albeit it took many years to develop services or models of treatment in the community that were responsive to the levels of after care needed. The U.S. is still struggling to meet the challenges of community treatment in a responsible manner, and with varying degrees of success throughout the country. In the U.S. today, there are more people with serious psychiatric disorders incarcerated in jails and prisons than there are in psychiatric hospitals. It is therefore with a great deal of humility and empathy that I am sharing my thoughts about my observations and the information I derived from this experience, as well as presenting my recommendations as to how to proceed in promoting a community-based system of care such as Madison, WI.

Japan embraced the concept of hospitalization especially in the decade of the 1960s. The hospital industry continued to grow and flourish reaching a maximum level of approximately 360,000 people in the early 1980s. Since 1984, with a greater emphasis on human rights, hospitalization has been slowly decreasing. As Mr. Mitsuo Kadoya from Obihiro said, since 1982, there has been a conscious effort in their community to discharge people as rapidly as possible. Today, there appears to be approximately 30,000 fewer people in the hospital, and future directives should further impact on further decreasing this number. Presently, the emphasis remains upon hospitals with regards to money, staff, power, and influence. Staff salaries for services in the community are apparently not commensurate with that of hospital staff. The medical model predominates, and community-oriented psychopharmacological psychiatry is almost non-existent. While the future direction appears to be in placing incentives in the community and more responsibility on the local levels (municipalities), thereby creating greater equitability and parity with other disabilities, there is currently a lack of emphasis on the comprehensiveness of services needed and the coordination of those services. Teaming in the context of the community remains relatively obscure, as does the integration of services and people into the main stream of society.

Hospitalization

Formal presentations about Japan's adult mental health system since 1950 were given in Obihiro and Tokyo. Mental health professionals in Kawaski also presented an historical perspective pertaining to their city and prefecture. I will briefly summarize this information, which represents approximately one half-century in the historical evolution of the Japanese adult mental health system. The following information is largely derived from the lecture presented by Mr. Rynta Furuya at the Tokyo forum.

The hospitalization movement started in the 1950s, with the advent of the Mental Hygiene Law that made involuntary hospitalization possible. During the 1950s, there were 85,000 people in mental hospitals. The largest growth in in-patient occurred during the 1960s. In ten years, the number tripled to 250,000 people by 1970; approximately 29 beds per 10,000 people. Today, there are 1670 hospitals and 330,000 - 340,000 people in them; 89% of hospitals are private (which is in sharp contrast with the U.S.). The government facilitated this growth in hospitalization by providing a National Insurance that paid for in-patient treatment. In each prefecture, the number of hospitals varies. There are 1.6 million hospital beds in Japan, of which 22% are for psychiatric treatment. Five percent of the total health budget is allocated for medical costs for psychiatric in-patient care.

It is apparent that hospitalization was a concept that was fully endorsed at all levels of government in Japan during most of the last half century. It has been promoted by a national insurance program that pays the bill for the largely private (89%) for-profit hospital industry. Most of the incentives and policies still support this industry and promote this practice, much to the consternation of many mental health professionals who would like to see a greater emphasis on support of community practices.