The mental health and welfare system and its related laws in Japan [inglese]

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MIZUNO Masafumi , MURAKAMI Masaaki ed Antonio A. RIZZOLI presentano in questo contributo in inglese scritto appositamente per lo Speciale 180 l'evoluzione delal legislazione psichiatrica giapponese

MIZUNO Masafumi*, MURAKAMI Masaaki**, Antonio A. RIZZOLI
*Department of Neuropsychiary, School of Medicine, Keio University, e-mail:mizuno@med.keio.ac.jp
**Department of Social Welfare, Faculty of Sociology, Meiji-Gakuin University e-mail:murakami@soc.meijigakuin.ac.jp
Servizio di Psichiatria 1°, Dipartimento di Salute Mentale, ULSS n. 9, Treviso: e-mail :aa.rizzoli@ve.nettuno.itFirst of all, I would like to take a general overview of the history of the mental health and welfare system in Japan. From the Custody Law for Mentally Ill (1900) to the Mental Hygiene Law (1950) 

The law concerning mentally handicapped persons in our country goes back to the "Custody Law for the Mentally-Ill" enacted in the year 1900. This "Custody Law for the Mentally-Ill " legally sanctioned the private confinement that was being arbitrarily performed prior to the law. Its main aim was to safeguard the public. Later, the "Mental Hospital Law" was enacted in 1919 and every prefecture in the country was obliged to build a public mental hospital. However, no progress was made because of a lack of economic resources, and World War II soon began.
After World War II, both laws were abolished in 1950, and the "Mental Hygiene Law" was enacted to replace them. The "Mental Hygiene Law" provides: first, that psychiatric hospitals be established by prefectural and municipal governments, second, that a mental hygiene consultation center be organized in every prefecture, and third, that involuntary admission by commitment is permitted by notifying persons showing abnormal behaviors that they may injure themselves or others because of a mental disorder, etc. The law's aim was not to confine mentally handicapped people but to ensure that they received medical attention.
In 1965, the Mental Hygiene Law was revised, because an unfortunate incident had occurred. Edwin O. Reischauer, the US Ambassador to Japan was stabbed by a young man who had experienced a psychotic episode in the past. This incident revealed the lack of a proper system for managing outpatients. The new system provided outpatients care at public expense, making it easier to manage and grasp attract outpatients. The system of hospital commitment was also reinforced to safeguard the public.
Psychiatry itself at that time was undeveloped, and there were no effective means of psychopharmacological treatment. Commitment was the main management strategy, and the importance of protecting society was emphasized. During this period, from the late 1950's to 1970's, a policy of increasing the number of psychiatric beds was adopted and was assisted by growing public expenditures to build new facilities. The number of psychiatric beds increased from 44,000 in 1955 to 250,000 in 1970, rising approximately five fold in 15 years. Moreover, the system of involuntary admission by commitment at public expense was widely applied, and the number of patients treated by the commitment reached 76,000 in 1970.
Technical advances in pharmacological therapy and rehabilitative medical treatment such as day-care since 1965's have ushered in a new phase of mental health care in our country. The importance of human rights was stressed, and patients were treated in a less confined environment.
A nation-wide survey was carried out on inpatients in 1983 to assess actual conditions. It revealed that about 20% of the 330,000 mental hospital inpatients could be discharged if health and welfare services were appropriately prepared. There was a strong trend toward socializing psychiatry but another unfortunate incident occurred.
The Utsunomiya Hospital Scandal, human rights violations in mental hospitals were severely criticized by society in 1984 as a result of an event in Utsunomiya Hospital in which inpatients died after being abused by the nursing staff. Human rights violation were not rare in such mental hospitals. This issue was raised in the ICJ (Geneve) and United Nation's ILHR, and members of the ICJ came to Japan to survey the state of affairs. The Japanese government was urged to undertake drastic revision of the Mental Hygiene Law. The most important point in revising the Mental Hygiene Law concerned protection of the human rights of mental hospital inpatients.
Psychiatric review boards, was newly set up by this revision. This board accepted complaints from inpatients, such as claiming that involuntary admission is unjust, and demands of leaving the hospital, etc. The designated physician on mental health was obliged to write the regular six months reports on the conditions of involuntary inpatients.
The next point that was stressed was promotion of rehabilitation. A new system of rehabilitation facilities was established for mentally handicapped persons, and rehabilitation and the promotion of mental health were added to the law's purpose, leading to a change in name from the Mental Hygiene Law to the "Mental Health Law". This 1987 revision is said to have promoted rehabilitation measures. Under the slogan from mental hospital to rehabilitation facility, from rehabilitation facility to community", rehabilitation promotion centers for mentally handicapped persons were founded.
Fundamental Law of the People with Disabilities and Community Public Health Law
Here, I would like to add an explanation of laws that are closely related to mental health.
The "Welfare Law for the Handicapped" was enacted in 1949 and the "Welfare Law for the Mentally Retarded" was enacted in 1960. However, there was no welfare law for the mentally handicapped. The "Fundamental Law for Countermeasures Concerning the Mentally and Physically Handicapped persons" which was enacted in 1970, include mentally retarded persons but did not include mentally disordered persons as handicapped persons.
Enactment of the welfare law for mentally handicapped persons had been requested for long time. The International Year of Disabled Persons in 1981 and 10 years of disabled persons by United Nations (1983-1992) made the opportunity to develop policies for handicapped persons in general and promoted the idea that mentally handicapped persons are not only patients with mental illness but handicapped persons with disabilities affecting their daily lives and social activities. These changes on the concept of the mentally handicapped extended the necessities for the welfare policies for the mentally disordered.
The revision of " Fundamental Law for Countermeasures Concerning Mentally and Physically Handicapped Persons" was enacted in December 1993, to the "Fundamental Law of the People with Disabilities". In this law people with mental illness were clearly defined as "handicapped persons" together with those with physical disabilities and the mentally retarded. So, it was requested to promote the welfare policy for the mentally handicapped person in addition to a current medical service.
In 1994 July, enactment of the "Community Public Health Law", stressed further strengthening of the community-based mental health system. It authorized the importance of the local government in the field of mental health services.
Aiming at the birth of the Law on Mental Health and Welfare for People with Mental Disorders (mental health and welfare law)
During the preparation stage for amendment of the Mental Health Law in 1995, the law still centered on the articles concerning admission treatment and additional components of rehabilitation. At the time, the concept of welfare for handicapped persons had not yet been established, and the contents and role assignments of local governments in community mental health service were unclear. The most significant point in the amendment was strengthening of welfare measures for the mentally ill. Sweeping reforms of the law were needed to promote policies for mentally handicapped persons on this occasion.
The most important and delicate subject in the revision of this law was the relationship between mental health and welfare of mentally handicapped persons. There were two points of view against mentally handicapped persons. On point of view, harboring distrust of medicine for a long time, some people demanded clear separation of social welfare from medical services, whilst others had another idea stressing the medical service for the mentally handicapped persons because they are patients.
Relation between the mental health and the welfare of mentally handicapped persons
Article 3 of the old mental health act defines the term, a "mentally disordered person" in the Law as referring to a psychotic person (including those who are intoxicated) , a mentally retarded person, or a psychopathic person. This means that the Law defines mentally disordered persons as persons having mental disease, and catch the mentally handicapped person in the medical concept. This idea is based on medical health policy such as prevention, therapy, and rehabilitation of mental disorders.
On the other hand, in the article 2 of Fundamental Law of the People with Disabilities (1993), a "mentally handicapped person" is a person having some limitation in daily or social life for a long time due to physical disorders, mental retardation, or mental disorders. This law includes mental disorders as disabilities in social welfare policy, and states that mentally disordered persons need assistance to enhance their social participation and independent daily living. Therefore, there are two aspects of mentally handicapped persons, as patients having mental disorders and as handicapped persons having limitations in their daily lives. In the official bureaus for mentally handicapped persons issues, it is not suitable to have two independent divisions as a health and medical department and a welfare department. Policies for mental health and mentally handicapped persons should be executed with intimate partnerships. Thinking about the merits of the integrated execution of medical and welfare services for mentally disordered persons, it was assumed that it was a realistic method to execute the welfare services in addition to a current services as the public health center which had been executing the mental health policies with the cooperation of welfare offices. Until that time, public mental health services had been provided by health centers and prefectural governments.
Based on the details described above, I will now outline the 1995 revision. The most significant point of the revision was the strengthening of welfare services for people with mental disorders. The law adds to its objectives the concept of welfare measures for people with mental disorders so that the assistance needed to promote their self sufficiency and participation in social and economic activities will be provided. The title of the law was changed from the " Mental Health Law" to the " Mental Health and Welfare Law", when the objectives of the law were changed. The revision also provides a new chapter on "Health and Welfare" that, in combination with the existing chapter on "Medical care and Protection", structures this legislation to include both pillars (health and welfare).
To strengthen the functions, a number of items regarding the welfare of people with mental disorders were added to the services and duties of various other organizations and personnel that were once part of mental health services. They include mental health centers (prefectural institutions that disseminate knowledge related to mental health, conduct research and high-level counseling and guidance for people with mental disorders and their families). In accordance with these changes, the names of these mental health centers were changed to "mental health and welfare centers", "Local Council on Mental Health and Welfare", and mental health and welfare counselors, respectively. Moreover, in order to promote mental health and welfare measures in the community, the amendment stipulated that prefectures and municipalities publicize the value of mental health and welfare, as well as provide counseling and guidance to people with mental disorders and their families. Rehabilitation facilities were reinforced, and four services: social training facilities, sheltered workshops, welfare homes, and welfare workshops.
In article 19, an accredited physician system was defined to attend a training course conducted once every five fiscal years, pursuant to Ministry of Health and Welfare ordinance, by the Minister of Health and Welfare or by other parties. Administrators of mental hospitals that admits mentally handicapped persons in the form of commitment, admissions for psychiatric care and protection or temporary admission, must have a full-time accredited physician on their staff.
Formulation of the Government Action Plan for the persons with Disabilities
In December 1995, the headquarters for promoting the Welfare of Disabled Persons adopted a "Government Action Plan for Persons With Disabilities: A Seven-Year Strategy to Achieve Normalization" that spans the period from fiscal 1996 to fiscal 2002. The Government Action Plan for Persons with Disabilities has the characteristics of a priority measures in implementing of the plan that will further promote the "New Long-term Program for Government Measures for Disabled Persons" formulated in March 1993. It has established concrete numerical goals that should be achieved by 2002.
The Government Action Plan for Persons With Disabilities aims to implement a concept of rehabilitation whose goal is to restore rights as a full citizen in all stages of life, and a concept of normalization that aims at a society in which people with disabilities live their lives the same as people without disabilities. As the priority measures implementation plan of the "New Long-term Program for Government Measures for Disabled Persons", it strives to promote the following measures on a priority basis.
First, to live together in the community, the plan establishes a system that provides a proper place for work or activities, a place to live, and needed health and welfare services at each stage of life.
Second, to promote social self-sufficiency, the plan ensures an education system finely tuned to the characteristics of each handicapped person. The system should develop measures to employ people with disabilities in accordance with their aptitude and abilities, and link education, welfare, and employment so that social participation is achieved through their occupations.
Third, to promote barrier-free access, the plan encourages vigorous efforts to remove obstacles in public spaces such as roads, stations, and buildings.
Fourth, aiming to improve quality of life (QOL), to achieve a qualitative improvement in the social life of the handicapped through self expression and social participation in communication and cultural activities, etc., it is necessary to promote the development of practical welfare tools and information processing equipment, etc. by using an up-to-date technology.
Fifth, to ensure a safe environment, it is necessary to promote the creation of an infrastructure to prevent disasters and expedite the building of local crime and disaster prevention networks and emergency communication systems.
Sixth, to eliminate psychological barriers, it is necessary to improve people's understanding of the handicapped through volunteer activities, etc.
Seventh, promoting international cooperation and exchange in the field of welfare appropriate to Japan, the government should do economical support for the exchange. The concrete numerical goals to be achieved by the end of the year 2002 are as follows:
There are now to be said 1.57 million mentally handicapped persons in Japan, with 330 thousand of them are being treated as inpatients in psychiatric hospitals. Some of them could not leave the hospital due to the lack of the availability of well-organized community welfare services, and thus this type of admission is called "social admission". It is estimated that about 27 thousands persons are already in remission after more than one and half years stay in the hospital. These mentally handicapped persons have a mental illness and daily and social disabilities, making it necessary to prepare both health and medical policies and rehabilitation and welfare services.
Therefore, social welfare facilities, such as rehabilitation institutes and group homes, have started to prepare for discharge of 20 to 30 thousand persons from psychiatric hospitals.
As shown in the slides, as support for independence in communities, social training facilities in Japan will be increased from 83 to 300 by 2002 year, about 4 times; Short-term stay services from 21 to 100, about 5 times, welfare homes from 80 to 300 about 4 times, group homes from 220 to 920 about 4 times, sheltered workshops from 83 to 400 about 5 times, welfare workshops from 1 to 59, social adjustment training services from 2356 to 3300, and community living support centers from 47 to 650. In addition from the standpoint of medical psychiatric rehabilitation, day care services will be increased from 372 to 1000.
Finally, I would like to explain about the enactment of the Psychiatric Social Worker Law which is the topic now.
Long-term hospitalization and so-called "social hospitalization" of mentally handicapped persons have been pointed out as problems in the current state of the mental health welfare in our country, and returning them to society and promoting their rehabilitation and social participation is an urgent problem as shown in this slide.
There have been psychiatric social workers (PSW) working as a co-medical staff for a long time, however, it was not a fully qualified occupation and their numbers have been insufficient. In order to resolve this so-called "social hospitalization" situation, the Ministry of Health and Welfare has decided to create a qualification board system to train 10 thousand competent PSWs in the next 5 years to promote rehabilitation and return of patients to society.

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