Suite à la traduction en français du livre de Junko Kitanaka, Depression in Japan: Psychiatric Cures for a Society in Distress, pubié en 2011 aux Princepton University Press, sous le titre De la Mort volontaire au suicide au travail: histoire et anthropologie de la dépression au Japon, en 2014, aux éditions d'Ithaque, un workshop a été organisé par Pierre-Henri Castel, Maurice Cassier, Alain Ehrenberg, Nicolas Henckes et Christian Galan (Cermes3 et CEJ). Il s'est tenu à l'Inalco le 23 mai.
Voici l'argument, suivi de quatre brèves contributions de Nicolas Henckes, Alain Ehrenberg, Sarah Terrail Lormel et Bernard Thomann à ce workshop.
Psychological labor, overwork depression and suicide : Comparing France and Japan
The aim of this workshop is to bring together a number of specialists from different disciplines in order to discuss Junko Kitanaka's contribution from a comparative perspective. To what extent our understanding of work-related suicide and depression in France could benefit from her description of what happened in Japan? What could be the relevant similarities and differences between the two countries? Are there practical consequences to be drawn from these differences, in terms of public policies or grassroots interventions, and which ones? And finally on a more general level, what do we learn from such an investigation about the local appropriation of global trends?
For Junko Kitanaka's book, Depression in Japan : Psychiatric Cures for a Society in Distress, now translated in French, stands at the crossroads of at least four major directions of investigation in present-day social science.
1. Anthropology of medecine and mental health : one key point of Junko Kitanka's argument is that the meaning of "depression" and "suicide" is overdetermined by culture and history. Even when the medicalization process, which is a global process, appears to standardize the meaning of these words (through pharmaceutical marketing, among other factors), they still remain rooted into local medical practices, cultural beliefs, and political fights with a strong historical background. Depression, in this respect, demonstrates that, rather that one and only one biomedicine, we may be facing a highly diverse collection of local biomedicines. In this context, how psychological labor can sustain a systematic comparison? And how such a comparison between Japan and France could help us to understand the common and specific meanings and uses of "depression" and "work-related suicide" in both societies?
2. Sociology of work and industry : can "psychological labor" (English for both "souffrance psychosociale" and for "travail psychologique") be constructed as a social or political universal? For it seems to rely heavily on cultural definitions of autonomy, mental health, and even of what count as an "individual" in Japan and in France. The dialectic of the local and the global seems to undermine the evidence of a sweeping "domination" of the neoliberal paradigm worldwide. But it might not boill down to a mere political issue of local "resistance" to globalized capitalism. On the contrary, local ressources, contextual forms of subjectivation and empowerment, all point to a more complex and dynamic interplay between socio-economic constraints and new opportunities for a greater autonomy of individuals. A core issue, in this respect, is the emergence of a new "psychiatric science of work", within the framework of the risk society. To what extent, on the one hand, this new science in the making, dealing with people' stress at work, does foreshadow a new form of social control? To what extent, on the other hand, the current medicalization of psychological labor is to be hailed as an "scientific" stopgap against the over-exploitation of emotions and cognitive abilities of workers?
3. Another striking feature of Junko Kitanaka's work is to de-estheticize the otherness of Japan : bringing her country closer to us, she shows that in the aftermath of the Lost Decade, and with the new policies implemented by Junichiro Koizumi and his successors, many seemingly "Western" moral and psychological plagues just bursted out in Japan as if there were no more Japanese "exceptionalism". How could Junko Kitanaka's book contribute to reshape the field of Japanese studies in France ? Is the entry through medical anthropology more relevant than any other ? In other words : how should we proceed to expand the inquiry?
Pierre-Henri Castel : Bridging the gap between medical anthropology and the sociology of work : Junko Kitanaka's on psychological labour.
Alain Ehrenberg : From idioms of distress to an anthropology of adversity in individualistic society : Propositions for a radical intellectual shift.
Nicolas Henckes : Standardized, localized and embodied. A commentary on the sociality of biological psychiatry in Junko Kitanaka’s ethnography of the clinic.
Christian Galan : Does Japan really exist ?
Sarah Terrail Lormel : Social phobia in Japan : A counterpoint to Junko Kitanaka's description of depression.
Bernard Thomann : The evolution of work ethics in Japan.
Nicolas Henckes. Commentary on Junko Kitanaka’s Depression in Japan
What makes Junko Kitanaka’s book wonderful is its multifaceted approach to depression in Japan, combining history, sociopolitical analyses and ethnography, highlighting through a variety of lenses both how depression has been adopted at different periods and in different ways by Japanese people as an idiom of distress and how it has come to change their very relationship to activities that have had deep cultural meaning in Japanese society, from work to suicide. But what also makes the book fascinating for a French reader is that it is not only a study of Japanese depression, but it is also a wonderful and too rare ethnography of biological psychiatry at work. And to the extent that biology is now the dominant current within global psychiatry, it is an ethnography of global psychiatry, albeit from a different perspective from the one we are used to in Europe and North America. This is a dimension to which, as an apprentice ethnographer of biological psychiatry myself, I am especially sensitive. And this is why I would like to comment on this very specific dimension of JK’s work.
At the end of chapter 4, following on anthropologist Allan Young, Junko comments on the contrast between a global psychiatric science and local clinical practices. And it seems reasonable that norms and knowledge be global and practices local. But I would like to suggest that in fact clinical work has a global dimension, that clinic itself is global. Or, to be more accurate, that clinical work as well as psychiatric science articulate in two different and contrasting ways the global and the local, that they both construct a local and a global. To some extent this argument might be referred to Timmermans and Berg’s tricky but stimulating idea of “local universality”: this refers to the specific ways in which universality is enacted locally by clinicians who rely on clinical guidelines to perform their work. But you probably don’t need formal guidelines: As has been shown by studies of clinical case presentation, the clinical encounter is framed by a series of norms and standards that are perhaps not less global than biological knowledge upon mental disorder.
For instance Junko tells how, in their encounter with depressed patients, psychiatrists work by suggesting a series of inferences that work by both creating a link or a correlation between the patient’s distress and some sort of underlying biological process and obscuring or setting aside. This is an analysis that can be found actually in earlier ethnographies of psychiatric work, most notably in Robert Barrett’s wonderful book in schizophrenia in Australia. But the fact that medical work transforms the patient into a workable person somehow detached from himself, is a central dimension of the analysis of medical discourse beyond psychiatry. As Katherine Hunter showed in her wonderful book on “doctor’s stories”, as patient present to the consultation, they are re-presented in clinical work. In this process you trace a line between the biographical elements that belong to the patient and those that are reconstructed by clinicians to make the clinical case.
Of course the outcome of this process, the very clinical case, is shaped by a series of specific, local factors that reflect a combination of organizational factors, cultural traits and scientific choices. And in this respect I am struck by the fact that JP hospital in Tokyo with its specific blend of biological, philosophical and psychological theorizing, is indeed a perfect place to address these issues in their complexities in the Japanese context.
But what is more interesting is what Junko does with this analysis to explain the success of biological psychiatry.
In Junko’s account, the normativity of the clinical setting plays a role that goes beyond the issue of defining what a given condition is about and how it should be understood, but it also bears upon the very ways in which psychiatric knowledge are framed. JK develops a stimulating hypothesis to explain why JP psychiatrists embraced biological psychiatry when she suggests that it might have been related to the changing relationship of psychiatrists to patients in the aftermath of the antipsychiaty movement. In other words it might have reflected a deep transformation in the ways the clinical encounter was framed socially. Patients just did not want any more that their psychiatrist deal with them in the way they had done so far. This is a stimulating account to explain why we did not experience the same shift in France, were antipsychiatry was noteworthy politically weak – and in any event was not predicated upon a patient’s social movement.
There is more to it. What makes Junko’s argument powerful is that she has had the opportunity to observe the various moments of the life in a psychiatric consultation, of consultations and staff meetings, of diagnostic decision making and treatment assessment. But what makes her work even more powerful is that she has had a chance to talk to patient before their encounter with psychiatrists. And to the extent that depression, at the time when JK did her observations, was a rather new phenomenon in Japan, she thus has had an opportunity to talk with individuals that had no prejudice against psychiatry, or no prenotion of what depression was about. This makes her ethnography almost an experimental setting that enables her to shed light on the very process by which patients discover, adopt or not psychiatrists’ version of their disorder, on how they learn or not to understand their condition as resulting from some underlying biological process. This is a rare situation.
And in this respect I am struck by the fact that Junko presupposes less in her analysis than what we have been used to in the literature on labelling theory or its recent followers – I am thinking again of Barrett’s book. Biological psychiatrists might well try to teach patients to see their conditions as resulting from a purely biological phenomenon. Junko doesn’t make grand hypothesis regarding the extent to which patients are actually transformed by this discourse. Some patients might have adopted this version of their disorder. Others seem to resist to it. But even more strikingly, many patients, but actually psychiatrists as well, seem to develop a somewhat reflexive and even ironic stance toward this discourse, knowing that it is indeed a discourse, a useful one, which you want to believe in to get better. There is of course a rich anthropological understanding of the therapeutic
The point is that biological explanations are pragmatic. Psychiatrists adopt them not so much because they work especially well to account for the experience by patients, but precisely because they don’t. And as a result because of their plasticity, as they might be useful for patients with so different experiences. There is clearly a point here about the status of symptoms that can be seen using David Armstrong’s idea of distal symptoms, a class of symptoms that are only loosely free floating above the condition.
There is an implicit argument in this analysis. Biological psychiatry doesn’t need a deep commitment by patients and psychiatrists to work. And this is what makes it so powerful.
Again this is indeed a wonderful analysis. But I wonder to what extent we want to stick on it. There is a general sense in the literature that biological psychiatry doesn’t work by rewriting the self. Even Nikolas Rose, who made an argument for the idea that we now had a new neurochemical self, argued in his last book that biological reductionism did not mean a reduction of our individuality to the brain. Quite to the contrary biological reductionism was foundational for a new psychological discourse in which we should act on our brains.
Now, in what ways psychological discourses are articulated to brain discourses, this is probably what is not that clear. The French psychiatrists I have been observing seem to have a very different way of articulating biology and psychology. Although they endorse a biological worldview, and, I think, really do believe in it, I was always struck by the fact that they also were deeply committed to a psychological discourse influenced by psychoanalysis – but also at times by other systems - to account both for the patient's situation and condition. Moreover, these discourses were developed in parallel ways by clinicians and in many ways did not intersect. This leads to my conclusion: The very ways in which psychological and biological discourses are articulated might be shaped locally by specific understandings of the relationship to the body.
A final comment. Junko insists on the role of antidepressants and especially the SSRI in the increase of depression rates in Japan during the 1990s, a finding that is consonant with what has been written by some scholars about the rise of depression in the 1970s and 1980s in Europe and North America, including Healy and Jean-Paul. I would have loved that you look at the creation of the antidepressant market in Japan, this would have made a wonderful additional chapter to the book. But there is more to it. Of course there are many anthropological works, both in northern and southern countries, that insist on the specific apprehension and understanding of pills by patients. Is there any argument of this kind to be made about Japanese people? Did the typus melancholicus have a specific way of thinking about pills as a therapeutic agent?
Alain Ehrenberg. What we talk about when we talk about mental health issues. Propositions for a radical intellectual shift
“One should neither laugh nor cry at the world, but understand it”, Spinoza
Alain Ehrenberg. What we talk about when we talk about mental health issues. Propositions for a radical intellectual shift
“One should neither laugh nor cry at the world, but understand it”, Spinoza
In the conclusion of her book2 Junko Kitanaka writes that anthropologists and sociologists are now starting to go beyond the domination/resistance model. This model can be characterized as a sociological analysis which is primarily political—domination/resistance being typical political vocabulary of power struggle relationships. But I must add: this is politics in a very narrow sense, politics conceived of by academics, a jeremiad3 denouncing social evils—the belabored self, emotional work, and other falls of public man—without indicating concrete levers for action. Too many scholars have adopted what anthropologist Francis Zimmerman called “the mourning paradigm” twenty years ago4. This is what I appreciate the most in Junko Kitanaka’s book: she proves this claim by making the leap beyond this simplistic model. In it, one can see a society in all of its concreteness and specificity, and this is why her book is genuine anthropology, I mean, a book in which anthropology is not just a label, but, as Marcel Mauss put it, an inquiry through which the reader understands what people do and think, and the reasons why they act and think like this.
Reading the description Junko Kitanaka gives of anthropology on these subjects in her introduction, I feel obliged to underscore how much my work fundamentally differs from this picture in what I talk about when I talk about depression5 and mental health issues.
The position I defend is that the sociological and political must be differentiated to depict human social life accurately, and hence, to have a means of improving the world by pointing out the levers for action.
This speech is organized to foster two discussions: one on French singularity and public policy—public policy being conspicuously missing among scholars on mental health—, and another on the anthropological status of mental health problems.
First, I’ll make a comparative remark on French society as a case in point of the domination/resistance model, where it is part of culture, and will make a proposal in terms of public policy in order to put the “science of work” in Japan and “psychosocial risk management” in France into perspective. Second, I’ll continue and add to Junko Kitanaka’s conclusion to propose a more radical stance for anthropologists and sociologists: to approach mental health as an attitude toward adversity resulting from social relationships which links the individual to common evil6. This invites a return to classical anthropology, as outlined by Marcel Mauss in France or Evans-Prichard in the UK.
France: from the domination/resistance model as a system of collective beliefs to public policy
France is a society in which politics is of particularly high value7 —“la question sociale”/“the social question” was at the core of French Revolution8— and the domination/resistance model is strongly anchored in collective representations—collective representations are not constraints that come from outside, they are expectations that determine or rather constitute us by affecting us in a total manner9. The concept of autonomy divides French society, the cost of autonomy being a topos of the national narrative, autonomy resembling a Kantian imperative, whereas it unifies the US, where the overloaded individual is a marginal collective representation. Specifically, when I say in France, I mean not only among academics, as in the UK, Germany or the US, where this is intellectual routine, but also and above all in society at large, in which anti-liberalism is a common conviction, part of a system of collective beliefs anchored in our old Jacobin tradition, according to which the State sets society in motion and frees individuals from their private dependencies. The State is the “instituteur du social” (“the State institutes the social”), an expression which connotes both the notion of institution and an idea of the State as a sort of primary-school teacher (“instituteur” is French for “school teacher”), an idea hard to believe for American individualism in which the Government is often seen as the main danger for “rugged” individualism—the division of American society regarding Obama’s healthcare reform being the latest episode of this history. The Jacobin tradition has been renewed in the new context of globalization, flexible work, unemployment, and “precarity”: many people think that we have to resist the tidal waves of neo-liberalism and globalization.
In France, generally speaking, the word “liberalism” is preceded by prefix “ultra”, “individualism” followed with adjective “frenzied”, and “autonomy” considered a danger for our life in common. These ideas permeate French collective representations, and French society is a case in point in itself of this domination/resistance model. For example, a book by John Dewey entitled Individualism and Social Action (1935) has just been translated into French with the title Après le Libéralism, as if it were impossible for French people to associate liberalism with social action. Actually, for most of us, this is certainly not a spontaneous association, though the fact that there are several types of liberalism and several neo-liberalisms. I must add that even a small dose of Dewey certainly wouldn’t harm French sociopolitical thought, on the contrary.
I would summarize French collective representations as follows: we have seen a shift from a social model, where individuals make up society, to a liberal (or neo-liberal) one, where this is no longer the case. This is the core expression of the French malaise. And it is in the concept of social or psychosocial suffering that this decline of social links has been invested. I must add that French people have very good reasons to think like this, but I have no time to explain these reasons, though this explanation doesn’t go beyond the scope of today's discussion.
In Japan, depression is anchored in overwork and worker suicides; in France, depression began as an illness of modern life at a particularly optimistic moment of our history—the first article published on antidepressants for GPs in 1958 heralded the arrival of a medication able to help people fight an “illness of modern life”10. It is with its transformation into “social suffering” around the year 2000, with the rise of two topics related to the workplace, psychic suffering caused by flexible work, that is overwork (“souffrance au travail”), and moral harassment11 (“mobbing” in other countries), that the domination/resistance model has found its expression, social or psychosocial suffering being the hallmark of the damaging effects of neo-liberalism and globalization. Starting in the 1980s, the French have gradually come to group these diverse problems in the concept of social suffering, a notion of people unified in their suffering that can be considered as stemming from French Jacobinism in the setting of modern mental health12.
Now I’d like to add a remark about what to do about the workplace above and beyond the “new science of work”. Pierre-Henri Castel ends his presentation by opening a discussion on “political and philosophical interpretation of the foundations of […] ‘psychosocial suffering’” (p. 18). I’d like to highlight two missing points: the sociological dimension, and public policy. Indeed, if one wants to discuss work and employment today in terms of public policies, one must expand the picture beyond medical anthropology to include both the sociology of organizations and work13.
If you look at these problems without having a sociological description of management practices, which can vary tremendously, there is a risk of giving an overly general picture of what’s going on inside of firms; the risk is the “craving for generalization” (Wittgenstein). Actually, problems of social suffering greatly depend on these practices. A sociology of depression in the workplace without an empirical sociology of management overlooks a fundamental descriptive step: flexible work raises various types of problems different from those related to divided work. In divided work, the core issue of management is coordination of action; in flexible work, it is how to make individuals cooperate. In this shift, the personal equation has arisen: this implies emotional issues, which were marginal before, but doesn’t imply that contemporary work is hell. We should think in terms of previously existing social risks, inherent in divided work, and in terms of new social risks, inherent in new ways of working14. One must not assess flexible work with criteria pertaining to divided work.
Indeed quality of working life is the subject of a large body of research at the European level, showing a marked increase in work effort in which “the long-term health effects of increased pressure are likely to be particularly severe among the low-skilled. This is because the impact of work pressure is mediated by the degree of control that employees can exercise over the work task. Where people are allowed initiative to take decisions about how to plan and carry out their work, they prove to be substantially more resilient […]. It is jobs that combine high demand with low control that poses the highest health risks”15 (not only depression and anxiety, but also cardiovascular and other somatic diseases). This is the point that should be highlighted before focusing the attention on psychiatric science, in the case of Japan, and on psychosocial risks, in the case of France. They are only part of the big picture. Here differential diagnoses are required because they are the only means to find the way for action. This is a much more difficult and demanding political task than general jeremiads on neo-liberalism. Building social dialogue between employers and employees takes time, implies a definition of methods, an elaboration of shared diagnosis by stakeholders, etc.
New social risks also require public policies regarding investment in the skills of individuals from their early age (preschool, etc.), adapting and securing professional trajectories, accommodating critical life course transitions, etc.16
The research gap between those who work on mental health issues and those who work on these topics is striking. This is a pathway the formers should take if they really want to improve the world and not only denounce its social ills.
From idioms of distress toward an anthropology of adversity in individualistic society
The idioms of distress approach is a consistent sociological alternative to the domination/resistance model, and the accurate and subtle way Junko Kitanaka develops the ethnographic part of her book shows its richness for a comprehensive understanding of the human condition. Nevertheless, I’d like to take the discussion a step further and deeper towards basic problems of anthropology and sociology. What I want to highlight is a point made by Junko Kitanaka when she writes: “Japanese psychiatry [has] succeeded in conflating the biological and the social […] in delivering a category framework which translates individual misery as a sign of collective suffering” (p. 39, translated from the French). The suggestion I’ll formulate has perhaps the advantage of offering a global sociological framework, which both accounts for depression and other syndromes as idiom of distress, and enables us to clarify the anthropological status of these idioms. It could help clarify what we talk about when we talk about mental health issues.
Mental health issues in our society must be regarded as what philosopher Peter Winch called the “attitude toward contingency”17 or adversity. In practices pertaining to this attitude there is a drama “in which there are ways of dealing […] with misfortunes and their disruptive effects on a man’s relations with his fellows, with ways in which life can go on despite such disruptions”. In other words, in these practices, two aspects are intertwined: the operative (or instrumental) and the symbolic.
As Junko Kitanaka writes, « psychiatry remains an area of medicine where all tensions of society are at the foreground » (309). She is right. Many of the problems grouped under the heading “mental health”—depression, addictions, ADHD, and others—tend to be systematically subject to social and political concerns about what is right, fair, unfair, good, bad; they tend to be a soul-searching area of life in society and have become objects of intense and ongoing social controversy. The controversies at issue revolve around the argument that these conditions are in fact not only illnesses requiring treatment (like schizophrenia), but also social ills involving values and ideals inherent to our way of life. At stake are the values we attach to our social relations—in school, the family, and the workplace, and by extension, in society as a whole18. Although these ills affect people individually, they also manifest a common ill or problem that is social, even socio-political in nature. This question of the value of social relations, of their human value, cannot be set aside: it is an intrinsic characteristic of these subjects; it belongs to their grammar.
There are cogent reasons for this situation, which are related to the core features of mental pathologies: they are functional pathologies in the sense that they are illnesses pertaining to ideas and moral feeling necessary to civilization, like guilt and shame, without which there would be no society at all. To be able to feel guilty in certain contexts is a right and good thing, having an excessive feeling of guilt is pathological: obsessional behavior is valued, obsessional symptoms are pathology. They are both values of civilization and symptoms. In the case of Japan, they are those closest to the highest values of Japanese society which succumb to the weight of depression. This is why we speak of social pathologies.
There are two intersecting uses of the idea of a social pathology that need to be differentiated in sociological terms: 1) a use serving to analyze the causes and reasons of a problem and the means to act on them; this use is practical and singularizing (this person's depression results from poor interpersonal relations within this department); 2) a use expressing a wider social ill. In this latter sense, depression, addictions, or post-traumatic stress are reactions to or forms of resistance towards such things as competition, flexibility, and subjective commitment required by the management of firms; they are ways to weigh their value for human beings. In this latter case, the use is rhetorical and universalizing: mental suffering is approached from the viewpoint of a malaise in society19.
Hence I propose to approach mental health issues as expressing a common attitude regarding adversity produced by social relationships (flexible work, competitive pressures on children at school, family disruptions, etc.). They link individual and common evil at two levels, practical/singularizing and rhetorical/universalizing. The political idea for which “society” causes psychic suffering should be replaced by the sociological idea according to which psychic suffering has been extended to social issues and must be approached as an “obligatory expression” of social ills —we should think of relations between the idea of idioms of distress and the Maussian concept of “obligatory expression of feelings”, published in 1921.
In this context, medicalization is less a medical normalization of multiple behaviors, contrary to what sociologists and anthropologists, supporters of the domination/resistance model, have repeated for decades, than a dynamic through which social relationships have entered the area of health—social relationships appear in the individualistic language of substances under the label of “behavior”, a hypostasis of social relationships. Thus, the tensions between the “medical” and the “social” are not only inevitable, but also an intrinsic part of this area.
Mental health concerns our ways of being affected by our ways of acting, and also how we act upon these afflictions. It is a major individualistic way of dealing with what the Ancients called passions; it offers a social form adopted both to name and to deal with passions when norms, values and social ideas tend to be entirely oriented toward individual action. In this way it intertwines our modes of action and passion.
Depression has been approached more in terms of accompanying transformations of ideals or collective representations than of power relationships, that is, a Durkheimian rather than Foucaldian orientation.
On the anthropological level, my hypothesis was that contemporary depression is the encounter between traditional melancholy, which affected the exceptional man, and the modern individualistic democratic dynamic for which everyone can become exceptional. It has accompanied what I have called the democratization of the exceptional.
On the socio-historical level, I read the history of depression in the 20th century through the history of the opposition between Freud's conflict model, in which symptoms have a moral dimension pertaining to guilt and are a compromise, a way for the individual to get out of his dilemma, but by reproducing them disguised, and the deficit model of Janet’s “mental disinfection”, which compensates for the lacking will of the patient by spiritual direction (“direction de conscience”). Whereas the neurotic for Freud is the subject of his own conflicts, for the logical reason that the patient is simultaneously the agent of his own change (the patients does the work, not the therapist), this is not the case with Janet’s concept. In terms of philosophy of action, the patient is the principal agent for Freud, and the immediate agent for Janet.
Beginning with the invention of electroshock therapy, I have described two periods in the contemporary history of depression. From the nineteen-forties to the beginning of the seventies, there were complementarities between the two models of illness, and depression was considered as a subfield of neurosis—even the more biologically-oriented French psychiatrists recognized how much they were indebted to Freud’s analysis of (unconscious) conflicts—, ECT, then neuroleptics and antidepressants driving the development of psychotherapies, considered as the “in-depth treatment” (“traitement de fond”)20. The disconnection between the two models during the seventies and the autonomization of depression disorder has led to the domination of the deficit model over the guilt model, and neurosis has been embedded in depression. In other words, depression today is the posthumous revenge of the Janetian mental disinfection on Freudian guilt conflict.
These two periods have been analyzed as corresponding to two ages of individualism. Neurosis is a tragedy of guilt, because its underlying question is: what am I allowed to do?, whereas depression is a tragedy of inadequacy, because its core question is: Am I able to do it?
Bernard Thomann. The evolution of Japanese labor ethics
The research of Junko Kitanaka suggests that the evolution of Japanese psychiatrist vision of depression and suicide is linked to the rather violent socio economic evolution Japan experienced this two last decades. Changes in the social and work environment, such as the weakening of emblematic practices like lifetime employment, contributed to the destabilization of the material and mental universe of the Japanese worker.
In parallel, according to the representation of the otherness of Japan that is usually developed in Europe and America, at the center of this worker mental universe, there is unique work ethic. In this perspective, the mutation of the psychiatric interpretation of depression and suicide that professor Kitanaka analyses is to be partly linked to a kind of disaggregation of the Japanese style work ethics.
Of course, Junko Kitanaka suggests a more complex relation between work ethics and the recent epidemic of overwork depression and suicide. With the growing global hegemony of the neoliberal discourse on individual competition, workers are less likely to develop a social, moral or political consciousness on their working conditions, and more likely to “worry on their somatic and psychological fragility”. Furthermore, if a growing number of workers are psychologically destabilized, it is not so much because of the disaggregation of their work ethic, as the result of the growing gap between a certain dominant discourse that valorize absolute identification and self sacrifice toward their enterprise and the real corporate practices they are confronted to. However, to really measure what is at issues in this growing gap, one has to avoid to think that there is such a thing such as a « Japanese style work ethic ». As professor Kitanaki avoid to take a naturalistic approach of such medical object as depression, we have see the “Japanese work ethics” not so much as cultural given than as a complex social and historical construction.
Since the first consequences of the industrialization, there was always coexistence between different discourses on labor and work, by varied actors, with different rationality. In Japan, as in other part of the industrialized world, there was a socialist discourse on labor exploitation, produced by left wing labor unions and political parties that focused on class-consciousness and solidarity. In parallel, most industrialists reinvented protoindustrial social relations and Confucian traditions to develop a paternalist and familialist discourse. Work ethics consisted then in a hierarchical exchange of service between the worker and his employer. Indeed, through the XXth century, Japanese corporate culture always developed a discourse on work values and labor relations negating their economic and market nature and the existence of class conflict. Social reformist and non revolutionary labor organizations proposed alternative solution to these irreconcilable position by developing a kind of personalist discourse on the respect of the human value (jinkaku) of the worker and of cooperation (kyôchôshugi) between labor and capital for the sake of a higher productivity that would be beneficial to all. This ideology was largely integrated in the corporate culture and encouraged by the State in the name of superior interest of the economic development of the nation.
This ideology largely spoke the language of science. Respect of the well being of workers was indeed not only an ethical issue, but also a biological one for the nation state, young working girls of the industrial revolution being future mother of future workers and soldiers. Scientific management of the workers body by labor science and occupational medicine was the condition of a higher productivity. But this expertise, the labor law, the administrative and corporate practices were not the result of pure science, but a compromise between contradictory interests and discourses on work and labor. And with time, the balance of power evolved. This historical process was not purely a Japanese one, but the content of the discourses, the tradition mobilized for reinvention and the balance between the different social forces could differ between Japan and a country like France. And what surely characterized Japanese process was the “hegemony”, to borrow the term used by Andrew Gordon, of a corporate culture that gradually no longer met any alternative discourse on work ethics. This worker dependence on representations produce by the corporate world produced a different social citizenship.
From this point of view, Junko Kitanaka analysis raises very interesting questions.
Is new social mobilization for the recognition of depression as the result of social environment, but also individual vulnerability, will be able to break this “hegemony”, produce a real alternative discourse on labor or produce an even more intrusive one, based on an even stronger bio power, as Junko Kitanaka seems to suggest?
Are the closer medical management that liability suits tend to promote result more in the capacity of the firm to select between the able and non able ones, than in the protection of the worker in the enterprise? In the absence of a sufficient number of labor inspectors, and considering the very weak influence of labor union on scientific expertise and administrative procedures, won’t the decision of which labor practices are normal or pathogenic (such as in the evaluation on the stress scale) be totally in the hand of the employers?
Junko Kitanaka suggests that psychiatric scientific discourse interact with lay knowledge, and popular epidemiology. Is growing involvement of psychiatrist in social questions will contribute to a better account of lay knowledge or a strengthening of corporate expert power, considering that dominant economic power having always an advantage in shaping the scientific expertise?
Is the development of a psychiatric normative discourse on labor not a very essential step in the development of various instruments necessary to the individualization of labor relations and in suppression of what remains of collective bargaining practices and discourse on social classes conflicts? Is global neoliberal discourse on individual responsibility tending to liberate Japanese worker from his relation of dependence with the firm or tend to produce an even worst kind of alienation?
Sarah Terrail-Lormel. Scattered comments on a few aspects of Junko Kitanaka's Depression in Japan – Psychiatric cures for a society in distress
Junko Kitanaka's fascinating study –beautifully translated to French by prof. Castel–, constitutes an important contribution to the general field of social studies of psychiatry and will be a classic for anyone interested in the contemporary history of psychiatry in Japan.
The organization of this workshop itself is also a very positive accomplishment, as scholars from the CEJ (Center for Japanese Studies) have been repeatedly calling, in the last decades, for a change in the lack of a real intellectual exchange in the social sciences between France and Japan, having here reunited eminent French sociologists and philosophers of mental health, Japanese medical anthropologist, and French specialists of Japan, is a sign that things are changing. And by “things” I mean our vision of Japan (not only an aesthetisized Other, but a real society dealing with similar problems) and the way we consider the non-Western world in general and –as a feedback effect– ourselves.
Though not being an anthropologist, my own research is rather close to prof. Kitanaka's, both in terms of the object (a clinical entity) and the historical period studied (XXth century). My first intention was therefore to propose the case of social phobia as a counterpoint to prof. Kitanaka's analyses, but turning unsatisfied with my first drafts, I've decided to limit myself to make a few comments on prof. Kitanaka's general approach (points 1 and 2), and ask her a few questions regarding the problem of psychotherapy (3 and 4).
A first important element of this book, is Prof. Kitanaka's approach of the medicalization process. For sure, in the last decades, many scholars in the fields of sociology and history of medicine have repeatedly criticized the simplistic description of medicalization as an oppressive process led by the medical profession and/or Big Pharma and driven by hidden motives such as the search of profit, professional interest, or the maintaining of social order; a picture in which naïve patients are reduced to a completely passive role. This sort of critique is nevertheless most diffused in the public discourse nowadays and not that uncommon among humanities scholars outside the circumscribed field of social studies of medicine. Moreover, I don't think I'm exaggerating much if I say that, this line of thinking, was the overwhelmingly dominant interpretation of the dynamic of the history of psychiatry in Japan, until the publication of prof. Kitanaka's book in 2012, followed by another brilliant study by a young researcher, Satō Masahiro the following year1.
Far from ignoring its potential dangers, Kitanaka nevertheless offers an extremely nuanced description of the current medicalization of depression in Japan and demonstrates the necessity of approaching it as a productive process that also enables patients –recognized as reflexive actors– to advance social causes such as the recognition of overwork as a cause of depression or suicide. Her description of the strong socializing dimension of the contemporary language of depression in Japan –beyond its biologically reductionist aspect– is indeed one of the important contributions of the book. It shows the partially liberating role played by psychiatry, legitimizing individuals' suffering and calling public attention on depression as an urgent issue. Though, as she points out, this socializing language of depression is not without pitfalls: psychiatrists' restrictive (conservative) definition of what counts as “social”; the strict avoidance of the psychological exploration of depression; the facilitating role this socializing discourse may have played in opening up the Japanese market for antidepressants.
The anthropological approach here demonstrates its strengths: the detailed observation of clinical encounters reveals the complexity of both patients' and psychiatrists' motivations, hesitations, convictions, dilemmas, and the limits of the power of psychiatry persuasion.
Because it makes the question of medicalization more complex (“complex” intended in a positive sense), describing it as a multi-layered, localized and opened process, this work is an important scientific contribution, and we may hope, also a social one.
Another important dimension of prof. Kitanaka's work, is the way she skilfully deals with the pitfall of cultural reductionism. Of course, the Culture & Personality school isn't mainstream anymore in anthropology and the nihonjinron paradigm (discourses on Japanese identity) isn't as prevalent in Japan as it was in the Post-War period. But the object studied by prof. Kitanaka is slippery as psychiatrists sure haven't been the last to explain particular differences (social norms of behaviour, language, etc.) between Japan and “the West” as absolute and a-historical “cultural” differences.
To take but one example, the understanding of the Typus Melancholicus by Japanese psychiatrists as a core feature of the Japanese self (p.75 Engl. version) appears as one of the many features promoted in the 1970s as typical features of a fantasized “Japanese psyche” –such as the amae (desire for passive love) or taijinkyofu (Japanese concept of social phobia). If I may allow myself a short parenthesis related to my own research, the long-lasting belief held by Japanese psychiatrists that taijinkyofu/social phobia was a typically Japanese neurosis (an idea that goes back to the 1950s) is to be linked to its inscription, in 1994, in the “Culture-bound syndromes” annex of the DSM-IV under the name “taijinkyofusho”. The very existence of the culture-bound syndromes category, as defined by the DSM, and its problematic implicit assumptions tells enough, I think, about the long-lasting effects of ethnocentrism and particularism –both in Western countries and in Japan– and the continuous necessity of always historicizing our objects of study.
To get back to the question of typus melancholicus, the way prof. Kitanaka approaches it shows that its appraisal as typically Japanese may not so much illuminate us about a supposed “Japanese psyche”, but may indeed be indicative of what was regarded as positive personality features, and expected of the Japanese male white collar employee during the “economic miracle” era.
Another illustration of this will allow me to make a transition with the two other points of my presentation, related to a particularly stimulating point of Kitanaka's demonstration.
The interdiction against psychotherapy in the case of depression (chapitre V, Fr. version) is one of the aspects of the book that have interested me most.
Prof. Kitanaka shows how different level of factors –such as past therapeutic failures, the lack of a systematized psychotherapeutic education, the long-lasting influence of Japan's antipsychiatry, and the current organization of psychiatric care– how these factors play a determining role in the caution shown by psychiatrists against any sort of psychological exploration. No need here to call in a typically Japanese “holistic” approach, or worse, a supposed “inanalyzability of the Japanese” as Lacan once did (1971).
Though these explanations for the “Japanese interdiction against psychotherapy” (p.92 Engl. version) are extremely convincing, some questions remain for me, regarding the extent of this “interdiction”. I mean here an institutional, a theoretical and a diagnostic extent.
a) Institutional constraint: is this “taboo” on psychotherapy for depression horizontal in all clinical settings in Japan or could it be a specificity of university hospitals and large hospitals –where, as you mention, “doctors work on incredibly tight schedules” (p.91 Eng / p.151 Fr). What about small clinics?
b) Definition of psychotherapy: it might only be a matter of expression, but as the title of the chapter suggests2, it seems that psychotherapy is here equated with reflexivity, and reflexivity intended as the certain type of reflexivity promoted by psychoanalysis (active exploration of the meaning of the symptoms). So the question is: does this taboo apply to all forms of psychotherapy or is it limited to the psychoanalytical approach? If we intend psychotherapy as any cure of psychological problems by psychological means, is psychotherapy really absent in the context of the psychiatric cure of depression that you describe? A patients' support group inspired by Morita's psychotherapy is mentioned (p.139-40 Eng. version). And it is very tempting to see the conscious establishment of a transferential relationship between the psychiatrists and their male patients (reproduction of their hierarchical work relationships) (p.135 Eng. Version). So couldn't this “interdiction against psychotherapy”, in a more limited way, be an interdiction against psychological introspection?
c) Depression specificity: does this interdiction against psychotherapy also apply to other mental illnesses deemed biological? Schizophrenia for example (which also has been the object of psychotherapeutic attempts in the 1960s-70s)?
Finally, still drawing on the question of psychotherapy, I would like to submit to prof. Kitanaka a very tentative reflexion regarding the possibility of a recent evolution in the kind of demand for mental health in Japan. My interrogation is: might we learn something about this by drawing closer the partial dissatisfaction of certain category of patients (women for example) towards the established cure of depression in psychiatric hospital context –as described in the book–, and recent evolutions in Morita therapy3? My comparison is based on the following elements: the status of personality types, work, introspection and the of the individual meaning of psychological suffering in psychiatric theory and cure.
We find both in the cure of depression and in Morita therapy a centrality of psychological types and a caution against the pathogenic potential of introspection. On another level, we see a displacement of the status of a certain attitude towards “work” (here understood in the very general acceptation of an activity one fully immerses itself into in an unquestioning manner –this point is quite questionable): a therapeutic means in the classic version of Morita therapy, it has become an etiological factor in the cure of depression (weight of the historical contexts, economic miracle vs uncertainty, devaluation of the previously promoted work ethic)
One the one hand, As prof. Kitanaka showed, contemporary psychiatrists' represent the depressed patient as the Typus melancholicus/“immodithymic personality” = hardworking white collar who pushes himself too hard. When curing these patients, psychiatrists avoid exploring individual psychological suffering as it may potentially “neuroticize” the depression (p.103 Eng.). On the other hand, Morita's therapy is directed towards people of a “nervous constitution”: smart, introverted and prone to excessive (pathological) self-consciousness individuals. According to Morita, discussing or encouraging those patients in analyzing their own symptoms would only help them in worsening their condition4. This is where work, or more precisely “occupation”, comes into play: after a period of absolute rest, the patient is gradually brought to engage in work activities (such as gardening, housekeeping, etc.) meant to distract him from his pathological introspective tendencies and allow him to reconnect to the “reality”. Work, here, has a positive, and therapeutic value: it prevents the patient from his self-alienating thinking.
Drawing from these elements, I am wondering if some evolutions observed in the galaxy of Morita therapy in the 1990-2000s, both on the level of theory and patients' expectations, may be echoing what's described in prof. Kitanaka's book. The formalization of an outpatient form of Morita therapy, in the 1990s, has brought changes to the therapy, one on them being a greater space granted to the discussion of symptoms (which was previously theoretically forbidden). More importantly maybe, in a Morita therapy-based patients' self-help group, older members (who have lived a part of their professional career in the period of economic expansion and who promote a classical vision of Morita therapy) have expressed their surprise towards the attitude of young new participants, and the gap between each generations' expectations. Young people, they say, tend to be more reluctant towards the principle of plunging oneself unquestioningly into the prescribed occupations, and are strongly asking to talk and be heard. The same senior members commented how these new expectations require more time and how “everyone's individuality has to be respected”.
I am wondering if what seems to be a growing inadequacy between this local, almost one century-old form of psychotherapy and younger patients, and the inadequacy of the contemporary –but outdated?– socializing language of depression for a part of the patients (especially women) may be stemming in part from the same cause: a lack of recognition of the individual meaning of psychological suffering (bound with the representation of psychological types)? Are we witnessing since the past 20 years a progressive shift in the sort of demand towards mental health –a demand for more recognition of individual suffering –or is it only a marginal phenomenon? And, if so, what therapeutic resources exist –or are being created– to answer this demand? Lastly, might it be indicative of ongoing changes in the modes of subjectivation in Japan?