Searching for peace of mind

One in every four adults in any given year suffers from a mental health issue according to the Mental Health Foundation and the Kim Foundation.   Be it anxiety (18%), a mood disorder (9.5%), or a social phobia (6.8%), some amongst us are going to experience psychological pain that might best be dealt by seeking outside assistance.  It would be hard enough in your own country to search for and find such help from a trained professional.  Just how in Japan does one go about finding a suitable professional and what can one expect?   We posed these questions to Dr. Linda Semlitz, an American trained and board certified psychiatrist (a physician).  Dr. Semlitz is Executive Officer of TELL and Clinical Director of TELL Counseling Center.

Not surprisingly, American trained and certified psychiatrists are not allowed to practice in Japan.   Only Japanese trained doctors can practice psychiatry.  Dr. Semlitz herself is not able to practice psychiatry here.  Only as recent as 2010 did Japan allow for specialty accreditation for physicians in psychiatry.  “That’s new,” said Dr. Semlitz adding, “It used to be as a physician you went through physician training and all the requirements, but there wasn’t any subspecialty requirements or subspecialty certification.”

More shocking, anybody can become a therapist.  As in most other countries, mental health is provided not just by psychiatrists but by psychologists, professional counselors, licensed family counselors, and social workers.  For these professions there are no national requirements.  Dr. Semlitz commented, “Anybody can be a therapist.  So can you”.

According to Dr. Semlitz, the Japanese national health insurance payer system drives the quality and type of mental health care that is available.  As we all know, the national health insurance provides a reimbursement for a variety of illnesses for all residents.  That includes psychiatry.  Psychiatrists are reimbursed for their time.  As a general rule it does not provide reimbursement for time-consuming counseling and talking therapies.  The average psychiatrist in a metropolitan hospital system has to see 40 to 50 people each morning or afternoon.  “They’re very, very busy,” noted Dr. Semlitz.  “That means psychiatrists can spend only three or four minutes per patient.”

That might be changing.  Psychiatrists are beginning to hire psychologists to provide psychotherapy on their behalf.  Under certain circumstances such therapy is covered by national insurance.  In addition, cognitive behavioral therapy may be reimbursed soon based upon accreditation by certain social workers.  Until then, psychiatrists will likely continue to refer perhaps one out of six clients to counseling.  Dr. Semlitz surmised, “There aren’t enough trained people to do psychotherapy.  Also, there’s not a strong likelihood that people are going to follow up because there’s no reimbursement.”  This underlines her belief that the payer system drives the level and type of available care.

Training also differs in Japan.  In the United States, North America, and Europe there is a requirement that all mental health professionals take part in supervised clinical work in addition to lectures and studies.  In order to become licensed they need to complete a minimum number of hours of supervised clinical service.  For a master’s level or doctoral degreed psychologist that’s accomplished through practicums or internships.  “These traditions don’t really exist in Japan,” Dr. Semlitz commented.  She added, “It’s very hard to know when you see a mental health professional in Japan what their background is, what their training is, and whether their title reflects what you think it is.  That’s really very challenging.  It’s difficult for you to know as a lay person who may not know a lot about the field or maybe are new to Japan.”

What type of therapy do Japanese psychiatrists offer?  Psychiatrists usually do not provide talking therapy.  Very few are trained to do so and there are no incentives because the payment system would not reimburse them for their time.  More often the average person gets a prescription.  “Actually multiple prescriptions,” said Dr. Semlitz.  “In the absence of paraprofessionals, people end up on medication.”

That’s also true on an inpatient basis.  In studies of Japanese inpatient programs Japan had far fewer psychiatrists and nurses compared with other inpatient settings around the world.  The length of stay is much longer too.  There is also a gradually changing tradition in Japan of using multiple relatively high dosage anti psychotics.  “This is generally not done in the West,” said Dr. Semlitz.  “My guess the reason for this is that paraprofessionals are rarely on the inpatient units to perform counseling and what is typically known as milieu therapy. Therefore doctors may feel the need to keep people subdued and sedated.  That does not mean that nurses aren’t very nice and aren’t doing their best.”

Japan differs from the West in other ways.  In the West you have a multitude of therapies such as milieu therapy and group therapies that don’t exist in Japan.  Here you’re getting rest in a safe environment with caring people. They end up taking care of the sickest people.  These are people who have psychotic disorders such as schizophrenia and serious forms of depression.  They usually involve long lengths of stay.  “It’s a very paternalistic system,” said Dr. Semlitz.  “In the United States they have very short inpatient lengths of stay because of the limitations of commercial or other reimbursements.  Japan is a society where people coexist in a densely populated country.  They can’t allow people going around being dangerous or disruptive.”  Dr. Semlitz believes that long-term psychiatric care provides a protective setting for these individuals.  Of course, most people with mental health issues that are treated on an outpatient basis are neither dangerous nor disruptive.

One similarity is that mental health is stigmatized universally, perhaps more so in Japan and throughout Asia than elsewhere.  Anyone who’s related to anyone who has psychiatric or mental health issues is stigmatized around the world.  “It’s particularly true in Asia, not just Japan,” said Dr. Semlitz. “I would imagine that you have colleagues who have had diagnoses of depression or anxiety disorder.  They may have indeed sought professional help.  They may be on medication and you would never know it.”

Adding to the stigma is the expense.  The days of everyone seeing an analyst are over.  Few can afford the cost.

For a Westerner living in Japan, finding a Western trained therapist can be difficult. Psychotherapy and mental health treatment requires the ability to communicate easily. That is very difficult to do if the language spoken is not your native tongue.  There are also cultural differences that need to be considered.  “The limitations of resources are challenging in Tokyo,” said Dr. Semlitz adding, “Outside Tokyo and other major Japanese cities it’s even more challenging.  There are very few options.”

A good starting point is Wiki-TELL, Tokyo English Life Line’s wiki based database containing a list of organizations which provide services for the international community in Japan.  You should also search the website of the International Mental Health Professionals Japan (IMHPJ).  IMHPJ is a professional association of private practitioners that provide mental health services to the international communities throughout Japan.  They do their best to assess credentials, but according to Dr. Semlitz, there aren’t enough English speakers scattered around Japan doing this kind of work.  Also check out the TELL Counseling Center.  It provides face-to-face therapy by Western trained and licensed psychotherapists that use evidence based models of care.

If all else fails and you can’t find a therapist locally, consider distance counseling.  With the advent of Skype, a counselor has the ability from afar to conduct therapy whilst looking a client in the eye.  They can see facial expressions.  Although technology is good today, it’s not quite like being in the same room with a therapist.  With distance counseling, there is always some loss of meta-communication.  Sometimes the technology cuts out, and you’ve lost the session.You really are better off having face-to-face sessions.  For people who live hours away, distance counseling like those provided by the TELL Counseling Center maybe the only option.

Linda Semlitz, MD.  Executive Officer, TELL (Tokyo English Life Line).  Clinical Director, TELL Counseling Center. (03) 4550-1146 Minato-ku, Tokyo

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