Home Confinement and Mental Hospitals in Japan — Shuzo Kure's Survey to the Mental Health Act, 1900–1987

This is Part 6 of the series A History of Psychiatry. Part 5 covered three drugs found in the 1950s. The first five parts were set in Europe and America; this time we turn to Japan. In the early twentieth century, most people with mental illness in Japan were not in hospitals. They were locked in a room in their own homes, under a system the law allowed: shitaku kanchi, home confinement. In 1918 Shuzo Kure, professor of psychiatry at Tokyo Imperial University, published a survey of those rooms, one by one, and called for hospitals to be built. The hospitals did eventually come. That was not the end of the story.

This series is a history of psychiatry, not advice on diagnosis or treatment. If you are struggling with your mental or physical health, please contact a medical service or a support line. The article describes restraint and violence inflicted on patients and deaths in hospital. It also contains diagnostic terms and expressions that are no longer used; they are kept as they appear in the historical sources.

A room in the family home, approved by law

Japan's first law on people with mental illness came in 1900: the Mental Patients' Custody Act (Seishinbyōsha Kango Hō). According to Kure, one of its triggers was the Soma affair of the 1890s, in which the confinement of the head of a former daimyo family on grounds of mental illness was challenged as unlawful imprisonment. Cases in which illness was used as a pretext to lock someone up and take their property were, he wrote, not rare at the time.

The act placed the duty of looking after a patient on the family side: a guardian, spouse, relative or head of the household. With permission from the authorities, these people could confine the patient. The patient or the family paid. A room built at home for confinement could not be used without official permission either.

Kure summed it up like this: home confinement means that a private person, with official permission under this act, sets aside a room in the house and shuts a mentally ill person in it.

He accepted the act as a step forward, since until then families had been free to treat patients however they liked. But he also wrote that the law was aimed narrowly at preventing unlawful confinement and left out any idea of treating the patient. The people who inspected the approved rooms were police officers, not doctors. In Kure's survey the most common frequency was two or three visits a month.

About 5,000 beds for more than 140,000 patients

How many people had mental illness at the time? A Home Ministry committee counted through the prefectures in 1917 and found 64,941 people, including suspected cases, as of 30 June. Kure thought this far too low. The reported statistics were crude, and judging by European and American rates, he estimated that the prefectures alone must hold at least 140,000 to 150,000.

Places to take them in were very few. The only public hospital of any size for mental patients alone was Tokyo Prefecture's Sugamo Hospital, with 446 beds. Adding psychiatric wards in university hospitals and rooms inside shelters for destitute travellers, public facilities had about 1,000 beds. There were 37 private mental hospitals in the country, with about 4,000 beds. That made about 5,000 in all.

What happened to the 130,000 or so who could not get into a hospital? Kure divided them into three groups. The first received treatment from a doctor at home or in a general hospital, and these were a wealthy few. The second were in home-confinement rooms, or were not confined but received no treatment either. The third relied on folk remedies at shrines and temples, such as prayer or standing under waterfalls. The second and third, Kure wrote, were the typical treatment of mental illness in Japan at the time.

364 rooms, visited one by one (1910–1916)

As head of the psychiatry department at Tokyo Imperial University, Kure sent his assistants out to the provinces every summer vacation from 1910. In six years (skipping 1915) they covered Tokyo and 14 prefectures, about a third of the country. In all, surveyors went out fifteen times. They inspected 364 confinement rooms, 14 built by towns or cities and 350 by private individuals. The rooms held 361 people.

The report presents 105 cases with photographs and floor plans. Kure and his co-author Goro Kashida sorted them into good (8), ordinary (27), poor (33), very poor (24), and cases supported by the local mayor (12).

Here is what the statistical chapter says about the rooms. The most common size was one ken by one and a half ken, about the size of three tatami mats (31.6 percent); next came one ken square, about two mats (20.6 percent). Rooms were most often inside a reception room of the main house or inside a storeroom (24.6 percent each); 6.9 percent were inside a storehouse. On hygiene, 58.9 percent of rooms were rated poor or very poor and only 10.8 percent good. Light and ventilation were poor in 51.6 percent; some rooms were so dark that from outside one could not tell whether anyone was inside. In almost every case the toilet was a hole in the floor of the cramped room. Food was passed in through a small hatch.

The longest confinement had lasted 27 years. Confinements of five years or less made up 58.2 percent, and six to ten years 23.9 percent.

What about treatment? 48.2 percent had at some point received treatment from a doctor that deserved the name. At the time of the survey, 22.0 percent were under the care of a doctor. The remaining 78.0 percent, Kure and Kashida concluded, were receiving no treatment at all.

In seven cases iron chains or wooden stocks were used: legs bound with iron chain, or a leg pushed through holes cut in two pieces of timber nailed together and tied to a pillar. Only 15 people (4.2 percent) were able to walk outside the room.

The report does not stop at blaming families. The most common reason for confinement was violence against family members or smashing household goods (27.4 percent), followed by leaving home and wandering far away (16.5 percent). More than half of the households (50.8 percent) were in the lowest wealth band, and some had used up their property caring for the patient for years. Early in the illness, Kure and Kashida wrote, families almost always nursed the patient devotedly; as the years passed they could no longer bear it and stopped looking after them.

"The misfortune of being born in this country"

In the report's seventh chapter, "Opinion", Kure and Kashida first say that confinement rooms like these should be abolished at once. They go on: the defects of the law played a part, but the biggest cause was the lack of facilities to take patients in. Then comes the report's most famous sentence. In plain English: the hundred thousand and more mentally ill people of our country bear, besides the misfortune of their illness, the misfortune of having been born in this country.

Kure's prescription was clear. Whether early or late in the illness, put the patient in a hospital and give full treatment. Home confinement as it stood was, in his words, "confinement without treatment", and only hospitals could put that right.

It is worth looking at the hospital figures Kure himself gave, though. At Sugamo Hospital, averaged over the eleven years from 1905 to 1915, 12.0 percent of patients were fully cured, 22.3 percent improved, 37.5 percent were not cured, and 28.2 percent died. Kure's own numbers did not show that hospital admission cured most patients. The advantages he listed for hospitals over home confinement were about how patients were kept: the rooms, cleanliness, food, nursing and exercise.

Incidentally, the report opens with the story of Pinel beginning to remove the chains at Bicêtre in Paris in 1792. As we saw in Part 1, the chains were actually taken off by the ward governor, Pussin. The textbook scene had reached Japan intact by the early twentieth century.

The year after the report, in 1919, the Mental Hospital Act gave the government power to order prefectures to build public mental hospitals. But public hospitals were slow to appear, and home confinement remained legal. So the lawyer Etsuro Totsuka recalled in a 1990 article.

The hospitals came — after the war, and private

What ended home confinement was the Mental Hygiene Act of 1950, passed after Japan's defeat. It abolished both the 1900 and 1919 acts and prohibited housing mentally disordered people anywhere other than hospitals and other designated facilities. People already in home confinement could be kept under the old rules for one more year, and only where there were unavoidable reasons they could not be admitted to a hospital.

Okinawa, under American rule, was an exception. The Ryukyu Mental Hygiene Act of 1960 set no deadline for abolition, and confinement at home, under another name, continued until the islands returned to Japan in 1972. Akira Hashimoto of Aichi Prefectural University traced this through contemporary records in a 2022 article.

The 1950 act also set the rules for admission: admission by order of the prefectural governor, and admission with the consent of a family member or other person obliged to protect the patient. Both were admissions without the patient's own agreement. The idea that a patient might go into hospital of their own accord did not exist in this law.

From here the number of beds rose fast. The 1986 report of the International Commission of Jurists (ICJ) quotes the Japanese Association of Psychiatric Hospitals: about 35,000 psychiatric beds in 1954, about 85,000 by 1960. Tomoko Kanata of Kobe College, in a 2016 article, points to two arrangements behind the growth. From 1958 a special rule allowed psychiatric hospitals fewer doctors and nurses per patient than general hospitals. From 1960 low-interest loans were available to build psychiatric hospitals.

In 1964 the US ambassador, Edwin Reischauer, was stabbed by a 19-year-old with a history of psychiatric treatment. The revision of the law the following year added community outpatient care, but also tightened control over patients.

In 1968 the British psychiatrist D. H. Clark, sent by the World Health Organization, reported that Japan had more than 800 mental hospitals, 80 percent of them founded since 1945. About a third, he wrote, fell well below desirable standards of comfort, hygiene and physical care, and the problems were worst where an owner seeking a return on investment pressed the medical staff to raise income by overcrowding.

By 1983 Japan had 320,068 psychiatric beds, 87 percent of them private. More than 75 percent of admissions were involuntary, and 70 to 80 percent of hospitals were run mainly as locked wards. The average stay had lengthened from 448 days in 1966 to 536 days in 1984. There were 28.1 in-patients per 10,000 people, against 20.5 in England and Wales and 14.6 in Italy. Between 1974 and 1983 the number of beds grew by 21 percent, while most of the European countries the report cites cut theirs by 15 to 29 percent between 1972 and 1982.

The Utsunomiya Hospital scandal, and two ways of counting

In 1981 Etsuro Totsuka visited Britain to study how the law dealt with mentally ill offenders. There he was asked how many people in Japan were detained in hospital against their will, and could not answer. Back home, he found that nobody, not even the Ministry of Health and Welfare, kept the figure. When he worked it out, more than 240,000 of about 300,000 in-patients, roughly 80 percent, were in hospital without their consent.

In March 1984 newspapers revealed that two patients at the Hotokukai Utsunomiya Hospital in Tochigi Prefecture had died after being beaten by staff. Five nursing staff were arrested, and the director was later arrested on charges under the laws on medical practice. According to Kanata, the hospital had opened in 1961 with 57 beds and grown to 920 by 1983.

On 4 April a director-general of the Ministry of Health and Welfare reported to the Diet: 58 in-patients had died at the hospital in 1981, 79 in 1982, 74 in 1983, and 11 so far in 1984 — 222 in all. The hospital's own death certificates called only 19 of these deaths unnatural, and the police confirmed only eight. Most of the bodies, Totsuka wrote, had already been cremated, so the other deaths could not be investigated.

The case was taken to the United Nations. At the human rights sub-commission in August 1984, the Japanese government replied that serious abuse was limited to a few exceptions, and that compulsory admissions were 12 percent, not 80. The gap came from the counting. The government counted only admissions ordered by governors and left out admissions with family consent — both of them admissions without the patient's agreement. In Part 1 we saw nineteenth-century American asylums' "nine in ten cured" shrink once someone counted differently. Here again, what you choose to count made the same hospitals look entirely different.

In May 1985 a four-member mission from the ICJ and the International Commission of Health Professionals spent two weeks in Japan. It concluded that the Japanese mental health system was seriously inadequate both in protecting patients' human rights and in treating them. The main reasons it gave were a lack of legal protection at admission and during hospital stays, and a system built around long-term institutional care with little treatment in the community. Economic factors, it wrote, pushed both hospital managements and families towards longer stays. One private hospital, on the director's authority, refused the mission entry.

In August 1985 the Japanese government announced at the United Nations, for the first time, that it would amend the Mental Hygiene Act. The new law was promulgated on 26 September 1987 under a new name, the Mental Health Act. It required hospital managers to make efforts to admit patients on the basis of their own consent: voluntary admission appeared in Japanese law for the first time. Totsuka points out that British law had taken up the same idea in 1930. Each prefecture was to set up a Psychiatric Review Board, to which people admitted against their will could apply for discharge or better treatment. The act took effect in 1988.

What could be done by this point, and what could not

First, what was achieved. By counting the confined one by one, measuring their rooms and photographing them, Kure and Kashida turned something hidden at the back of family houses into a record anyone could check. Thirty-two years later, home confinement was outlawed on the mainland. In 1987, admission by the patient's own choice and a way to check from outside the hospital whether an admission was justified entered the law for the first time.

Then, what was not. Kure tried to solve "confinement without treatment" by building hospitals. The hospitals did multiply: about 5,000 beds around 1917 became 320,000 by 1983, more than sixty times as many. But most were private, with locked wards, and run in a way that made long stays pay. The share of beds in private hands, about four in five, had barely changed since Kure's day. The place of confinement had moved from the home to the hospital, but confining people and treating them had still not been clearly separated.

And there was the difficulty of counting. Kure's survey began with counting, and so did Totsuka's campaign, with a figure nobody had. The government counted 12 percent of the same in-patients as compulsory; the lawyers counted 80. The drug trials of Part 5 created a way to test whether a treatment works. The question of whom to treat, where, and with whose consent remained a question of law and of how to count. This article stops at the 1987 act and does not cover later revisions.

Next time is the final part, on the attempt to make diagnosis consistent: Rosenhan's 1973 experiment, deinstitutionalisation as the United States closed its large hospitals, and DSM-III in 1980. It brings us back to the problem Earle showed in Part 1 — that the numbers change when the person doing the judging changes.