A Disability of the Soul: An Ethnography of Schizophrenia and Mental Illness in Contemporary Japan by Karen Nakamura (review)

Karen Nakamura’s A Disability of the Soul offers a close look at a remote and in some ways utopic place: a residential community for mentally ill, largely schizophrenic, patients in a small, remote town, Urakawa, located on the southeastern edge of Hokkaido. In pursuing research on psychiatric disability and the effects of deinstitutionalization, Nakamura wondered where she could find communities that had promoted the agenda of allowing people with psychiatric disabilities to live actively and independently. She was pointed to Bethel House. Nakamura spent eight months living at Bethel (in a small house with little privacy, located near the parking lot of Bethel’s associated Red Cross Hospital), participating in the life of the community, and getting to know the residents and social workers. The result is a very intimate study of this close-knit community, which is accompanied by two short films, Bethel and A Japanese Funeral, both of which demonstrate the trusting relationship that Nakamura was able to cultivate with her informants and her attention to the representation of these disenfranchised people.

While the book’s subtitle, “An Ethnography of Schizophrenia and Mental Illness in Contemporary Japan,” suggests a broad sweep, in fact Nakamura focuses largely on Bethel, with its idiosyncratic forms of care developed by a charismatic, poor, and devoutly Christian social worker, Mukaiyachi Ikuyoshi. In the social context of a society in which mental illness has been severely stigmatized, and in which the mentally ill have historically been either hidden at home or warehoused in suboptimal institutions, Bethel is extraordinary.

The home has its origins as a support group for discharged psychiatric patients and alcoholics, which Mukaiyachi founded soon after he was hired as the chief social worker at the Urakawa Red Cross Hospital in 1978. The group began to meet in the old Urakawa church, and, together with Sasaki Minori, a schizophrenic patient who became the head of the group they called the “Acorn Society” (Donguri no Kai), they christened the old church Bethel House (Beteru no Ie, or “house of God”), a reference to a psychiatric hospital in Germany (the Bethel Institution) reported to have resisted orders by Adolph Hitler to euthanize its patients. In order to sustain themselves and to provide the residents with a livelihood, the group began an enterprise in packaging seaweed produced in the area to be shipped all over Japan. The seaweed proceeds continue to be an important part of the livelihood at Bethel and have allowed the organization to expand to include four group homes, four shared living facilities, and several private residences. In addition, Bethel residents travel around the country speaking and raising awareness of the condition of the mentally ill and the stigma they face.

The organization has developed a philosophy of group living and rehabilitation that eschews psychodynamic approaches (they describe the past as “the garbage can of the soul” [kokoro no gomibako]). It derives instead from Christian teachings, Alcoholics Anonymous (their slogans include “meeting is more important than eating” and “trust in the power of the group”), and vestiges of the antipsychiatry movement and its contention that the “real world” can be the cause of mental disorder and that “normality” itself is a social construction. Mukaiyachi and the doctor who later became the chief psychiatrist at the Red Cross Hospital, Kawamura Toshiaki, feel that the medication given to patients in psychiatric facilities not only dampens their hallucinations but also dampens their emotional expression and their ability to experience social life. The Bethel method is to reduce medication to a level that allows for social functioning and then offer strategies for patients to manage the disturbing and distracting voices they hear. Social workers encourage patients to name and address their auditory hallucinations (which they call genchō-san, represented visually as cute Pac-Man-like figures) and to recruit the...