Protests of a Good Wife and Wise Mother: The Medicalization of Distress in Japan
The great strategies of power encrust themselves and depend for their conditions of exercise on the level of the micro-relations of power.
—Michel Foucault, Power-Knowledge
A visit to the health-related book section of any reasonably well-stocked bookstore in Japan today leaves one with the impression that here is a nation bent on educating itself in preventive medicine, self-care, self-diagnosis, and the correct selection of appropriate professionally supplied therapeutic alternatives. A large proportion of the books are variations of what is known as katei no igaku (family medicine). Such books furnish up-to-the-minute accounts of basic physiology and anatomy, of first aid, and of the contemporary symptomatology, diagnosis, and treatment of all but the most rare of diseases. For those who use traditional techniques in addition to biomedicine, there is a shiny new volume on the modern application of herbal medicine, acupuncture, moxibustion, and massage. These books are usually published by respectable and apparently neutral sources such as the Japanese Broadcasting Corporation and the Asahi and the Mainichi newspapers, and they are often a gift of the local government to residents of certain cities as part of preventive medicine promotion campaigns. Such books are the culmination of a long tradition of publications related to self-care in Japan, and they shore up an old value: that individuals and primary groups are basically responsible for the maintenance of health and the occurrence of illness.
Apart from the “home doctor” and “family medicine” books, there is a large selection of medically related volumes written mostly by doctors but also by journalists. A quick perusal of the titles and chapter headings immediately excites an anthropologically trained reader, since they provide evidence that culture-bound syndromes are proliferating in modern 131Japan. Titles include mention of the kitchen syndrome, moving-day depression, child-rearing neurosis, refusal-to-go-to-school syndrome, and so on. Other titles use names that North Americans are more familiar with: hypochondriasis, hysteria, sleep disorders, impotence, hyperactivity, and anorexia. But even when labels are focused on this more psychophysiological level, there are some surprises, such as “disharmony of the autonomic nervous system.”
The “medicalization of life‚” as Illich calls it, is clearly rampant in Japan. Medicalization is usually depicted in the literature as a process in which the medical community attempts to create a “market” for its services by redefining as diseases certain events, behavior, and problems (see, for example, Freidson 1970; Illich 1976; MacPherson 1981; Merkin 1976; Szasz 1970; Zola 1978). The institution of medicine is seen as serving the interests of powerful controlling groups in a society; in Zola’s words it is “a major institution of control … nudging aside law and religion” in which ordinary people lose their rights of control and autonomy over their own lives. Zola believes that this tendency is reinforced by the haste with which many people bring everyday troubles to the care and attention of the doctor.
Studies on medicalization have been criticized most frequently for their apparent lack of attention to the fact that the institution and practice of medicine itself reflects the structure of the society in question. Medicine therefore serves to express and reinforce the social relations of the larger society including those of class, race, sex, and age (see, for example, Ehrenreich 1978; Frankenberg 1980; Krause 1977; Stark 1982; Waitzkin and Waterman 1974; Young 1982). The incidence of disease and illness is reflected in these same social relations, but when physical disorder is conceptualized as either a biological or a personal problem it serves to divert attention from the larger social issues involved.
One of the tasks of the anthropologist is to explore how physical illness, which frequently serves as a symbolic representation of social and interpersonal conflict, is dealt with by ordinary people and by professionals, how its management reproduces the values of society at large, and how the original conflict is or is not resolved in the process.
In the West, one response to the recent barrage of criticism against biomedicine has been the emergence of the holistic health movement, which encourages self-responsibility in connection with health and illness. Guttmacher (1979, 16) points out the advantages of this viewpoint but hastens to add that by seeing health as an end in itself and by 132emphasizing individual responsibility the movement has in fact exacerbated the medicalization of many areas of life and reinforced a basic biomedical premise: that disorders should be dealt with largely at the personal level. Guttmacher adds that this attitude receives government support since it is equated with cost containment.
In Japan, there is an even stronger tendency than in North America to reify health, to consider it a personal or often family problem, and to rush to the doctor for medication and psychological support. The roots of this behavior can be found in traditional East Asian medicine (Lock 1980) and indigenous psychotherapeutic systems (Reynolds 1980) as well as associated philosophical and religious systems, all of which are active today and enjoying revived support. The mass media has recently coined the phrase kenkō-būmu (health boom) to describe the burgeoning interest in natural food. This, together with the vast popular medical literature, attests to a keen public interest and sense of personal responsibility for health and illness.
In this chapter I discuss forms of protest in Japan, including the somatization of distress, especially in women. Some approaches to the management of somatization by the medical profession in contemporary Japan are considered. An attempt is made to show how these approaches are influenced in part by a belief in science and technology, at times by the self-interest of the medical profession and, in addition, by ideas of long standing about self-responsibility for health and illness. Management of somatization is also influenced by shared ideas about acceptable modes for the expression of conflict and, in connection with female patients, by current ideas about the nature of women and the family. The medical system and medicalization, however, act not only as mirrors of social organization and cultural beliefs, but also potentially as vehicles for social change. Biomedicine is not a monolithic organization, even within one society, nor is it a single systematized form of medical practices and beliefs. At the level of physician-patient interaction, it represents a perpetual reworking of changing values, new knowledge, and new technology (Gaines and Hahn 1985). It most frequently appears to act as a force for conservatism and, at times, of repression, but since its basic business is the management of suffering and pain, which by its very nature raises questions of ambiguity and paradox, it can also act as a stimulus for the creation of new meanings, and hence social action. In the following pages I also try to show how in the process of medicalization private distress and suffering become public knowledge and are 133exposed to scrutiny. This process, therefore, can serve potentially to instigate an awareness of the “hegemonic” forms of certain social institutions (Gramsci 1971) and hence sow the seeds for change, in this case in the status in women.
“Soft Rule”: Japanese Concepts of Power
A well-known Japanese intellectual historian, Kamishima Jiro, distinguishes Japanese sociopolitical development, which he describes as an “assimilating unitary society,” from typical Western development, which he labels as an “alienizing composite society.” He believes that much of Western history is based upon a pattern of conquest and subjugation of people that sets up situations of conflict and a questioning of political authority. In contrast, until World War II Japan had never been overrun in historic times. As a consequence its culture has developed by absorbing and assimilating things from the outside, by “making the strange familiar” (Kamishima 1973, 8).
Georg Simmel (1969) claims that for people to develop a clear conception of political authority and thereby to demystify it, they must have experience of more than one kind of authority; only thus can they learn that authority is not part of an inalienable natural order. Koschmann (1978), drawing on the work of Bellah (1962), Harootunian (1974), and Kamishima (1973), among many others, demonstrates how the “givenness” of authority is reflected in Japanese religious and ethical traditions and reaffirmed through linguistic domains such as the distinction between watakushi (I or me) and oyake (the public). In the Meiji era (1868–1912), for example, oyake was always associated with high-sounding purpose: public tranquility and order, fairness, and the “consultation of public opinion” (kōgi). Watakushi was identified with irregular dealings, bad faith, selfishness, personal feelings, and private desires. In the inevitable encounter between the public and personal realms, individuals were admonished, as a kind of moral imperative, “to dissolve the personal and honor the public (messhi hōkō)” (Harootunian 1974).
The actual exercise of power in Japan has been characterized as “soft rule,” in which the preservation of harmony and suppression of conflict takes priority over individual rights and needs. Koschmann (1978, 19) states that “when oppression is soft and persuasive, feelings of dependency and relatedness persevere to obscure the irreducible atom of individuality and perpetuate the belief that what is real is to be found outside 134 the individual, between himself and others rather than within.” Psychological studies carried out in contemporary Japan reinforce this conclusion (DeVos 1973, 144; Doi 1973).
The Expression of Resistance
In a social system such as Japan’s, forms of resistance to the all-enveloping cloak of authority are not usually those of open conflict, which are in any case disparaged, but tend to be less direct (see White 1984 for some notable exceptions to this pattern). Tsurumi (1974), a sociologist using historical and contemporary sources, concludes that two types of resistance, “retreatism” and “ritualism,” are frequently used in Japan. The tradition of voluntary or forced separation from the community (retreatism) is called yamairi (entering the mountains) and was traditionally used to imply permanent seclusion. A 1975 survey (Murray 1975) estimated that ninety thousand contemporary Japanese had voluntarily undergone ningen jōhatsu (“human evaporation,” that is, they had completely vanished). These people had apparently chosen retreatism as a form of protest. The second form of resistance, ritualism, involves the preservation inside oneself of nonconformist values while at the same time outwardly conforming with established behavior patterns. Koschmann (1978, 20) states that “ritualism means the preservation internally of contradiction. It implies accommodation within the personality of mutually contradictory elements (including values, belief systems, emotional responses) rather than their external expression and resolution through conflict.” Japanese society as a whole can best be viewed as pluralistic or having multiple layers of value orientations and ideology (Bellah 1957; Lock 1980), and Tsurumi (1972) characterizes both Japanese social structure and Japanese personality as multilayered; the psychological mechanisms of suppression and not repression appear to be dominant.
Ritualistic resistance is probably the usual form of protest in Japan. Like retreatism, it does not lead directly to reform or social change. There are two characteristic styles of ritualistic resistance. The first, more common mode is institutionalized or “orderly” conflict. This is conflict acted out “in a predictable manner (often implicitly expected and accepted by the adversary) primarily for the purpose of symbolically affirming the separate interests, identities, and goals of the participants” (Krauss, Rohlen, and Steinhoff 1984, 9). The best-known example is the annual 135“spring labor offensive,” during which the national unions go on strike for a prearranged day or two. Such ritualized resistance avoids direct confrontation and is not designed to bring about major changes in institutional structures but rather serves to remind everyone involved that there are ground rules to be observed.
The second type involves a dramatic self-sacrifice, often by one or more individuals who usually know that their goals are unattainable but who nevertheless choose to demonstrate sincerity of purpose and purity of motive. This form of resistance is frequently expressed through ritual suicide. The cases of Mishima Yukio and Okamoto Kozo (of the Red Army) are two of the best-known recent examples. Rather than trying to implement social change directly through organized, instrumental action, such protest is designed to create “symbolic affirmation of [one’s] own principles” (Krauss 1974, 111) and, in addition, to try to incite one’s antagonists to action by inducing guilt in them (DeVos, 1973, 472).
Not only at the level of group conflict, but also in cases of interpersonal conflict, nonconfrontational tactics are considered more appropriate than an outward, abrupt shattering of the peace. Lebra (1984b, 41) identifies seven strategies that are resorted to with regularity in potentially tense situations. One strategy is anticipatory management. Negative communication, that is, remaining silent when a response could be expected, is another. A third tactic is situational code switching, in which people who are in discord in one situation can be cooperative in other situations. Open confrontation may also be avoided by triadic management, in which a third party is resorted to as a go-between to aid negotiations. The strategy of displacement occurs when a disgruntled party, acting consciously or unconsciously, complains indirectly by stating that a third party rather than themselves is dissatisfied or by complaining to a third party or by expressing dissatisfaction through the mediumship of the ancestors or the spirit world (see also Yoshida 1984, 85). The sixth strategy, that of acceptance, represents a fatalistic resignation to an unsatisfactory state of affairs and is well documented as characteristic of Japanese behavior (Lebra 1974). The final nonconfrontational tactic commonly manifested in situations of discord is self-aggression, which can take the form of belittling oneself, expressing inadequacy or, in extreme cases, committing suicide. This last tactic, the interpersonal version of ritualistic resistance, is usually associated with the induction of guilt in others, especially if those others perceive themselves as the cause 136of suffering. I believe that somatization often represents a special but common case of self-aggression. As a form of protest, somatization, like other types of self-aggression, may often be unconscious, or only partly conscious; but, nevertheless, like ritual suicide, it can represent an attempt to induce changes in the behavior of the people affecting one’s life.
Somatization and Interpersonal Relations
Somatization can best be defined as “both the expression of physical complaints in the absence of defined organic pathology and the amplification of symptoms resulting from established physical pathology (e.g., chronic disease)” (Kleinman 1982, 129). It has been hypothesized that whether one uses predominantly psychological or physiological modes for the expression of distress depends upon two major determinants: “actual adult experiences with symptoms and illness on the one hand, and cultural influences on the definition of illness on the other. Whereas reporting physical symptoms is culturally more neutral, reporting psychological symptoms is more dependent on social acceptability” (Mechanic 1980, 154).
Research carried out by both anthropologists and physicians indicates that the body is habitually used symbolically as a vehicle for expressing stress and oppression. The form that the expression takes is culturally constructed and can range from a dramatized performance or ritual, to the employment of altered states of consciousness, to direct verbalization of the problem, through to more subtle forms in which the corporeal body rebels. These symbolic representations can also be interpreted in a more constructive light, not only as an “idiom of distress” but as a plea for help, for change, for release from drudgery or humiliation (Comaroff 1982; Comaroff 1985; Devisch 1985; Good 1977; Helman 1985; Lewis 1971; Lock 1986; Mechanic 1980; Minuchin, Baker, and Rosman 1978; Nichter 1981). Kleinman, after reviewing recent research on the topic, stresses that somatization need not necessarily result from or represent psychopathology; it might be regarded as a particular “cognitive-behavioral type” with adaptive or maladaptive consequences that involve assessment of particular social and cultural as much as personal variables (1982, 130).
In Japan several aspects of the cultural heritage in addition to the attitudes toward conflict described above serve to reinforce a tendency to 137somatize. The form that interpersonal relations and their related language takes is important and so, too, are ideas derived from the Confucian and the Buddhist heritage.
Interpersonal Relations and the Expression of Needs
Every society appears to make some distinction between ideal and actual behavior, but the Japanese language employs several dichotomies that indicate to what a fine art this discrimination can be developed. For example, one situation is distinguished from another according to whether it is defined as uchi (in, inside, internal, private, us) or soto (out, outside, external, public, them), and one modifies one’s behavior accordingly. But these distinctions are not fixed; they are, rather, fluid categories, socially relative, and dependent, for example, upon whether one is dealing with another individual, one’s family, a Japanese company, or a foreign company.
There is a second dichotomy, that of tatemae and honne, which refers not so much to social expectations, as do the above categories, but more to one’s personal intentions. Whereas honne means one’s real or true intentions, tatemae refers to the principles that one should act by. These two concepts represent a source of conflict that all individuals everywhere face, but the emphasis in Japanese culture is upon the indirect expression or even suppression of honne for the sake of smooth interpersonal relations.
Formal behavior is based upon the notions of tatemae and soto (outside), which are close to the concept of a persona. Much of daily behavior in the home, school, or at work is the formal type of behavior, in which speech styles, gestures, and postures reinforce the nature of social relations between the people involved. Certain regions of Japan are known to express less honne than others. The mayor of Osaka said recently that the difference between Tokyo and Osaka is that Tokyo is more tatemae while Osaka is more honne. Not only is there geographical variation in the expression of honne, there is also variation due to status and role. In general, men, especially elderly men, can express honne most easily and acceptably. Women, usually both within and outside the home, should not express honne, although when alone with female relatives or close friends they may release their feelings (hence the importance in traditional life of wellside gossip and the public bath).
If during most of a person’s daily life the direct expression of emotions 138and needs is frowned upon, other forms of expression become adaptive. Somatization, in addition to the other nonconfrontational tactics described above, is one such adaptive technique. It is acceptable to talk about tiredness, pain, dizzyness, palpitations, being languid, having tingling sensations, and so on ad nauseum and then to manipulate (often unconsciously) the behavior of others as they respond to the distress that is being expressed. Somatization and the presentation of nonspecific complaints are frequent reasons for visits to the doctor’s office in Japan (Lock 1980; Reynolds 1976; Vogel 1978), and an examination of their meaning to patients and physicians as well as their management can provide insights into the process and justification for medicalization. These insights serve in turn to highlight those situations and relationships in Japanese society that are often associated with conflict, distress, and ambiguity.
Interpreting and Managing Illness
There has never been a split between psyche and soma in Japanese thinking. Both physicians and patients readily attribute nonspecific somatic complaints, symptoms of depression (yūutsu) and other “psychosomatic” symptomatology to stress. An exploration of the principal factors contributing to stress will usually lead rapidly to concern about relationships within the family or at work. But this concern is generally expressed in an abstract or neutral fashion and only rarely will patients in a clinical setting make a direct statement about their personal situation or feelings. The restraints of formal behavior and communication, reinforced by Confucian mores, do not allow the expression of what is uchi (in this case, within the family). Illness and somatization are interpreted as expressions of stress at the social level, but since harmony is highly valued and the forms of social behavior and distribution of power cannot easily be questioned (and take primacy over the individual), the individual is expected to adjust so that harmony is restored. The first resort, therefore, is to medication in order to assist in this adjustment. The majority of physicians and patients believe that if physical order is restored, then, since psyche and soma are indivisible, emotional balance and social harmony will return as well. Family members, employers, and friends can be very patient and supportive during this process, and insurance companies allow long periods of hospitalization (Lock 1980). The ultimate objective of taking medication is not to provide relief of symptoms 139 (although this is naturally welcome) but to facilitate reintegration into one’s social role.
Use of nonverbal and nonconfrontational forms of communication reflect and are reinforced not only by Confucian mores but also by the Buddhist heritage, which gives high priority to inductive, intuitive, and experiential forms of learning. Buddhism encourages the view that verbal interaction is a form of communication obviously necessary to cope with daily life but incapable of fully expressing the complexity of one’s inner state, which is better not revealed, or only partially revealed through thoughtful action (Lebra 1976, 46; Reynolds 1980).
Responsibility for Health and Healing
Illness represents disorder, and the activities and explanations that people use to deal with illness are an attempt to restore order and control. Medical activities and knowledge, both lay and professional, are shaped by their cultural context (Good 1977; Kleinman 1979; Lock 1980), and the core values that provide a sense of coherence to an individual’s life are also relied upon in attempts to interpret and attribute meaning to illness. These same values are drawn upon to structure relationships between physicians and patients, and patients and their families.
Explanations about the causes of illness and misfortune have implications for the allocation of responsibility in connection with the occurrence of the events. It is characteristic of the medical systems of nonliterate societies (those using externalizing discourses, in Young’s terms ) to locate the causes of illness outside of the sick person’s body, in important events leading up to an illness episode, and in so doing they tap religious beliefs, kin relationships, and economic and political alignments. By explaining the causes of illness in this way, the occurrence of illness is associated with morality and norms of conduct. In medical systems (such as the traditional system of Japan) that use theories of balance and homeostasis as their basis, individual and family responsibility for the preservation of balance is considered important. The occurrence of illness in this type of medical system is not associated so much with immorality as with irresponsibility and neglect. In the biomedical system the incidence of illness is theoretically interpreted as a neutral event (Habermas 1971); but, due partly to the critical scrutiny biomedicine has recently undergone, new approaches, including that taken by proponents of the holistic health movement, have led to the frequent allocation 140 of responsibility for illness to patients, their families, and occasionally to employers or the state.
In Japan, early socialization stresses individual and family responsibility for health and hygiene, and the occurrence of many types of illness is associated strongly with a sense of guilt and failure (DeVos and Wagatsuma 1959; Lebra 1982; Lock 1980). This is another reason for focusing on the somatic level in discussions about illness: it allows one to avoid dealing openly with the affect-laden psychological and social levels of explanation. The body is objectified, and discussion around it is dispassionate and incorporated into the world of tatemae and soto, although therapists, patients, and families are well aware of the implications of the discussion for the realms of uchi and honne (Long 1980).
This preliminary exploration should facilitate an interpretation of the data that follow on somatization and medicalization.1
The Vulnerable Female Body
The presentation of nonspecific complaints to a doctor in Japan is frequent and, as in North America, leads very often to overmedication, dissatisfaction among patients, and subsequent shopping around for other physicians. The expression for nonspecific complaints, futeishūso, is well known to everyone and, as in the West, is associated more frequently with women than with men. In a book entitled Nonspecific Complaints: An Unknown Female Illness (1980), three physicians working at a large Tokyo hospital tell the general public how they deal with this problem. They state that they have had thirty years’ experience in this matter and have completely healed many women who had been suffering for years and were unable to get satisfactory medical help.
The problem of futeishūso is characterized by complaints about headaches, feelings of coldness (hieshō), shoulder stiffness (very common in Japan), dizziness, palpitations, nervousness, back pain, premenstrual pain, and feelings of depression, among many other symptoms. The three doctors believe these symptoms to be the result of something they call “chronic infectious pelvic disease” (mansei kotsubannai kansenshō). The existence of this disease, they add, cannot be proved at the present time, but they believe that it affects the autonomic nervous system, which, in turn, is the cause of the symptoms. They base their statements upon observation and treatment of five hundred patients who presented 141one or more of a total of fifty-six types of symptoms. The doctors claim that many women contract chronic infectious pelvic disease either as children or later in life; it occurs only in women because women’s abdominal cavities are directly connected to the outside via the fallopian tubes, uterus, and vagina. When these tissues are damaged, particularly in association with miscarriages, abortions, childbirth, or ordinary menstruation, the way is open for bacterial infection. The doctors further state that the occurrence of an infection depends upon the “strength” of the bacteria and the resistance of the person in question; hence, physical responses vary greatly, but a mild chronic infection is very common.
The doctors have established diagnostic criteria for this disease that include symptoms of a malfunctioning autonomic nervous system, menstrual disorders, especially involving pain or the production of scarlet blood, and tenderness of the pelvic region. As treatment they recommend extended bed rest as well as avoidance of spicy foods, alcohol, overheating of the body, sexual intercourse, pregnancy, and most exercise. They recommend traditional herbal medicine as a preventive measure and professional consultation for anything more than a mild problem. Many of the patients of the authors of the book have been hospitalized, often for as long as fifty or sixty days. They are issued symptom charts that the women themselves check off each day; their diet is restricted, and the principal feature of their treatment is ice packs on the abdomen. When describing case histories, the authors take note of social and psychological dimensions, which they associate specifically with the onset of symptoms. Noted also is the transference experience of many patients, who talk openly for the first time in their lives with their doctors while undergoing the prolonged isolation in the hospital. But these aspects are not developed during or after leaving the hospital. Treatment is applied entirely at the physiological level, and the patients are returned to their former lives and situations.
The invention of this disease represents an interesting case of how biomedical “forms of medical treatment reinforce the perception that the ‘truth’ of human existence lies concealed within the confines of our own physical bodies” (Comaroff 1982, 59). The explanations given by the authors of Nonspecific Complaints possibly represent very careful observation and analysis of data; the book may be scientifically accurate up to a point, in that a bacillus may be a necessary factor in the onset of the illness. However, the numerous social and psychological reasons for differing 142 human resistance to infection are not taken into consideration or dealt with to any extent, and the problem is treated in an extremely reductionistic fashion characteristic of much of biomedical practice.
The interchangeable terms jiritsushinkeishūcho (lack of harmony) or jiritsusushinkeifuanteishō (instability in the autonomic nervous system) are used very frequently by both Japanese physicians and patients. This categorization is often applied to cases that are hard to diagnose and that everyone readily agrees may have social or psychological implications. Both men and women can suffer from this problem, since it is agreed that “stressors” can affect the autonomic nervous system directly, but women tend to suffer from it more frequently. Explanations offered for the increased incidence among women vary. The most common is that, since hormonal changes influence the autonomic nervous system, women are prone to experience instability or lack of harmony in this system before menstruation or at menopause (which, in Japan, is usually considered to be a fifteen to twenty-year span). A second reason given for women’s vulnerability is due to their disposition (seishitsu), which inclines them to be more nervous and hence easily stressed. A third interpretation given by a physician who is trained in traditional medicine as well as biomedicine is that “stale blood” (oketsu) collects in the female abdomen as the after result of childbirth and menstruation and affects the functioning of the autonomic nervous system.
Despite the apparent variations in interpretation described above, the focus of attention in each case is upon the physical body. Discussion centers around that apparently most scientific and abstract of terms “the autonomic nervous system” and the removal of unwanted symptoms, usually through hormones, tranquilizers, and sleeping pills.
Some informants, professional and otherwise, acknowledge that the use of “scientific” labels neutralizes the doctor-patient encounter, allowing it to proceed comfortably without incurring guilt or exposing the patient’s private life too much. They also state that there really is not much that can be done about problems of the autonomic nervous system except to “stick it out”—“gamman suru.” One “home doctor” book, put out by a small company known as the Life of the Housewife Press, after stating that no one knows if imbalance of the autonomic nervous system is really an illness or not and after giving a long list of symptoms, concludes that the best prevention is to review one’s own habits and to try to improve them. Although clear assignment of guilt is avoided, responsibility for dealing with the problem is turned back to the patient 143and all discussion of social dynamics is studiously avoided (Katei no igaku zenshu 1983).
The Good Wife and Wise Mother
Two of the illnesses in modern Japan with the most striking names occur only to women: the “kitchen syndrome” and “moving-day depression.” These ailments are not known by everyone, but the majority of the physicians interviewed had heard of the former and several of them the latter. The term “kitchen syndrome” was coined by Dr. Katsura Taisaku, who has had training in psychosomatic medicine and psychology and has written a book (1983) and several articles on the topic for the general public.
After ruling out serious organic malfunctioning, Dr. Katsura recommends the use of medication to control the symptoms but adds that the role of the physician is to listen and then to offer solutions by talking things over with the patient. All the physicians questioned on this subject agree that it is primarily a social problem, that Japanese women are still judged first and foremost by their roles as “good wife and wise mother” (ryōsai kenbo), and that, although they are well educated, there is virtually no possibility of their developing a sense of an independent identity (jibun ga nai) after they are married. Finding gainful employment other than in a factory is extremely difficult for a married women and is in any case socially frowned upon. The physicians also pointed out that women have no outlets for complaints. In the words of one specialist in internal medicine, “Many modern Japanese women are bored with their lives and they use ‘organ language’ to express this frustration, especially since the world of tatemae prohibits them from verbalizing their complaints.”
In one case history documented by Dr. Katsura, the woman resorted to the use of men’s linguistic forms; another patient went on wild shopping sprees; others suddenly started to buy food at random in addition to suffering from the kitchen syndrome. All these women had been people who formerly took great pride in their housework and in the organization of their family life.
Patients with moving-day depression also have numerous nonspecific complaints and are frequently diagnosed as depressed, although the rationalization for the symptoms by the patients themselves is often that the water in their new places of residence does not agree with them 144(Sasaki 1983, 146). These patients, too, tend to be perfectionists who, after removal to a new part of Japan—almost without exception in connection with their husband’s work—feel that their personalities have somehow changed and that they have become unable to run their homes as usual. Long rest and medication are advised for such cases. Frequently, husbands are noted as being sympathetic about their wives’ illness, but this only serves to induce more guilt in the already sensitive women.
Recommendations by psychological oriented physicians for both of these problems are that some changes be made in the running of the household. It might be suggested, for example, that the family eat out now and again or that the mother not be expected to prepare several hot meals each evening as her children and husband return home one after the other. Taking up hobbies or a sport is also suggested, and occasionally it is recommended that the patient start some socially acceptable work (such as running a cookery school at home). Some of these recommendations no doubt help individual patients, sometimes very effectively, but the wider social ramifications of their problems are not held up for scrutiny. Although a physician might write a popular book on the subject of these ailments, thus offering the opportunity to question the social order, the issue is rarely taken up, and recommendations for treatment and change remain focused at the individual level.
Illnesses Caused by Mother
A well-established tradition in Japan holds mothers (and not parents) responsible for the health of their children, and bogenbyō (illnesses caused by the mother) are considered common occurrences. A well-known pediatrician, Dr. Kyūtoku Shigemori, has written a best-selling book (1979) and lectures widely on this subject. Dr. Kyūtoku believes there are two kinds of common colds, those caused by viruses and those originating in the upbringing of the child. Colds of the second type he classifies with childhood asthma and other psychosomatic problems as what he calls “diseases of civilization.” He believes that although Japanese mothers were formerly good at child rearing, in the past twenty years they have become poor at it. Industrialization has distorted the “natural child-rearing instinct” into something that satisfies the mother’s “narcissistic ego” but does not produce a healthy child. (The recorded incidence of asthma among children has doubled since the end 145of the war.) Mothers, Dr. Kyūtoku states, are usually too bossy or too protective. Another major problem is caused, he says, by the rise of the nuclear family, displacing the large, extended family, and the simultaneous urbanization of the nation. These developments isolate women, who cannot turn to the extended family for help and advice. Children who grow up in families such as this develop an unstable autonomic nervous system, the product of both genetics and environmental influences. Recommended treatment for severe cases is “parentectomy”—the removal of the child completely from the mother’s charge for extended care in a hospital.
Dr. Kyūtoku believes that reduced breast feeding, overprotection of the child from climatic variation, and encouragement of passivity in the child are all factors contributing to childhood psychosomatic illnesses. While he thinks all children should be raised only by their own mothers until they are one year old, he acknowledges that this is not always a realistic possibility. Although he maintains that nursery schools were created not to raise the status of women but simply to exploit them as part of the labor force, he nevertheless adamantly opposes the widely held notion that mothers “abandon’’ (suteru) their children when they leave them in nursery schools. Dr. Kyūtoku stresses the view that mothers as much as children are victims of modern society and makes some practical suggestions for breaking down isolation and the sense of competition felt between Japanese mothers. He has recently written a book entitled Fugenbyō (Father-created illnesses), in which he attacks the organization of company work in Japan, which virtually precludes the involvement of fathers in the raising of their children.
Bogenbyō focuses largely on early socialization and child care and assumes the unproven existence of an inherent child-rearing instinct in women. The author, however, does raise the issue that analysis of the influence of modern Japanese society is crucial to finding lasting solutions to the majority of psychosomatic and somatic problems. At the same time, he retains a rather romantic notion of the extended family and the “good old days.”
These examples serve to illustrate the various forms that medicalization can take in connection with nonspecific symptomatology and common psychosomatic problems. Some recommendations for change focus almost exclusively on the physical body, others incorporate both somatic treatment and suggestions for personal adjustment, while a few question, 146 in addition, the social forces that contribute to oppression and resultant ill health. This variation is hardly surprising, given the complexity of Japanese society.
Images of Modern Middle-Class Japanese Women
Recent studies and government surveys of Japanese women (Kokumin Seikatsu Hakusho 1983; Lebra 1984a; Pharr 1976; White and Molony 1979) indicate that most middle-class women are largely satisfied with their roles as housewives and mothers and many of them enjoy their relatively easy life (although they do not usually see it as being easy) of housekeeping for a husband and family of two. Nevertheless, large numbers of women are bored, lonely, frustrated, and retain a strong feeling that they have no sense of personal identity or fulfillment. The rising divorce rate among fifty year olds is perhaps testimony to this situation (Madoka 1982). The following case studies illustrate some of these problems.
Mrs. Hori is a 49-year-old housewife whose oldest child is married; the second child has just entered college but lives at home. She is college educated, worked as a secretary until her marriage twenty years previously, and since that time has devoted her life to the care of her husband and children. Her husband works as the manager of a division of an electrical appliance firm that has branch offices throughout Japan. The Horis had been relocated once by the company when the children were young, and both of them had come to assume that they would not be moved again since this is less frequent in the case of senior managers. But Mr. Hori had been relocated three years earlier, at the age of fifty, to northern Kyushu, hundreds of miles from his home. The company assumed that Mrs. Hori and their younger child, who was still in high school at the time, would probably not accompany Mr. Hori and made no provisions for them to do so. Upon making extensive enquiries, it became clear to the Horis that no high school within a reasonable distance of the Kyushu branch office was prepared to take a new student. (There is no legal requirement that a child attend high school and therefore no obligation for a school to cooperate.) Mrs. Hori knew that even if they eventually were able to find a suitable school, her son would have difficulty in fitting in with a new group of students, and she had read several horrifying accounts to confirm her fears in this direction. Mrs. Hori foresaw that she, too, would have a problem fitting in. It is difficult 147to make meaningful new friendships in adult life in Japan, friends being almost exclusively composed of lifelong companions (Plath 1980, 161). Because her parents and closest friends would be seven hundred miles away, in Tokyo, Mrs. Hori could look forward to a life of isolation if she moved to Kyushu. She therefore decided very reluctantly to stay behind. Her friends and neighbors, many of them in a similar situation, told her that after a month or two she would get used to being without her husband; several of them added that, really, life is better without husbands anyway.
Mr. Hori had not been gone long before Mrs. Hori developed asthma and also started to suffer from frequent debilitating headaches. She talks of being bored and feeling sad and lonely much of the time, and adds that once her second son is married, her life will have no meaning. Shortly after her husband’s departure Mrs. Hori started to take part in some local, slightly controversial political activity to relieve her boredom, but her husband was told by his company seniors to ask his wife to stop such activities because they might reflect badly upon the company. Mrs. Hori’s doctor sympathizes with her situation, tells her that life is hard, and gives her medication for symptom relief. She expects nothing further from her doctor. Neither the Horis nor their family physician think that any alternative is possible to the present situation, although they all believe that Mrs. Hori’s symptoms represent her distress about the family separation.
Mrs. Hori is ambivalent about her health problems. On the one hand, she feels somewhat embarrassed and guilty. She believes that she is not devoting herself fully to her son and that she causes other people trouble by being sick. On the other hand, she believes that she must endure this situation. She is resigned to it (akiramete imasu), and she has not tried the alternative traditional health care recommended by her neighbor. She does not seek to create a new life because she says that she was quite happy with the old one and, when pushed, admits that she has no confidence in her ability to do so. Since Mrs. Hori’s husband is likely to be transferred back home from Kyushu in another few years, she is in an ambiguous position. Mrs. Hori’s situation is a very common one in Japan, and for many women it may prove more difficult than divorce. The loss in such cases is seen as temporary, not a real loss, something to endure. Even though Mrs. Hori and those like her may have to endure for a considerable number of years, there are strong sanctions against creating anything new for themselves in compensation. 148
The practice of sending men away to work for extended periods, leaving behind wives and families, is not new; it is a tradition found among the samurai class in feudal Japan. Today it is widespread not only among businessmen (the Friday evening airplanes and long-distance trains are packed with men going home for the weekend) but also among farming families. The usual situation in the Japanese countryside today is for women to run the farm and raise the children while the men live in a neighboring town or city and work in an office or factory. The effects of an absent husband on all family members, not just wives, have yet to be investigated.
Several factors exacerbate the sense of loneliness and futility that many women feel. First, in a traditional family Mrs. Hori and others like her could expect, after working hard as “professional housewives” all their lives, to arrive, at the age of fifty, at the time of life when they would manage a large household but with a daughter-in-law doing most of the work. As a mother-in-law, the older Japanese woman in a traditional family enjoyed considerable power, freedom, and leisure. The nuclear family does not take away the mother-in-law’s position, but it does convert it into a meaningless and empty privilege. The urban fifty year old today contemplates quite a different future from that of her predecessors. She lives in a small house with a husband who is often out for fourteen or fifteen hours a day. She and her husband usually expect to lead separate lives, and once the children are married a woman in a nuclear family is left with no sanctioned role except that of looking after her husband. Virtually no one will employ her, and she is expected to fill her day with hobbies of one kind or another. In fact, when asked what they do with their time, many women of this age reply that they sleep (see table 1). Vogel (1978) reports that older women often enjoy the freedom that a nuclear family offers and are happy not to be principally responsible for the grandchildren as was the case in an extended family, but other women complain that they can never “retire.” A frequently used Japanese adage goes “Teishu wa jōbu de rusu ga yoi” (A good husband is one who is healthy and absent). In retirement many men may become excessively dependent upon their wives and insist that they always be present in the house to do the husband’s slightest bidding (Vogel 1978, 35). Hence, subservience is all that many fifty-year-old women can look forward to in old age, a state that is compounded for many by caring for ailing and bedridden parents-in-law.
Of course, not everyone endures the situation stoically. Mrs. Morita, 149forty-five years old, is college educated, the mother of four children (unusual in modern Japan), and married to a man who works in an advertising company. The Moritas have not moved, and so Mrs. Morita does have some long-standing friends, including a group of women with whom she regularly meets and discusses her problems. Mr. Morita usually returns from work at ten o’clock every night of the week and expects a hot meal to be waiting for him. Mrs. Morita says that her husband complains about her all the time and has done so for years. He criticizes her appearance, the way she raises the children, and tells her that she does not sit or talk like a decent woman. Mrs. Morita also says that she has been hit “quite often” by her husband. She does not retaliate directly because she says she is afraid to do so, but she grumbles and weeps with her friends very readily. For the past five years whenever her husband has touched her, she has developed a florid skin rash at the point of contact; lately, even touching his dirty laundry has induced this response. The doctor whom Mrs. Morita occasionally consults has not suggested any form of help beyond medication. Mrs. Morita talks with her friends about a possible separation or divorce, but she believes, with considerable justification, that, given the Japanese legal system, she is likely to lose the children and/or to be left in a state of poverty and with no possible chance of employment.
Table 1. Daily Routine of Housewives
|Three hours or less spent in housework per day, on average||89||49|
|Part-time work, 1–4 hours per day||16||9|
|Involvement in community activities once a week or more||20||11|
|Weekly involvement in hobbies or recreation outside of home||56||31|
|Three or more hours spent actively watching TV per day||51||28|
|Reading for one hour or more each day||5||3|
|One hour or less spent with husband each weekday||80||44|
|A daytime nap taken most days||27||15|
|Visits from or to friends, weekly or more||22||12|
Interviews with the wives of fifty-five businessmen confirm that the cases described above are not unusual (see table 1). These housewives, ranging in age between forty-five and fifty-five, live in nuclear families, with the exception of four whose in-laws reside with them. It must be stressed that although many women lead what to an outsider appears a rather dull life, thirty-eight out of the fifty-five respondents stated that 150they were happy with their lives. Of the seventeen who were not happy, twelve attributed it to their very poor marital relationship, and two added that their children were not doing well, which compounded their unhappiness. Ten said that the lack of companionship was their major problem. All of the respondents expressed the belief that their unhappiness affects their health, and eighteen of them complained of recurring physical symptoms of various kinds. Of the total sample of fifty-five, fifty-three respondents believe that a woman is largely responsible for her own health and illness, although it is agreed that infections and serious diseases cannot usually be avoided. When asked what changes might improve their lives, ten of the fifty-five respondents said that they were thinking about trying to find a part-time job; five of those added that their husbands are against such an idea. The other forty-five had no ideas of any kind for improving their lives and added that they were tired of PTA work, housework, and consumer groups and often dissatisfied with their recreational activities as well.
Clearly, one cannot make any accurate generalizations from this small sample, but the results suggest a number of variables that should be investigated with a larger group of respondents. These include class differences and differences between women living in extended and nuclear families, living with and without supportive husbands, with and without children at home, as well as differences between women who have and have not moved and those who do and do not work. These variables need to be compared and then correlated with the occurrence of symptoms, physician visits, the use of medication, and the use of support groups.2
Modern Japanese society is perceived as very stressful by those who participate in it. There is one group of people, middle-class housewives, who are often singled out as an exception. Housewives are thought in general to enjoy an easy and rather spoilt life-style. Their daily round is sarcastically characterized as san shoku hiru ne tsuki (a permanent job with three meals and a nap thrown in). Many women enjoy the role of sengyō shufu (professional housewife), and make the most of the leisure time associated with that role. Others, however, fret over their lack of self-identity, and a considerable number suffer unremitting feelings of loneliness and oppression. Those who suffer believe themselves to be stressed and can usually articulate what they perceive to be the nub of their problem: discordant 151 family relations, sometimes exacerbated by physical separation, and an inability on their part to endure the situation. If physical symptoms occur, the woman and her family are likely to interpret them as a response to stress. There is an ongoing dialectic between stress and symptomatology, in which either variable, depending upon the particular context, can be considered as causal of the other, and in which intervening psychological states do not usually figure to any great extent.
The occurrence of sickness in women is not altogether acceptable in Japan. Males can be dependent, but women must nurture and nourish the family, and guilt associated with illness is particularly acute for women, who often believe that their whole family will suffer in turn (Lock 1982). However, if symptoms can be legitimized through a doctor’s opinion or by appropriate labeling (see Rosenberger, this volume), then somatization becomes a powerful form of nonconfrontational communication. Women themselves, therefore, tend to welcome medicalization of their problems; many of them actively seek out professional care and willingly imbibe medication for problems that they believe originate in social conflict.
Features of Japanese social organization that disparage open confrontation, and encourage nonverbal communication and self-responsibility for health and illness, function to focus the attention of both physicians and patients upon the physical body and appropriate somatically oriented therapies. The reductionistic thinking characteristic of biomedicine coupled with a strong reliance on technology add to this tendency, which is further exacerbated by a largely unquestioned business ethic in medicine. Physicians derive much of their income from the sale of medication, and many of them also run private clinics for profit. There is considerable incentive for Japanese physicians to try to exert control over a population of people in distress (although this is somewhat countered by the fact that the majority of people are cared for by a general practitioner with whom they have a close, lifelong relationship [see Steslicke and Long, this volume]). Excessive use is made of medication in Japan (Sakuma 1969) but not simply, I think, as a result of physicians acting in their own interest. It is also due to an aggressive pharmaceutical industry and can, in part, be attributed to a willing and gullible public.
Medication and the small life-style modifications suggested by professionals for some women no doubt often help to ease the sense of oppression that patients experience. At the same time, medicalization can act as an “opiate,” and can deflect attention away from the social origins of 152distress. Lebra (1984b) warns about some of the problems that can arise when nonconfrontational modes of dealing with conflict are widely used; quiet or subtle messages can easily be ignored. Moreover, the sufferer’s easy access to medication can facilitate avoidance of receiving the message directed at the offender, whether it be a husband, an employer, or the state.
Women often link their allergies, asthmas, stiff shoulders, and poorly functioning autonomic nervous systems to their immediate social relationships, and especially to their subordination to their husbands and other people who figure centrally in their lives. They may sometimes tentatively question these relationships, but they rarely see the links between the structure of society at large and female subordination in general (Cook and Hayashi 1980). Nor do they seriously question the pressures imposed by the larger, fiercely competitive society on all its members. Female protest about the stress they experience is usually expressed through their own bodies and by griping and gossiping about their immediate family members. There are exceptions to this, and some women’s groups have organized to promote change, but they are relatively rare.
In the actual clinical encounter, the social origins of distress are not explored to any great extent; nevertheless, the titles of the books that medical professionals are currently producing indicate that they are aware of at least some of the social ramifications of their patients’ problems. Like many of the women themselves, the majority of health professionals writing popular books hold a rather negative stereotype of women. Women’s general physical vulnerability to sickness is widely accepted; prevalent also is the belief that, unlike women of previous generations, women today lack self-control and the ability to suppress individual needs. Moreover, a life of ease dominated by extravagant and selfish motives made possible through the rise of the nuclear family and rapid economic development is considered central in the undoing of the “good wife and wise mother” (Lock 1986). The authors of many of these books sermonize about weak and willful women and suggest several ways in which they should “shape up.” However, in delivering their harangue, the books’ authors inadvertently reveal chronic points of stress and tension in Japanese society, usually associated with the subordinate position of women (despite their official equality [Pharr 1984]) in the family and the workplace. They also sometimes reveal the way that business 153 and the state exploit individuals and families by the expectation that personal needs be subordinated almost without exception to the demands of business and industry. Popular literature on the subject mercilessly depicts the life of the “salary man,” for example, as mindless, pointless, and totally exploited by his employers (Skinner 1979).
In societies where social participation in ritual events is commonplace, there is the opportunity for women to readily discover that their distress is shared by others (Comaroff 1985; Parsons 1984), and articulation of social problems can then be facilitated through collective ritual performance. The alienation of middle-class urban dwellers is increased by isolation, and there is no opportunity to understand how common their problems are nor to appreciate their social rather than personal origins. The popular literature written by physicians is not uniform, it gives a range of opinions, and some of it, such as the book by Kyūtoku, raises for scrutiny a few of the paradoxes and contradictions in the lives of modern Japanese women and their families, thereby allowing an attentive reader to become sensitive to alternative possibilities. Certainly the writing of popular books lines the pockets of physicians, just as it functions to medicalize a problem (since none of the physicians disassociate themselves from giving care). But if at the same time some of this literature acts as a catalyst in breaking down the isolation and oppression of middle-class women, then it might also sow the seeds for future de-medicalization of that problem and pave the way for some appropriation of control by the women involved.
1. Data presented in this study are the results of work in progress and have been obtained from textual sources and open-ended interviews with twelve physicians (internists and gynecologists) and fifty-five urban middle-class housewives.
2. This research is at present in progress with a sample of 1,700 women.
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