Most of the matters described in this book are based on the facts and the history I have experienced in my real life.
The first job I obtained was during a time when work was scarce for female university students. It was between the first and second oil shocks, preceding the enforcement of the Equal Employment Act. Lacking a specific reason or vision, I started working for an apparel maker as a salesperson. With regard to psychiatric care and welfare for those with mental disorders, I saw matters from outside as if they were in another world.
Although I was attracted by the interpersonal service in the first workplace, there were limited opportunities for women in private companies at the time to keep working for the longer term as well as marry and raise their children. Therefore, I promptly decided to give up my position there and sought a job where I could indeed work for an extended period. Luckily (?), I was able to obtain the position as a clinical psychologist (hereafter 'psychological personnel'）in the field of municipal child welfare. The venue where I took my first steps as a psychological personnel was a care institution for children with severe cerebral palsy, developmental disorders or intractable diseases. The children had tended to be excluded from conventional care institutions, nursing homes and ordinary schools due to being labeled as "people who cannot be trained." While working for the institution, there had been spontaneous changes in my feelings. I became aware of the need for community activities with the view of fieldwork (so-called clinical psychological support for the community or social work) and interested in consulting in adulthood.
Then through social work, in which I had participated as a consultant personnel in the mental health and welfare sector, I considered the borderlines defined in the clinical services to be so artificial. And then I felt that subjects, categories, methods or techniques in child welfare and/or welfare for the disabled were seamlessly merged, which sparked my interest in studying social work. Consequently, I enrolled in graduate school and then touched upon the reality of professional education by getting a job as a university teacher. Finally I wrote my doctoral thesis on which this book is based.
Therefore, in addition to my experiences of clinical practice, this book incorporates further findings gleaned from my experiences in staff education for support professionals in social welfare settings and professional education as a university teacher starting out etc. The main theme of this book is related to conflicts or struggles between "users and professionals" in clinical settings. Moreover, those among "professionals," and between "users and families" and "practice and education" are also mentioned. This is because of my qualifications as a mental health welfare professional and clinical psychologist, and the fact that my career of work experiences started before the qualification system was established. Moreover, I have been engaged in education and research with long-term clinical experiences. Here I present my views on mental health welfare services and the related experiences briefly.
As mentioned above, my career as a psychological personnel started in the municipal child welfare field. At the time, the institution of physically disabled children where I worked had taken on the role of "care center for severely disabled children" that was established due to local residents' campaign as a municipal project. The institution had been operating for the past decade. Besides a psychological personnel, there were many other posts, such as physical therapists, children’s nurses and speech therapists and all staff had sought to care for "severely disabled children." Families' associations still retained the momentum of its establishment period and acted as monitors or educators for the institution staff. The families' associations severely criticized the institution staff if the staff mishandled their assignments. As there were questions in the institution concerning mandatory policies of the care certificate system or schools for the disabled, I had a great opportunity to tackle problems of nursing and education within regular classes in ordinary schools for disabled children in cooperation with other staff and families as well as the chance to consider the needs of social work. Conducting intellectual examinations of "severely disabled children" who were not catered for by existing developmental tests, and diagnosing personalities within worried families were out of the question. Therefore, I was all too aware that the so-called "functional maturity model" was useless.
In particular, for those who are like me, who had occupied pioneering roles in collaboration with many professionals and who had faced existing "unauthorized clients" in a social welfare niche as objects of clinical psychological support for the community since before the arrival of the certification of the clinical psychologist, it was difficult to claim that a counseling model of clinical psychology, in the form of a one-on-one counseling model, was attractive or realistic. There are fatal disadvantages in the one-on-one counseling model for its prosecutors. "Clients" with criticisms against counselors often leave without expressing their opinions, and thus many opportunities to listen to their direct criticisms are lost. Moreover, the limited opportunities to work with other professionals reduce the chances of listening to their criticisms. In other words, counselors face only "clients" who voice some pleasantries and constantly visit their "office."
In general, one-on-one counseling imposes certain strictness in terms of time and place. However, where counselors are engaged in community activities, it is difficult for them to control encounters with "clients" in everyday life in various occasions and they become to think that it should not be controlled although they attempt to do so by regulating time and place.
Current "clients" come to counselors as members of various communities or organizations, such as those requesting support, consumers of services, cooperators of services or members of organizations for the clients themselves and lobby groups. It is naturally impossible for psychological personnel to control solely clinical settings at a micro level without understanding the community environment. Indications of the one-on-one counseling model are realistically acceptable for a psychotherapist model such as "contract", "dispatched" and "independent" therapists targeted for "clients" who visit their offices. It is largely dissociated from the reality of most psychological personnel employed as fulltime workers to handle organizational matters in their workplaces.
Similar timing applied to the occurrence of various issues concerning the privatization of welfare institutions. It took place during reports of the Second Ad Hoc Commission on Administrative Reform that had been established since 1981 and costs on social welfare were questioned (it was the same year as the case of Utsunomiya hospital). At the time I became a mental hygiene consultant dealing with consultations and support for adults with mental disorders.
By the way, although the term "mental hygiene consultant" is one used in government to refer to public officers engaged in services under mental health laws, they prefer to refer to themselves as "psychiatric social workers: PSW." The term PSW has been used wider than the image presented by the term "psychiatric," and has included not only social workers working for psychiatric care institutions but also consultant personnel dealing with consultations relating to mental health laws as public officers.
At the time, various fault lines emerged between support activities based on the philosophy of social work at which those identified as PSW attempted to achieve, and services requested under the actual laws or within actual workplaces. In addition, those who requested support whom PSWs had encountered included not only individuals with mental disorders in the narrow definition but also those who existed within a niche of welfare policies with various diseases, disabilities or life histories, or who were excluded and isolated from communities. Among them, some were offended by the community, while others attacked the same.
Under this circumstance, the subject of mental hygiene consultants naturally had no choice but to become not the "office" but the "communities" or "field sites" for which they were responsible. If the reference points of their assignment were set out on the workplace rather than the type of professional, "community" or "field site" rather than the workplace alone, joints obviously perceived by negative reference points gradually become ambiguous. Once matters are recognized in terms of seamless viewpoints, irrational phenomenon caused by the artificial joints, namely the social injustice, can be specifically identified.
My new assignment started in a community contiguous to urban districts. What surprised me for the first time was the minimal number of support personnel responsible for substantive consultations. Having once worked in an area of child welfare which is regarded as the royal road of the discipline, I was keenly aware of the considerable gap in welfare services that existed by knowing that users who became 15 years old were suddenly to lose their consultation support and the fact that many of "the unauthorized disabled" were forced to live alone in the community without welfare services for the disabled. In addition, in contrast with families' critical ability against professionals in the field of child welfare, families' "weakness" against professionals in charge of psychiatric care and welfare services for those with mental disorders was remarkable. Moreover, what affected me were the terms used in the area of social work. I felt the efforts of professionals facing the distressing environments of individuals with mental disorders were stated in misleading sugar-coated terms.
The mental hygiene consultation at the time also fulfilled a role similar to that of a rescue shelter. There came the mentally disabled, isolated from the community, or their intellectually disabled peers and their families, incapable of adjusting to community life without care certificates. The majority of such consultations were so-called "people who discontinued medicine." Although they received severe discrimination from the community on one hand, some individuals having developed acute symptoms due to their untreated status were considered "persons with some demented symptoms" in a harmonious way and welcomed to the community's rice planting or village events on the other.
What are the implications of this?
In textbooks, community work in Japan has been referred to as community welfare as if it were linked to the efforts of social welfare councils which existed within each governmental jurisdictional scope. However, issues that I faced unfold as a mental hygiene consultant definitely emerged in communities in which a bold climate existed rather than those defined by the governmental unit. At the same time, the climate has already incorporated the culture of the new residential community. The time when the above-mentioned cultures were combined and the psychiatric care subsequently added coincides with the time when Japanese psychiatric care was poorly developed. Behind the existence of "those who discontinued medicine," is the fact that other many long-term hospitalized patients still continue social hospitalization.
"Those who discontinued medicine" escaped from or were helped to escape from social hospitalization. At the same time, however, they were labeled as people with "mental disorders" by "urban" psychiatric care institutions, with all the subsequent decision-making left to local communities, and isolated from the communities. The individuals in the categories of "long-term hospitalized patients" and "those who discontinued medicine", isolated from communities, are artificial products generated as a result of the policies of Japanese psychiatric care. The unprecedented and depressing case of Utsunomiya hospital finally saw the mood change, whereby there was a feeling that consultation services for such people was what government should strive to enhance. It was the same as when I started my carrier as a PSW.
Since then, I have been involved in many establishments of social resources, such as alcoholics anonymous, local family associations, recreational homes or workshops for people with mental disorders and psychiatric clinics in local communities. We have faced considerable resistance from communities every time. Processes and events in which the members involved in the activities explain their understanding of those with mental disorders and request cooperation with their families could be stated in beautiful words. In accordance with the amendment of the mental health law under the Mental Health Welfare Act, mental hygiene consultants changed their job title to mental health consultants. Following the national qualifications prescribed for mental health welfare professionals, they also started using the same job title. These transitions seem to be perceived as a process whereby the philosophy of social work has been accorded with its reality. However, is this really true?
Nowadays, people previously classed as "those who discontinued medicine" are included under umbrella of welfare services for the disabled. Many of those engaged in mental health welfare failed to question the establishment of the mental disability certificate system, since the implementation of the national certification system for mental health welfare professionals was too soon for professional organizations at the time to even properly consider the system. However, what is the end result? Will welfare services for those with mental disorders develop in accordance with the benefits of users?
Reflecting on such questions, I transferred environments in which I occasionally dealt with both pathology and the health of users. During my engagement as the position involving rehabilitation of those with mental disorders, I experienced periods as the bubble era of mental health welfare in which policies and social resources were improved. I had many opportunities to be involved in the positions located on the fringes of the professional scope of a psychological personnel or PSW. Those opportunities have allowed me to work alongside various professionals, and be involved in education for the same or staff education for support professionals. These have provided some answers for my questions.
Social hospitalization, however, remains unresolved. Here, "those who discontinued medicine" have been transferred from hospitalism and the psychiatric care from which they had sometimes been desperately trying to flee to that of welfare services for the disabled. The latter accepts and controls passive people while closing the gates behind them. Just like users, the fields for professionals and support professionals may also be taken away. This book is written in accordance with such questions.
As for those engaged in human services, the fields are so sacrosanct that no tarnishing thereof should be permitted.