Research into the history of Japanese psychiatry has shown some signs of change in the last couple of decades and is now undergoing a remarkable transformation. As in many other countries, the history of psychiatry used to be studied almost exclusively by Japanese psychiatrists, who wrote for their colleagues. Such research became an integral part of the enterprise of psychiatry, and in Japan it emerged at the same moment as academic psychiatry. Kure Shûzô, a professor of psychiatry at the University of Tokyo from 1901 to 1925, holds a double crown as the founding father of psychiatry in Japan and of the history of Japanese psychiatry. Inspired by his example, many psychiatrists have taken up historical research for nearly a century. Kaneko Junji, who was a student of Kure, compiled bibliographies and anthologies of materials related to psychiatry and mental illness; they remain indispensable tools for every scholar in the field. Matsushita Masa'aki, another professor of psychiatry at the University of Tokyo, founded the Japanese Society for the History of Psychiatry in 1997, which is now flourishing. Okada Yasuo, another eminent psychiatrist-historian, has been an indefatigable researcher and writer; he has amassed by far the richest private collection of materials on the topic. These scholars represent the first wave in the history of Japanese psychiatry: psychiatrists writing for psychiatrists.
We are now witnessing the rise of a new wave. Although there are still psychiatrists who work in the field, authors with different backgrounds have appeared who write for a different audience. The history of psychiatry is now being written by scholars trained in sociology, science studies, anthropology, literature, and history. At the recent annual conferences held by the Japanese Society for the History of Psychiatry, roughly half of the participants have nonmedical backgrounds.
A representative of the new wave is Serizawa Kazuya who received his doctorate in sociology from Keio University. His work displays a new potential to throw light on the deep-rooted problems in both psychiatry and contemporary Japanese society. Serizawa's intellectual trajectory reflects a broader trend comparable with what happened in Europe and North America in the 1960s and 1970s when young scholars in the humanities and the social sciences inspired by the critiques of psychiatry offered by Michel Foucault and others turned a critical eye on the field.
Not only authorship but readership too has changed. Quite naturally, the authors of new history do not write just for psychiatrists. Their articles are published in humanities and the social science journals, and their books look decidedly nonmedical, although psychiatrists certainly read them. With their very different training and disciplinary emphasis, the new historians of psychiatry have asked novel questions and examined different aspects of psychiatry than their predecessors. They are less interested in great psychiatrists and the therapies that ostensibly alleviated the suffering of many patients. They are more interested in social and cultural analysis of the discourse and the practice of psychiatry.
Akiko Hyôdô's recent book is one of the best works of psychiatric history published to date by the new wave. As far as I am aware, it is the first monograph on the history of Japanese psychiatry by a scholar with a humanities background. Hyôdô's areas of specialization are history and ethnology, and the latter discipline has provided the key themes that run through her book: religion and possession. Based on her dissertation, the book maintains high scholarly standards throughout. Plenty of little-known historical documents have been examined and analyzed, and new light is thrown on the well-known material. Sophisticated theories inform the accounts of historical changes and their significance. Although the book lacks a bibliography, in all other respects the scholarly apparatus is satisfactory. I believe that this work will become a landmark in the field, and the author must be congratulated for her achievement.
The long period covered stretches from the early modern period to the early 1940s, with some forays into contemporary Japan. As I have already mentioned, the two themes of religion and possession provide the key to her account. Put in a nutshell, this book argues four things about the period it deals with: (1) there was a decline in belief in possession; (2) there was an increase in the confinement of the mentally ill; (3) these two phenomena were closely related; (4) there was a fundamental shift in the conceptualization of mental disease from what Hyôdô calls a relational or connective view of mental disease to a substantive or objectified view. The core of her argument is a combination of the historiography of demystification proposed by Max Weber and of the great confinement described by Foucault. Into this framework the author integrates a considerable amount of original research tinged with a large dose of antipsychiatric interpretation.
To hear Hyôdô tell it, the modern rise of psychiatric power unleashed a wave of repression. Psychiatry abetted criminal legislation and harsh policies aimed at social undesirables, and it was used against the new popular religions that mushroomed from the late Meiji period. Homicidal lunatics were widely reported in exploitative newspapers: the only conceivable treatment was lifetime confinement. Furthermore, in the Showa period psychiatric power acted in a prophylactic capacity, targeting those who considered likely to commit crimes or antisocials; those who might breed such individuals also were targeted, with a little help from a newly popular science called eugenics.
These accounts are based on painstaking research into hitherto unknown obscure sources and little-known cases. Readers will find these elements of the book most useful and interesting. Take, for example, the account of the battle between new academic psychiatry and popular religion in Chapter Five. The chapter is constructed around the career and ideas of Nakamura Kokyô, a student of literature who turned to psychology. Hyôdô uses him as a lens to examine the very different ways that science and religion conceived of the mind in early twentieth-century Japan. As in contemporaneous Western countries, research into mesmerism, hypnotism, and hysteria was causing great excitement among scientists and laypersons.
Kokyô was one of the most active proponents of psychic research and mental science; Hentai shinri, a journal he edited, served as a showcase for new psychological theories. The new psychic research was often used to criticize conventional medicine as being materialistic and inattentive to the mind. From this dissatisfaction sprang two attitudes toward the mind: Hyôdô calls the attitude of new popular religious movements “spirit” and that of psychiatry and psychology “psycho.” The boundaries between the two were often blurred. Despite considerable affinities, in the end conflicts broke out between the two groups and psychiatrists helped the state to suppress religious leaders–psychiatrists. Shifting to an intimately personal aspect of Kokyô's struggles to understand other minds, Hyôdô describes the agony the scholar experienced when his troubled brother became so unmanageable that he was confined at home in a cage; Kokyô concluded that the new religions were literally a product of mental disease.
Another example of fine scholarship and analysis is Chapter Six, in which the development of psychiatric confinement under the Mental Hospital Act (1919) is juxtaposed with the emergence of new ideas about legal responsibility and the punishment of criminals laid out in the new criminal code (1907). Echoing Foucault's famous dictum about the emergence of the “person” as the subject of the discourse of power in the modern era, Hyôdô points out that the new criminal code shared with Taisho-era, psychiatry a focus on the “person,” whether as the basis for punishment or for controlling mental illness.
This was the most characteristic example of the “substantive” view of mental illness presented by Hyôdô. Once a person suffering from mental illness was convicted of committing a crime, according to the code he or she was to be placed under psychiatric confinement until the illness had been cured. Such confinements often lasted for life. Two cases of lifetime confinement of homicidal lunatics are presented. The first is the story of Irie Saburô, a murderer who escaped from psychiatric confinement three times in 1916 and 1917. He eventually died in a high-security mental facility. The second is Sakakibara Shikasaburô, a convicted murderer who escaped twice between 1916 and 1923. In the end, Sakakibara committed suicide in a high-security cell. Newspapers reported these cases in sensational and lurid terms, selling the public a rather fantastic picture of homicidal mania. Through her analysis of these cases, Hyôdô attempts to show the tragedy that ensued once psychiatrists and the state departed from the relational view and adopted the substantive view of mental illness.
In these chapters and others, Hyôdô displays an ability to excavate little-known but important materials. Many of the events she has discovered are “must-read” items for historians of psychiatry in Japan, whether or not one agrees with the interpretations offered.
Now I turn from the flesh to the bones of the book: the decline of possession and the rise of psychiatric power. Hyôdô argues that the demise of the theory of possession started before the Meiji Revolution, during the late Tokugawa period, as Confucianism began to work its influence on medicine. For a long time, the role model of the Japanese physician had been the Buddhist priest; now he patterned his practice on that of the Confucian scholar, a move that implied significant ascent in the social hierarchy. The rational worldview of Confucian philosophy was more antagonistic to popular superstitious beliefs, among which was the belief in fox possession. Before the introduction of Western medicine, indigenous forces pushed early modern Japan toward demystification.
Hyôdô astutely analyses the difference between the “relational” view of human beings which supported belief in possession and the “substantive” view of Western psychiatry. Possession and exorcism were embedded in the personal relationships surrounding the possessed individual and those who instigated the possession through the use of foxes and other animals. Explanations of how possessions came to pass generally involved envy, hatred, or anxiety about community standards, as well as beings with supernatural powers, whether they were animals, spirits, or gods. (The situation was comparable that of witchcraft in early modern Europe.)
Modern psychiatry, on the other hand, assumed that the mental disease of an individual had its ultimate basis in the individual. Although interpersonal relationships contributed to mental illness, they were, Hyôdô argues, ancillary subjects. This is a bit of an oversimplification of Western psychiatry, a failure to take into account the traditions of phenomenology. But she deals with Meiji-era psychiatry of Meiji era under the heavy influence of Kraepelin, so this is a minor point.
The transition Hyôdô describes appear in the earliest clinical records of modern Japanese psychiatry, namely, those of the 44 patients confined in Tokyo's public psychiatric hospital. Some of these were reported to having been possessed, found wandering the streets. The authorities were determined to cleanse the city of disorderly elements, so as possession was recast as mental illness undesirables became the basis for the new psychiatry taught at the university. The appropriation of power to interpret and define aberrant behavior by doctors educated in modern medicine delegitimated the theory of possession, and particular individuals were now to be cured through confinement. In a similar vein, early psychiatrists such as Simamura Shu'ichi, Araki Sotaro, and Morita Masatake visited rural areas and observed alleged cases of fox possession. They reinterpreted the cases as outbreaks of mental illness. Thanks to this work, leaders of new religions were later declared to be suffering from psychological disorders.
All these analyses are finely presented in Hyôdô's book. I have, however, some fundamental reservations regarding the book's factual bases and interpretative frameworks. Distinguishing the theory of possession from modern psychiatry is one thing; arguing that this difference represented a historical shift is quite another.
To nail down Hyôdô's argument concisely, allow me to begin by citing a characteristic passage: “The meaning of fox possession was fundamentally transformed from a curable disease to [a family of] dangerous and incurable diseases. At the same time, a parallel shift occurred in which a possessed body became a confined body. When this happened, the sufferers of fox possession/mental disease were treated differently. Instead of being treated with folk therapies and temporary detention, they were brought to psychiatric hospitals and were permanently confined” (34). Here, Hyôdô is on an unstable ground on many levels, both factual and conceptual.
Take, for example, the assertion that detention was temporary during the early modern period during treatment for fox possession. As far as I know, there is no historical evidence to support this assertion, either in other historians' works or in Hyôdô's own book. In fact, scattered and fragmentary evidence suggest otherwise. In the mid-eighteenth century, diaries kept by a samurai family living in Edo mentioned about 250 deaths of friends and acquaintances over a span of 30 years, five of whom “died during confinement due to insanity [ranshin].” The confinement associated with ranshin involved cages built, most often, in private houses, although the diaries do not mention location. These early modern cases resemble, in this sense, the later cases of long confinement Hyôdô presents elsewhere in her book. And the early cases involved protracted confinements: two people had been confined for 2 to 3 years, one for 5 years, one for 19 years, and one had been confined for 40 years (Ujiie 2009). This piece of evidence strongly suggests that long-term confinement was not an invention of modern times. Hyôdô's thesis that early modern people believed that antisocial behavior could be cured relatively quickly seems to be based on limited evidence which does not apply to mental illness during the Tokugawa period.
Likewise, Hyôdô's assertion that the modern period saw the rise of long-term or even lifelong confinement (“constant confinement”) at home or psychiatric hospitals is again based on limited evidence and is only partially true. Certainly protracted confinements occurred in the modern period, but before World War II psychiatric hospitals were numerically dominated by short-term patients. My own research on a private psychiatric hospital in Tokyo shows that between 1925 and 1945 over 80% of the admissions were for less than 3 months, and under 3% of patients stayed for more than a year (Suzuki 2003).1 During this period psychiatric hospitals had both long-term and short-term patients, but the vast majority were released within a few weeks of admission. There is no question that Hyôdô has misrepresented the prewar situation.
* Time in hospital was so short because patients were paying for their stays. The situation was very different for public hospitals or public sections in private hospitals, where patients stayed much longer. Whereas the median period in hospital for private patients was about 1 month, the figure for public patients was between 1 and 3 years.
Even more problematic is her thesis of the shift “from fox possession to medically defined mental illness”. I was not able to find in the book any support for referring to a shift. A historian can talk about a shift when it describes changes in the same group of phenomena. In a discussion of government, one can talk about a shift from monarchy to democracy; in cosmology one can speak of a shift from Aristotelianism to Newtonianism. One cannot however talk about a shift from, say, monarchy to Newtonianism. This leads us to the alleged shift from fox possession to mental disease. Is Hyôdô arguing that groups interpreted the same set of symptoms differently? Or, is she arguing these groups used different sets of concepts for the same kind of social problems?
It is certainly true that some people who might have been regarded as possessed in the Tokugawa era were actually diagnosed as suffering from mental disease in the modern era. Indeed, we can infer this from Hyôdô's own account of two wandering lunatics in Meiji-era Tokyo described by contemporaries as suffering from “delusions of fox possession” (103–4). They believed they were possessed, while the doctors at the university believed they suffered mental disease. Although one can be fussy and claim this is a difference between actors rather than a historical shift, one can safely argue that patients and their families adhered to the old model and the doctors adopted the new model. This evidence supports Hyôdô's thesis that a shift took place. She does not clarify, however, how important these “shift” cases were to the making of modern psychiatry. She writes that out of 44 cases confined in the public mental hospitals of Tokyo there were two cases that involved the delusion of fox possession. So what were the other 42 cases about? Do they support her thesis of the shift, or do they not? She does not say anything about 95% of her sample. Yet again, one cannot help feeling that the author has been highly selective in her choice of supportive evidence.
One might take another line of inquiry, asking whether Hyôdô thinks Irie Saburô, a homicidal patient discussed in Chapter Six, would have been regarded as temporarily possessed by a fox if he had exhibited the same behavior during the Tokugawa era? Maybe. There was, however, an early modern word commonly used for describing insanity, particularly in a forensic context: ranshin, literally meaning “disordered in mind.” When a person suddenly became distraught and killed those around him or her without any understandable reason, the person was described as suffering from ranshin. I believe that ranshin is a much better candidate than possession as a predecessor to the modern mental diseases Hyôdô talks about, since most of her materials for the modern era could be categorized under the headings forensic psychiatry and social policy. If she had talked about ranshin and modern mental illness, she would have been able to talk about a shift in the forensic context.
Hyôdô's historical framework lacks the conceptual rigor that would permit discussion of a “shift.” It remains unclear whether this was a real shift in the history of Japanese psychiatry or different conceptualizations of mental illness. Part of the reason for this conceptual confusion seems to come from the author's lack of engagement with other scholars, particularly psychiatrists. She writes about “mental illness” as if it was a single affliction. Although she cites the works of psychiatrists, she is generally too quick to dismiss their findings and arguments and too eager to offer her own interpretations. For me, her failure to take Hiruta Genshirô (1985) seriously constitutes a very unfortunate decision. Hiruta's concrete findings confirm that early modern rural Japan witnessed cases of possession and ranshin (followed by confinement). Some cases were called both possession and ranshin. Such findings seems to complicate, if not refute, Hyôdô's basic framework.
Another shortcoming of the book is neglect of the West, both in terms of history and of historiography. Instead of integrating her theoretical and historiographical apparatus into international scholarship, Hyôdô relies almost exclusively on Japanese material. This attitude runs counter to the current trend in the history of Japanese medicine.
In the end, however, I would like to conclude this review with a more positive note. Despite its conceptual and historiographical shortcomings, there is no doubt that this book provides a fresh look at the subject and includes numerous thought-provoking ideas. It has also brought new and important materials to the attention of a new generation of historians. In short, it will establish Hyôdô as one of the promising scholars working on history of madness and psychiatry in Japan. I am certain, in spite of my reservations about her first book, that she will produce works which will engage our attention. Hyôdô's fine work seems to promise that we will see the rise of a third wave of studies of the history of psychiatry in the not-so-distant future.