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Environment and Wellbeing Clinical Practice and Challenges to Orthodox Psychopathology: An Ethnographic Account of Mental Health Care in the Japanese Context

Ben Epstein
University of Edinburgh

PhD Research Proposal, Social Anthropology,
February 2013

NOTE: This paper is a proposal for a PhD at the University of Edinburgh in Social Anthropology. As it is still in the very early stages of development, any comments, suggestions or criticisms would be strongly appreciated.

 

Research aims

The broad aims of this research project are: 1) to conduct an anthropological investigation of Disaster Mental Health[1] as a means of exploring the environmental impact on physical as well as psychological wellbeing both as to (2) assess Japanese challenges to orthodox psychopathology, particularly DSMIV,[2] and to (3) produce an ethnographic account of mental health care in the Japanese context. 4) This research also aims to be a contribution to the literature in transcultural psychiatry, particularly in terms of establishing “on the one hand the universality of general psychiatric symptoms (as seen in western conceptions of mental illness), and on the other the realisation that different people (in nonwestern cultures) experience psychiatric trauma and anxieties differently”.[3]

 

Background

“Yet people appear to be afraid of radiation, which is like a ghost that never appears.”[4]
– Sakurai Katsunobu, mayor of Minami Sato

In March 2011 the most powerful earthquake in living memory devastated the Eastern Coast of Japan leaving 20,000 dead or missing and billions of dollars in damages in its wake. Reactors at the Fukushima Daiichi Nuclear Power Plant (NPP) went into meltdown. In a single day over 100,000 people by optimistic estimates became refugees following a massive tsunami and were forced into refugee centres, crammed into school gymnasiums, municipal buildings and camps. All 21,000 inhabitants of the town of Namie, one of a dozen towns and cities within Fukushima’s exclusion zone in the Tohoku region were forced to evacuate and scattered across 44 of Japan’s 47 prefectures as nuclear refugees. Virtually abandoned by the government and with little hope of compensation by TEPCO,[5] the corporation in charge of Fukushima Daiichi NPP; Many still demand accountability and compensation from the corporation and the government. Some 5000 of the Namie refugees relocated to nearby Nihonmatsu, a city of 60,000 unaffected by the exclusion zone but flattened by the earthquake.
Whilst homes around Fukushima NPP remain empty and desolate, forming part of a tangle of ghost towns and villages in the outlying area, thousands of inhabitants are still living in temporary housing, almost exactly two years since the event, whilst their houses sit intact but in an environment too toxic and dangerous to return to.

Foreshadowed by the twin spectres of Hiroshima and Nagasaki, debates rekindled surrounding the potential damage radiation will cause to human life rage-on and public opinion about the effects of radiation based on the theory of NLT[6] is divided. The Japanese authorities have set aside $100 billion for the reconstruction but concerns over risk assessment and public health continue to slow the process of relocation. Many inhabitants wish to return to their homes but will certainly be unable to do so for the foreseeable future, and for residents within the 20km radius of Fukushima Daiichi NPP itself not for at least a hundred years.

In May 2011 sales of Geiger counters in Japan soared to over %200 of pre-March figures. Kath Weston, an anthropologist present in Japan at the time, argues that this constitutes a move by the Japanese people to regain personal sovereignty from “risk analysts, medical practitioners, and scientists who have cornered the market, as it were, on the valuation of toxicity, danger, and threat”. She claims that this constitutes a “form of technostruggle, in which people attempt to seize the means of production—in this case, knowledge production—by seizing the means of perception[7],” a struggle no doubt exacerbated by the trenchant gulf dividing politicians and people on the ground.[8]

Whilst on the one hand events after 3/11 have led to a sea-change in Japanese perceptions of the government and particularly it’s nuclear power program, which has effectively ceased, this new kind of empowerment reflected in Weston’s perhaps romantic notion of technostruggle and other ‘before and after’ discourses, has also hidden another consequence of the disaster: the psychological and emotional distress that has already claimed the lives of many survivors. Suicide rates amongst refugees some reports have claimed have risen dramatically. Whilst other sources, particularly government sources,[9] suggest that this rise is fictitious it is clear that anxieties over radiation have not abated. In a recent interview Dr. Noda Fumitaka, a psychiatrist at Yotsuya Yui Clinic in Tokyo, cited disagreement over statistical evidence from the WHO (Table1) that suicide cases are expected to grow amongst survivors of the nuclear area.[10]  

Mental-health practitioners were among the first responders, reflecting a shift in attitudes towards mental health that began around 1995, (coincidentally, the same year as the Great Hanshin earthquake that devastated the city of Kobe) when legislation concerning the ban on the sale and marketing of anti-depressants was lifted.[11] The Japan Medical Association started large-scale programs to educate doctors and the population about depression and suicide and suicide-prevention campaigns have marked what was previously an unspoken –but accepted– facet of life as a medical issue for the first time[12], boosted further by the mega-marketing of anti-depressant medications.[13]
Yuriko Suzuki, a psychiatrist at the National Institute of Mental Health in Tokyo stated:

In January 2012, researchers sent out questionnaires to all 210,000 evacuees to assess their stress and anxiety. The levels tabulated among the more than 91,000 respondents were “quite high” Roughly 15% of adults showed signs of extreme stress, five times the normal rate, and one in five showed signs of mental trauma — a rate similar to that in first responders to the attacks of 11 September 2001 in the United States. A survey of children, filled out by their parents, showed stress levels about double the Japanese average.”[14]

Above all, the fear of radioactivity takes a unique toll. “It’s something you don’t feel; you don’t notice what happened, and yet you understand that there are these long-term risks. It’s scary”.[15] Controversial psychiatrist Hirooko Yabe even coined the term “radiophobia” to describe the particular symptoms surrounding the threat of radiation.

The fear of an invisible enemy, of radiation and sickness, and the exceptionality of the situation of having to leave houses empty –an absence of closure and the feeling of having left things unfinished– permeate the stories of those who have been in contact with the mental health relief efforts especially those of psychological debriefing[16] (DB). Dr. Yabe, a neuropsychiatrist at Fukushima Medical University who has been working with both nuclear evacuees and survivors of the tsunami is reported to have said: “The tsunami-area people seem to be improving; they have more positive attitudes about the future.” Nuclear evacuees however, “are becoming more depressed day by day.”[17] Clinical treatments that have been made available to treat those affected largely have included antidepressant and anticonvulsive medications as the services sent to the disaster zone have been unable to cope with the sheer number of cases, notwithstanding the fact that Japan has one of the highest psychiatrist to patient ratios in the world.

Methodology and Access

The consolidation of my research will take place after data collection: qualitative data gathered from informants in the form of transcripts over the course of 18 months and other data compiled in medical and epidemiological research will be deployed to form a picture of the interrelated themes of wellbeing and perceptions of the environment as well as of the Japanese psychiatric system and the psychological and psychiatric response to the Great Tohoku Earthquake of March 11th 2011. I aim to use disaster mental health as a means to examine the status of transcultural psychiatry, psychopathology and the pharmaceutical industry whilst making an enquiry of the ways in which the perception of ‘nature’ or the environment comes to form wellbeing and mental health. The perception of ‘nature’ in Japan has also been the subject of several recent studies[18] and will thus also form part of a critique of the traditional Nihonjiron discourses (discourses of Japanese uniqueness)  found in many anthropological as well as popular accounts of ‘Japanese culture’.[19]

A research design organised around the topic of disaster mental health is necessarily multidisciplinary and given the fact that my work will be shaped by issues of access, will require collaboration both across the caring professions and from academic institutions. As I am being put in contact with Dr. Junko Kitanaka (Keio University) Japan’s leading expert on the anthropology of psychiatry, I am fortunate to have the possibility of accessing a very rich pool of informants. Psychiatrist Dr. Yuji Sato also at Keio has been put in contact with me through Dr. Chris Harding, (University of Edinburgh) who has also offered invaluable assistance since the original inception of this project, as well as Dr. Stefan Ecks (University of Edinburgh).

Whilst at this stage in my research I am unable to confirm exactly which sites I will be permitted access to, as well as the level of access I might be granted, I accept that any plans will have to reflect circumstances of access and I am prepared to adapt my plans and research questions once in the field and throughout the period of fieldwork. Although I am keeping my options open, I am anticipating that data collection for this project will take place in a multitude of sites in and around the Tohoku region and I have considered a couple of potential field sites, particularly refugee centres in Nihonmatsu and Medical Training Schools at Soma City and around the Fukushima prefecture.[20]

Soma City has a particularly interesting and unique relationship to psychiatric services. It is reputed for having a tradition of long mistrust and conservative attitudes towards mental health services due to the infamous murder in 1892 of Tamatone Soma, a Samurai, allegedly mentally ill, who died in psychiatric confinement by what is thought to be poisoning. The death was blamed upon psychiatrists and led to the historical popular mistrust of psychiatric services in Japan.  Due to the alleged conspiracy, until recently not only psychiatric hospitals and related clinics but also psychiatric outpatient departments at general hospitals were no longer accepted inside Soma City.  Prejudice towards psychiatric services continued up until the earthquake of 2011.

Whilst Soma presents itself as a city of unique ethnographic interest, and of appropriate size for a sustained ethnographic report (pre-earthquake population estimates were thirty-eight thousand, with the elderly counting %25 and with ten thousand employed in tertiary industries)[21] ethical considerations and also proximity to the exclusion zone means that it may be impossible to carry out fieldwork there. Should this be the case I intend to follow up on the case studies presented during the period of psychological debriefing made by Dr. Noda Fumitaka, a psychiatrist at Yotsuya Yui Clinc in Tokyo and the psychiatric team of Fukushima Medical University that had commenced a support program under the direction of Professor Shinichi Niwa in Soma City soon after the disaster struck, pending permission to access such sensitive data.

Ethical considerations concerning anonymity and confidentiality within the medical profession may mean that in order to gain access to patients these will have to be recruited by the doctors themselves or in elective responses to announcements that I will make in refugee centres, Town Halls and other public buildings where I might advertise my research interests and recruit participants for a relaxed informal style interview. I should expect that at first it will be difficult to gain trust with people I meet but as long as I remain honest and open about my intentions and the remit of my investigation, it will be feasible to recruit potential participants willing to discuss their experiences and encounters with mental health services following the disaster. Other issues surrounding for example class, gender, age, and nationality are not to be discounted and should the informant or the researcher feel uncomfortable at any time during fieldwork, interviews or encounters will be aborted. This also applies to the generally painful nature recollection of the events of March 2011 may bring.

The second potential field site is Koriyama City, 100km South of Fukushima City. With a population of over three-hundred thousand it is the busiest city in Fukushima Prefecture and home to a very large number of refugees,[22] stigmatised as the so-called ‘nuclear persons’ (genbaku jin), a term painfully reminiscent of the appellation given to the disfigured women of the Hiroshima nuclear attacks, the ‘nuclear-maidens’ (genbaku otome) and nuclear explosion victims (hibakusha) who, for a variety of reasons, endured stigma and discrimination in post-war Japan.

I specifically aim to collect data through participant observation, semi-structured and informal interviews as well as by analysing the primary literature surrounding events preceding the earthquake including newspapers, websites, diaries, magazines and pamphlets. I also wish to make the collection of data through photographs and I hope to take images that will be relevant and of sites selected by informants. Any images, video and audio data collected will later be available for archival reference. Participant observation would start at the individual refugee centres and move outwards where mental health responses were most visible and would mean gaining the trust of those displaced by the earthquake and learning about their perceptions of the environment and how their wellbeing has been affected by the disaster, and also to understand and learn from individual stories about survival in a time of environmental collapse through the multitude of strategies and coping mechanisms people develop. These refugee camps are not closed sites and movement in and out of them is to be expected. Gaining access will pose several ethical and methodological problems but these should not hinder the overall research project as alternative routes and sources of information will inevitably present themselves.

Fukushima City would seem to be the obvious place for this research as this is where the largest number of displaced people due to radiation are and also where many wish to leave but are unable to do so.

However, these research sites are not in any way mutually exclusive and I consider a multi-sited ethnography to be a more suitable approach for this field research. People move, sometimes by choice and often out of necessity. The same goes for ideas, images, and facts. The notion of fieldwork in a single, isolated fieldsite is no longer appropriate in contemporary anthropology, especially an anthropology that takes both the world in which people live and dwell as well as people themselves as points of study.

Tokiko Noguchi, a mother of two children living in Fukushima City nevertheless wrote of her frustration of not being able to leave the city after fears for her children’s health revealed small tumours in her son’s thyroid: “The Fukushima prefectural government announced on Nov. 5th, 2012, that it would no longer be accepting new applications for families who want to receive housing assistance if they choose to move out of the prefecture. This means that after Dec. 28th, 2012, families who are living outside of mandatory evacuation areas will no longer be able to receive support for housing.”[23] Her petition highlights the fact that whilst many refugees and evacuees are currently receiving some support from the government, there is no longer assistance available for those living even just outside the exclusion zone but who seek to leave the region for health concerns.

A citizen attitude survey conducted by the city of Fukushima concluded that 90% of Fukushima residents said they were “somewhat worried” or “very worried” about the impact of radiation on the health of their family members. And nearly half of families with young kids said that “even now, they would like to move away” due to radiation fears.[24]

It is useful to quote Numazaki here, who entreats anthropologists studying disaster to investigate the political economy of disaster itself: a political economy “which examines the structural and historical inequalities that make certain regions and particular groups of people especially vulnerable to disaster”. He also suggests that the recent and perhaps morbid fascination with disaster has left out analyses of the reaction and behaviour of people outside the immediate disaster zone. Why did, Numazaki asks, people in Southern Japan downplay the nuclear power-plant accident and focus on more-tsunami related issues? It is quite possible that should research in Tohoku region prove impracticable, there will be equally rich data to be collected in other regions not directly affected. Tokyo too was affected by fallout, so, quite rightly, “Tokyo itself could be regarded as part of the disaster zone… But how can you keep the people outside the immediate danger zone calm and rational in the age of global media and YouTube? This ought to be a serious question for the anthropology of disaster.”[25]

Another principal concern however will be to understand how psychiatrists themselves have come to see the situation after the earthquake. How do their coping mechanisms differ from those whom they themselves label as sufferers? Kato, Uchida and Mimura, psychiatrists at the Department of Neuropsychiatry at Keio University, wrote of being unable to meet the psychological needs of those affected by the disaster. In a report, following an in depth review of the psychological relief effort he said:  “In fact, we found that the situation was beyond the capacity of the medical university staff and volunteers […]  medical support teams could not give long-term help due to the limitation of the schedule and staff fatigue… Mental care, especially during this crucial period is vital and we need to take care of these people.” Concomitantly, the number of volunteers coming to Fukushima and northeast Japan has plummeted and many volunteer groups face bankruptcy and the shutdown of their activities for want of donations and staff.[26]

Whilst I acknowledge that there is a high chance that psychiatrists may not want to discuss such matters with me, an untrained layperson, I hope that the more academically minded informants will recognise my serious commitment to the field of psychiatry and see the potential for inter-cultural dialogue as well as for the development of the field of transculural psychiatry. I will therefore provide psychiatric informants with detailed and extensive information regarding my research, besides the acceptable level of information sharing needed to comply with informed consent to participate in anthropological research. Ethics are covered separately and more in depth in the separate attached level three ethics form as required by the University of Edinburgh Ethics Board.

 

Objectives

I hope that my research will illuminate the role of ‘culture’ as it has come to be understood in twentieth century cross-cultural psychiatry by firmly grounding the notion in space and place. As such, the literature on the anthropology of space and place as well as the literature on transcultural psychiatry will be a key theoretical resource during the writing-up phase of my doctoral research.
Transcultural psychiatry troubles the waters of both anthropology and psychiatry because in effect it vexes the neat distinctions between culture/nature, environment/society, health/illness and naturalistic and personalistic explanatory frameworks, especially with regards to the study of affect and subjectivity.[27] Most if not all cultural psychiatrists would argue that culture plays a critical role in the diagnosis, prognosis and treatment of mental illness, and yet there is little working out of what the culture construct really alludes to in the trans-‘cultural’ paradigm, nor is there conclusive evidence to support many of its claims from the perspective of a more grounded anthropology.
Through interviews, participant observation and the analysis of texts and other forms of material such as photographs, policy documents and newspapers I aim to form a picture of how people in Japan (where Shintoism, the supposedly ‘animist’ state religion, is practiced) have changed their attitudes and understanding of ‘the environment’ and what such a term actually ‘means’. How is the perceived disorder in the environment reflected in other forms of disorder, particularly those manufactured and ratified by psychiatric understandings of disorder and distress? Assessing psychiatry as it is practiced in Japan is no small task. Some commentators of the system claim that in it’s drive towards modernisation local conceptions of healing have been side-lined in favour of putatively Western frames of ‘normality’ and ‘illness’[28] but this is difficult to qualify since the overall homogeneity of Japanese psychiatry is in itself no way absolute.
How does the material aspect of culture then, (in this instance the material aspect denoting a non-abstract place and time: a holistic environmental and social framework relying on embodied dispositions for translation of cognitive and bodily orientations in the world) actually affect things like diagnosis and prognosis, as well as psychopathology, and what is the actual content of such specificity in the first place? If we wish to argue for the ontological multiplicity of medical conditions[29] in psychiatry I contend that we must be able to actually locate cultures in space and place in order to form a fully grounded culturally sensitive psychiatry that can deal with it’s own assumptions as well as promoting health care that is locally relevant and culturally sensitive in contexts where very often local ecologies have been edited out by the clinic.[30]

Table 1 Effect of a disaster on mental disorders (WHO estimates of prevalence).

Epstein1

Notes


[2] The Diagnostic and Statistical Manual of Mental Health Disorder 5th Edition

[3] Crozier, I, Journal of the History of Medicine and Allied Sciences 2011; 67 (1): 69

[5] The Tokyo Electric Power Company

[6] Linear No-Threshold Dose hypothesis

[8] Fisker-Nielsen, A. ‘Grassroot responses to the Tohoku earthquake of 11th March 2011. Anthropology Today,  28(3). 2012

[9] Makiko Segawa, “After The Media Has Gone: Fukushima, Suicide and the Legacy of 3.11,” The Asia-Pacific Journal, 10(19). No. 2, May 7, 2012

[10] Mainichi Shinbun January 11th 2011

[11] Kirmayer, L Psychopharmacology in a Globalizing World: The Use of    Antidepressants in Japan. Transcultural Psychiatry, 2002; 39; 295.

[12] Kitanaka, J. Depression in Japan: Psychiatric Cures for a Society in Distress. Princeton, NJ: Princeton UP, 2012.

[13] Watters, E. Crazy like Us: The Globalization of the American Psyche. New York: Free, 2010. Print.

[14] Brumfiel, Nature 493, 290–293 (2013)

[15] ibid.

[16] Fassin, D, and Richard Rechtman. The Empire of Trauma: An Inquiry into the Condition of Victimhood. Princeton: Princeton UP, 2009.

[17] Brumfiel, Nature 493, 290–293 (2013)

[18] Robertson, J. A Companion to the Anthropology of Japan. Malden, MA: Blackwell Pub., 2005. Print.

[19] Befu, H. Hegemony of Homogeneity: An “anthropological analysis of Nihonjinron”. Melbourne: Trans Pacific Press. 2001/ Print.

[20] Kato et al. Keio Journal of Medicine 2012; 61 (1): 15–22

[21] ‘The Pacific coastal region that includes Soma City, Futabamachi, and Iwaki City is now called the “Sousou area,” with the initial characters of each city’s name making up the term. It is almost the size of a small prefecture and contains 200,000 people, but it lost all facilities relating to psychiatric practice once the earthquake struck’. (Kato et al. 2012) ibid.

[25] Numazaki, I. Too Wide, Too Big, Too Complicated to Comprehend: A Personal Reflection on the Disaster That Started on March 11, 2011, Asian Anthropology, 11(1) 27-38. 2012

[27] Byron, J Theorizing the ‘subject’ of medical and psychiatric anthropology Journal of the Royal Anthropological Institute 18 (3) 1467-9655. 2012.

[28] Breslau, J. Globalising Disaster Trauma: Psychiatry, Science and Culture after the Kobe Earthquake. Ethos, 28.2 (2000): 174-197. Print.

[29] Mol, The Body Multiple: Ontology in Medical Practice Durham, Duke UP 2002.

[30][30] Jadhav, S and Barua The Elephant Vanishes: Health Place. 2012 ;18(6):1356-65

2 Comments
  1. Hi Ben,

    This is a great project. During the SHOT workshop, we kept coming up against psychology and emotion-laden responses as something we needed to grapple with in order to speak about recovery and resilience (and the trauma associated with the event itself), but also encountered a stiff warning that social scientists don’t often know much about psychology and therefore ought to proceed very carefully when resorting to psychological explanations. But then again, if social scientists can comment on physics, why not psychology? I do recognize my slippage here–psychology as an explanation to psychology as an object of study)— but for exactly this reason, I’m glad that your project takes the latter approach in the manner we’re accustomed to in science studies. What you produce, in turn, should help provide interpretive frames for the former, and the more analytic work you propose to do in terms of a transcultural understanding of psychology seems especially important.

    On this point, I wonder whether the dichotomy you create between Western and non-Western psychology isn’t a bit off. Western knowledge systems have permeated Japan (and most other nations), especially in a field such as medicine and psychiatry. At this point, I’m not sure whether the modern-traditional dichotomy works very well as a framing device, and it may in fact go against the grain of a true transcultural analysis. What I suspect is that differences internal to the country may be more important, and perhaps accountable in temporal terms, similar to the way that psychology and psychiatry was taboo within the United States around 60-80 years ago. The distinct cultural forms that persist in Japan, including the myth you tell of that circulates in Soma City, are interesting from an ethnographic standpoint, but it would be important to identify the general phenomenon of which that I a part.

    I worry a bit about your remark that “the consolidation of my research will take place after data collection.” I think it’s important to figure out in advance what frames of analysis you plan to use during your interviews and for site selection. I am an ardent supporter of grounded theory, so some initial fieldwork to establish what the relevant issues are, but it is important to define and refine what it is that you are studying during your fieldwork, not after. Perhaps that’s not what you meant. But definitely yes to political economy, and yes to a focus on the knowledge systems produced by the psychologists themselves, and whether their encounter with a) Japanese culture, or b) disaster transforms this knowledge system in any way. Also, I would love to see you speak to people (patients / residents) in Tokyo as well as the most heavily affected regions. After all, the psychological effects of a disaster need not correspond directly to its physical effects, and this would seem especially true for radiation (and especially true given Japan’s historical relationship with radiation—not just Hiroshima and Nagasaki, but the nuclear village and feelings of oppression by a corporatist-state that will no doubt have psychological manifestations; this may be more intensely felt in a metropolitan setting). I would also blur the boundaries about what you consider to be valid subjects. While clinical data will be important, it may be that the attitudes of residents without clinically diagnosed traumas may help you cast a wider net onto the psychological dimensions of disaster, and this would certainly relieve you of some of the access issues that you have.

    Also on the issue of access, my sense is that as you speak with psychiatrists and psychologists, perhaps first about their knowledge (as opposed to what you gain from their patients), you will become something of a valuable asset to them. The body of knowledge you’re seeking to document is an emergent one (psychology & psychiatry of disasters), which suggests that you yourself may become an instrument for the circulation of this knowledge. This will also help with the general access issues, but also raise a separate set of theoretical (and general ethical) issues related to your own influence on your subjects. I don’t think this is about arms-length, “objective” research.

    Finally, you continue to use the “culture” concept in quite general terms. Culture is of course what anthropologists trade in, but I wonder whether the other anthropologists who are following this conversation could advise you on how to think more precisely about culture when deploying it as an explanatory frame.

    Good luck with your project!!

    Atsushi Akera
    Department of Science and Technology Studies
    Rensselaer Polytechnic Institute
    Troy, NY USA

  2. Ben Epstein permalink

    Dear Atsushi,

    Thanks for your comments:

    I would like to try and answer some of the points you raised:
    1. Psychology as an explanation / psychology as an object of study: we need to be careful about how we define psychology in this case. You can talk about ‘folk’ psychology vs. clinical psychology for example. We all make assertions that may be based on vague notions overheard or not fully understood about people’s ‘deep’ motivations/drives and these come with a host of implications, assumptions and loaded frameworks. Psychologists also have them too, but the work that they do has very different ramifications. What kind of work do psychologists and even psychiatrists think they are doing in fact, and how they justify their actions, I think should be a focus of study for the anthropology of psychiatry and psychology, rather than psychiatric and psychological anthropology which concerns itself with, for instance, the cognitive aspects of cultural difference.
    2. I would say you are right about Western-non-Western dichotomy being problematic, and it’s something I come on down quite harshly even with my undergraduate students who make judgements about such things as how people think and how things are done in ‘the West’ versus ‘the rest’ without laying out their incipient assumptions. But in effect, there has to be a point where we use these terms as short-hand to explain much larger social forces at play, particularly where we can see difference is occurring. How can we account for difference meaningfully? For example a recent study indicated that DSM and ICD criteria may not be sufficient to diagnose depression and some have argued that the type of depression now known in Japan as ‘modern type depression’ may be more suitable for a new international diagnostic criterion. In some cases Japanese psychiatrists were less willing to offer pharmacotherapy when dealing with the ‘modern type’ depression emergent in Japanese epidemiological studies as opposed to the classic case depression, and this may be due to Japanese psychiatrist’s own sociocultural and historical contexts. But here is where I find myself in a bind: to what do we attribute these differences? Is it to do with a sociocentric self? A kind of collectivist work ethic? Or shame, as Ruth Bennedict once wrote?
    Another example to illustrate how complex the issue can be: the idiom of distress found in Okinawa labelled ‘kamidaari’ which, according to Takie Lebra, includes symptoms ranging from physical weakness to disturbing dreams, and sometimes eye disorders in the form of partial blindness, may be diagnostically heterogeneous or even non-pathological from the psychiatric perspective. Conversely, prevailing and relatively homogenous psychiatric nosologies will seem locally diverse. In other words what to a Japanese psychiatrist trained in neurobiology might look like depersonalisation disorder may appear to be several different problems from the perspective of a local shamanic healer. So here we have two axes, if you will, playing on our understanding of what is going on. On the X axis you Japanese psychopathology and non-Japanese (or Western) psychopathology which are in a sense in creative tension, and both of these are in fact equally alien to the ‘local perspective’ on the local(emic)/psychiatric(etic) Y axis.
    So whilst differences internal to the country may be important (Y axis) we shouldn’t discount the differences at play in the international classification of mental health disorder.
    3. The consolidation of my research. Thanks I will need to rework this or leave it out and I completely agree that grounded theory is essential in this kind of research.
    4. As far as valid subjects: I just came out a meeting with my advisor and we discussed purely ‘studying-up’ to look only at the response to the disaster from the perspective of the psychiatrists. This would mean cutting everything to do with internally displaced people out but I’m not sure yet how great an idea this is, although I can see why he would suggest this, although focusing on psychiatrists and what they think they are doing may not help with examining the psychological dimensions of disaster on the ground.
    5. As for culture, like many anthropologists working today, I have a very fraught and ambivalent relationship to the term, and this goes back to your first point about tradition/custom/nonwestern versus modernity/Western binaries. However, following Appadurai, there has to be a way of formulating culture not as something that is a timeless and past orientated obstacle to people’s development, but in fact a resource and a capacity that gives us, as you mention, resilience. But how to explain this without reifying difference in the first place?

    Thanks for your comments again and for giving me so much to think about.

    Best,

    Ben Epstein
    Dpt. Social Anthropology
    School of Social and Political Science
    University of Edinburgh

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