The Emergence and Development of a Psychodynamic Approach to Japanese Managerial Operations

The Need to Heal Japanese Mental Institutions: How to Restore the Splitted Self and Adapt to Reality

Changes in the Environment Surrounding Mental Institutions

Japan is currently in the midst of a trend toward significant structural change. This major structural change has been brought about primarily by plunging into an era of low economic growth and a rapid increase in the number of elderly persons in society. Inevitably, mental institutions in Japan are also being required to adapt to this structural change. Low economic growth strengthens the pressure to curb health care costs, which as a result, requires to achieve greater efficiency in health care resources. In addition, it also becomes necessary to switch from quantitative expansion to qualitative expansion. As the number of elderly in society continues to increase in the future, it will be necessary to establish a system for accepting the elderly both in terms of facilities and services, including the social security system.

Maladjustment of Mental Institutions to Changes in the Environment

The pressure resulting from this structural change has forced mental institutions in Japan to implement "functional differentiation". Conventional mental institutions in Japan did not maintain adequate communication with other mental institutions, thus causing each individual institution to fulfill all the roles of a mental institution in a self-compensating manner. Consequently, mental institutions in Japan tended to have poor cost efficiency as well as be lacking with respect to the quality of health care. Moreover, in terms of the future, there was apparently a shortage of hospital beds for the elderly. In order to solve these problems, every mental institution has been forced to clearly define the role it is to play within the framework of the medical realm in which it exists, as well as to make an effort to fulfill that function. In other words, every institution will have to define its primary area of medical services, whether that be treatment of the acute phase of schizophrenia, treatment of the chronic phase of schizophrenia, treatment of the elderly or treatment of alcoholism, as well as determine what types of services it will provide, such as focusing primarily on in-patients, out-patients, home nurse programs or day care programs and so forth. In addition, naturally this "functional differentiation" has had to be implemented throughout all mental institution wards and out-patient facilities. The Ministry of Health and Welfare has been implementing these reforms for more than 10 years. To begin with, the Health Care Act was revised twice during that time, and legal and administrative environmental measures have been implemented through the adoption of the Gold Plan. Unfortunately, change has not occurred at many mental institutions. Next, continuous revisions were made in the number of insurance points. Revision of the number of insurance points made it possible to manipulate the income structure of hospitals, enabling changes in mental institutions to be promoted from economic aspects. As a result of these efforts, there was a definite increase in the number of hospitals that exhibited changes toward "functional differentiation". Although there were numerous hospitals observed that immediately began implementing hospital reforms, a large number of hospitals remained that still showed no signs of changing.

The Illogical Reaction of Mental Institutions

There are some extremely severe aspects of the economic tightening resulting from the revision of insurance points implemented by the Ministry of Health and Welfare. Numerous hospitals are faced with bankruptcy unless they comply with the trend towards "functional differentiation" induced by revision of the number of hospital points. Why then are there so many hospitals at which signs of change are still not seen despite these circumstances? One possibility is that some of the hospitals are managed by incompetent administrators. In addition, there are also probably some administrators who have lost their enthusiasm for hospital management due to various circumstances. These alone, however, would not explain the placement of operant conditions on mental institutions by the Ministry of Health and Welfare not generating adequate effects.

The splitted Self of Mental Institutions

In Japan, the majority of mental patients had been provided health care through family members in the home. Following the enactment of a law passed in 1950, however, patients began to receive both medical care and nursing care at mental institutions. Following the Second World War, the number of patients admitted to mental institutions increased rapidly. If the level of health care technology had improved with this increase in the number of patients admitted, problems would not have occurred. Unfortunately, however, health care technology did not advance that significantly. Consequently, the prejudice towards mental disease easily resulted in prejudice towards mental institutions. As a result of mental institutions, enthusiastic over pursuing the ideals of mental health care, encountering strong prejudice, splitting occurred in the form of a defense mechanism. In order to reduce the pressure produced by this prejudice, the outer self resulting from this splitting lowered its own sensory functions, recognition functions and ability to act, while barely maintaining adaptation to its surroundings. On the other hand, having been isolated from the outside world, the inner self (Laing, 1960) became increasingly autistic, earnestly striving to create a paradise made up of mental patients alone. Thus, with mental patients being isolated from the outside world, mental institutions became isolated from society. It is therefore inevitable that mental institutions that presently function as a result of following such a course are indifferent to changes in the outside world. Even if a mental institution notices the changes in the outside world, it is clear that it is not easily able to achieve "functional differentiation" in the form required by the outside world. Thus, it is understandable why the placement of operant conditions on mental institutions by the Ministry of Health and Welfare have not produced adequate effects.

Restoration of the Splitted Self

Two approaches are necessary in order to achieve the "functional differentiation" being required by changes in the environment surrounding mental institutions. To begin with, it will be necessary to attempt to restore the splitted self of mental institutions. Theoretically, the fundamental solution is to eliminate prejudice towards mental disease. Unfortunately, however, that is not a realistic option. Therefore, the next best step that can be considered is eliminating prejudice towards mental institutions. In recent years, rehabilitation through the use of day care facilities has come to be known as an effective means of returning mental patients to society. These day care facilities could be the very impetus for enabling mental institutions to also return to society. Realistic exchange with the outside world within the process of assisting mental patients in returning to society would pave the way for elimination of people's prejudice towards mental institutions. It also serves to return a sense of reality to mental institutions as well. Thus, it is first important to proliferate the concept that rehabilitation through day care facilities is an effective means of enabling mental patients to return to society, and then use this to enlighten and act on both the general public and mental institutions. Persons hoping to promote "functional differentiation" should first take notice of this point. In recent years, there has definitely been an escalation in activities oriented towards returning mental patients to society in Japan as well. However, these activities have not advanced to the extent that mental institutions have been able to adequately regain a sense of reality. Further educational and enlightenment activities are therefore required. Through these efforts, it is thought that the operant conditions placed on mental institutions by the Ministry of Health and Welfare will act more effectively.

The Concept of Illness of a Hospital Ward

It has been previously mentioned that the regaining of a sense of reality by the splitted self of mental institutions is a prerequisite to implementing "functional differentiation". Next, some problems are considered that may occur during the course of actually implementing "functional differentiation" at a mental institution. At the majority of mental institutions currently operating in Japan, the individual wards are not organized to handle a single or single group of disorders. It is not uncommon that a single ward may provide treatment for schizophrenia, depression, dementia, alcoholism and so forth simultaneously. The following illustrates an actual example at this type of mental ward. I was participating in treatment as an alcoholism consultant in a certain hospital ward. The ward consisted of a reputable ward physician, a capable ward nurse with excellent leadership abilities, and a hard-working nursing staff. Treatment of schizophrenia was performed extremely well in that ward. There were also a large number of new patients admitted. On the other hand, the ward's record with respect to treatment of alcoholism was not that favorable. Acting out was conspicuous within the ward, and many patients dropped out of therapy. There appeared to be no problems in terms of the abilities and enthusiasm of the health care personnel and nursing staff. What then was the reason for the ward's poor results with respect to the treatment of alcoholism? By mere chance, I happened to find out that the husband of the ward's head nurse was an alcoholic. Thus, the head nurse herself was an enabler of an alcoholic. Consequently, the alcoholics being treated in the ward and the ward's head nurse had the tendency to fall into an co-dependent relationship. From the standpoint of the alcoholics admitted to that ward, it was as if there was "another spouse" in the ward. This was the reason for the treatment record of alcoholism in this ward not being that satisfactory.

Hidden Problems in Implementing "Functional Differentiation"

In hospital wards in Japan, the influence of the ward's head nurse is considerable for patients admitted to that ward. The ward's chief physician has the responsibility for treating more than 50 patients even under good conditions. Thus, there is little time for contact with patients due to considerable time being required for clerical processing. The nursing organization has a strong tendency to be vertically oriented. Consequently, the greater the capabilities of the ward's head nurse, the greater the possibility that head nurse's concept of illness developing into the concept of illness of the entire ward (Kets de Vries, 1984). The previous illustration is a good example of this. Due to the head nurse's concept of illness, although the ward's record with respect to schizophrenia was excellent, its results in the treatment of alcoholism were poor. Although precise figures are not available, a large number of health care personnel are said to exhibit the behaviorof adult-children. If the favorable aspects of the concept of illness possessed by an adult-child is demonstrated, this results in an extremely capable member of the health care staff. However, unfavorable aspects of the concept of illness of that staff member may be emphasized and demonstrated in certain situations. "Functional differentiation" in a hospital ward has the aspect of organizing hospital wards for each disease. In the previous example, since patients with various mental diseases were combined in a single ward, the shortcomings caused by the concept of illness possessed by the head nurse were diluted. However, as the "functional differentiation" of a hospital ward progresses, and each ward is organized according to individual diseases, there is a greater possibility that the unfavorable concept of illness possessed by the head nurse will be demonstrated in a more concrete form. Hospital administrators will be required more than ever before to assign personnel while taking into consideration the concept of illness possessed by the head nurse. Self-analysis will also be required on the part of the head nurse herself. Unless this is done, there will be a greater possibility for the occurrence of the contradictory situation in which the greater her leadership capabilities and skills become, the poorer the treatment record of that hospital ward. As a result of that, the number of people that are negative with respect to "functional differentiation" will increase, thus leading to the failure of "functional differentiation" at that mental institution. Mental Institutions in a Post-Industrialized Society Japanese mental institutions are being required to implement "functional differentiation" accompanying the structural changes taking place in society. "Functional differentiation" means that non-hospital functions will play a larger role in hospital operations in the future. Functions such as home care, nurse visitation programs and training patients to return to society through the use of intermediate facilities will become active in the future. When this happens, the vertical relationship within the mental institution will transform into the horizontal relationship outside the mental institution. This truly represents the coming of the "post-industrialized society" of mental institutions. What then should we focus our attention on in welcoming the arrival of this new era? What is important is the form in which we confront this "post-industrialized society" by skillfully proceeding with "functional differentiation". The key to achieving this is considered to be the extent to which problems currently facing mental institutions and mental wards as described in this paper can be effectively resolved.