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International Mental Health Professionals in Japan: Challenges and Opportunities
CIRP member Carolyn Enns is spending this year in Japan working with the International Mental Health Professionals Japan (IMHPJ). In this article she and colleague Jim McRae provide an overview of the institutions and issues in mental health services to the international community in Japan.
Picture the scene. A snow-covered Mt. Fuji towers outside the large glass windows of the Fuji View Hotel. A short walk away is Kawaguchi-ko, the largest of the five lakes that surround the base of Fuji-san. This site was the setting of the 2007 annual conference of the International Mental Health Professionals Japan (IMHPJ), an interdisciplinary conference that brings together a broad range of clinicians from different disciplines who are engaged in providing mental health services to the international community in Japan. Conference participants attended sessions on topics such as play therapy, adult ADHD, and the link between humiliation and mental health problems. In addition to hearing excellent presentations, attendees soaked in the hot spring baths (onsen), enjoyed an exquisite 8-course Japanese dinner, gazed at the stars, participated in karaoke, and had the opportunity to take an early-morning bird-watching excursion (appropriately entitled “Toward a psychology of observation: Experiential approaches to the avian world-view”).
IMHPJ was founded in 1997 as a multidisciplinary professional association of clinicians. Members hold degrees in the specialties of psychiatry, social work, clinical psychology, education, social work, nursing, school psychology, and neuropsychology. English and Japanese are the most common languages used in psychotherapy practice, but some psychotherapists also provide services in French, German, Polish, Dutch, and Spanish. Although many IMHPJ members are expatriates from places such as Europe, North America, and Australia, a substantial proportion of these providers are originally from Japan with advanced degrees in psychology in the United States or the United Kingdom. Most IMHPJ psychotherapists work with a wide array of psychological issues; some also specialize in areas such as play therapy, trauma-related issues, or transgender issues.
The IMHPJ website identifies its primary goals as improving the “quality, quantity, and accessibility of mental health services available to the international communities in Japan.” During its short ten-year history, IMHPJ has hosted 11 annual conferences and sponsored regular continuing education opportunities for members. A sample of conference themes include: “Psychotherapy East and West,” “Many Cultures, Many Minds,” “What’s Going on in Our Community,” and “A Different Lens: Perspectives on Therapy and Asia.” During the past year (2006-2007), continuing education has sessions on psychopharmacology, domestic violence, and providing services for survivors of natural disasters. Members in the Tokyo area also hold a monthly breakfast meeting to facilitate regular communication and information sharing, conduct regular business, and provide interpersonal support and friendship.
IMHPJ clinicians face a variety of challenges, which makes the presence of this organization especially important. These challenges include finding creative ways to organize a viable practice in a country in which professional counseling is still not used extensively as a method for addressing psychological issues. In addition, many mainstream psychological theories, including those based on domestic multicultural concerns in North America, seem inadequate for working with the cultural challenges facing many clients. Intercultural intimate relationships and bicultural households are increasingly common in Japan. Some estimates indicate that in the Tokyo area, 1 in 10 intimate relationships are those in which partners are from two different cultures. Within these relationships, the complexities of negotiating the diverse and sometimes conflicting cultural norms related to communication, intimacy, child-rearing, gender roles, education, work styles, and extended family relationships are frequent catalysts for seeking psychological services. Furthermore the children of bicultural couples often view themselves as “third culture kids” who struggle to create identities that transcend the boundaries of their parents’ cultures. Creating theoretical and practice models for understanding and working with “third culture kids” is a particular concern of many IMHPJ members.
Mental Health Regulations in Japan
At present, IMHPJ members work in a Japanese environment in which licensing and certification procedures in mental health fields are still evolving. Within Japanese clinical psychology programs, the master’s degree is considered the degree of practice, and persons with this degree may seek registration and certification as a clinical psychologist (through the Japan Society of Certified Clinical Psychologists) or as a psychotherapist (through the Japan Federation for Psychotherapy). However, the government does not license or regulate psychological practice. The Japanese government licenses medical doctors (including psychiatrists) and social workers, and as a result, some psychologists work under the umbrella of social welfare licensing laws. Psychologists are not able to seek reimbursement for services through the Japanese national health insurance system, unless they receive this reimbursement indirectly by working under the direction of a licensed psychiatrist, typically in a hospital setting. However, these arrangements are somewhat rare and gaining regular access to the services of a hospital-based psychologist is difficult.
Psychologists and mental health practitioners with appropriate credentials are often able to gain reimbursement for services to expatriate clients whose overseas insurance coverage (e.g., from the UK, USA, Australia, other European countries) includes outpatient psychological services. Clients who are Japanese citizens and hold Japanese health insurance policies must generally pay the full fee of psychotherapy. Although some therapists provide a sliding fee scale, the absence of health insurance supports for service further decreases accessibility in a country in which psychotherapy practice is not well understood. Japan also has rigorous drug testing procedures, and many of the newer medications used for the treatment of psychological problems in North America are not available in Japan. Thus, knowledge of alternative medications available in Japan and close consultation with psychiatrists is often essential for providing comprehensive services.
Membership in IMHPJ
Within the complex and evolving landscape of mental health services in Japan, it is still possible to advertise services as a psychologist or counselor without appropriate academic credentials, training, or supervision. Thus, providing information and verification about IMHPJ’s members was a major impetus for the formation of this organization. Qualifications for IMHPJ clinical membership can be met by completing a master’s degree or higher in a field of clinical mental health and fulfilling at least 250 hours of direct clinical supervision (50 of which must be post graduation). Clinical membership can also be granted to members who come from countries in which clinical practice is permitted with a bachelor’s degree and who have fulfilled all requirements for practice in the country in which they received training. In such situations, members must be able to document ten years of supervised full-time post-baccalaureate clinical practice.
IMHPJ Raises Awareness of Ethical Issues in Practice
In light of these issues, one of the major contributions of IMHPJ is its attentiveness to an ethical foundation for practice. The IMHPJ ethics code is posted on its website and includes elements of the APA ethics code that are especially relevant to psychotherapy practice issues within Japan. The major sections of the IMHPJ code focus on privacy and confidentiality, client rights, professional competence, and the treatment relationship. In the section on the treatment relationship, guidelines related to dual relationships receive special attention. As noted by the IMHPJ ethics code, the code not only provides standards for mental health providers, but also educates members of the public about the importance and nature of ethical behavior. Given the relative absence of external bodies that regulate practice, IMHPJ members also engage in regular discussions about ethical practice.
Practice in Japan: Example
The backgrounds and practice experiences of IMHPJ clinicians are diverse. We conclude by providing a brief glimpse of the practice experience of one of the co-authors, Jim McRae, who is a founding member and current president of IMHPJ. Originally from the United States, Dr. McRae has worked as a clinical psychologist in Japan for 23 years and his career exemplifies a long-term commitment to mental health practice in Japan. He works with adults and couples. He estimates that about half of his clients come from North America, about 10 percent are Japanese, and the rest are from all over the globe. Most are relatively high functioning people who want to understand and change aspects of themselves that get them into similar difficulties wherever they live. Many are from the business community; many teach English, either as a short term adventure or as a long term profession; and many are long-term residents in Japan. For backup, Jim works with several physicians and psychiatrists, although he notes that the resources for dealing with emergencies and/or difficult cases are limited. The “managed health care” struggles that have been affecting practice in the US so extensively are not present in Japan. Most of Dr. McRae’s clients pay cash and many receive reimbursement from their non-Japanese health insurance policies.
Jim McRae notes that his practice in Japan has been very rewarding, in part because people are able to apply a dual lens to their lives. During treatment, people’s use of the mirror of their own culture of origin as well as the mirror of whatever part of Japan with which they are involved adds greatly to the possibilities for insight and growth. Ψ