I had the pleasure of joining the monthly Fukushima University GP training group last Sunday. The session focused on doctor-patient communication and, in part, mental health (I suspect mostly for my benefit). It was a fascinating day and warrants a blog of it's own but for today's piece I want to extract a statement from one of the many conversations I had during the meeting which introduced me to a concept that begins to, at least partially, explain the well-publicised phenomenon of 'Karoshi' in Japan or 'death from overwork'.
The article published by the BBC this week, 'The young Japanese working themselves to death' has expedited my writing on the subject but even without this latest interest, covering this topic was always going to be inevitable.
As an idea it understandably makes for shocking headlines and, as seen most recently with the high-profile suicide of advertising agency worker Matsuri Takahashi in 2015, it is now a subject discussed by many world powers. The scrutiny Japan has come under as a consequence has led to the implementation of changes in the workplace but as the news continues to flood in, it's becoming clear that enforcing new rules in the office will only go so far in dealing with a problem or habit that is so ingrained in the nation's culture and history.
Japan has long battled one of the highest suicide rates in the industrialised world. In 2013, its national rate of suicide stood at 21.4 deaths per 100 000 people ̶ well above that of other high-income countries (12.7 deaths per 100 000 people). The staggering mental health statistics were one of the reasons for choosing to include Japan in the project, not purely because of the numbers but because of the huge efforts that have gone into combatting the problem. For the first time since 1998, the last few years have seen the annual suicide rate drop below the 30,000 mark and in many ways this is a reflection of the success of national suicide prevention programmes, rolled out in response to the crisis. I wanted to see what I could learn, that might benefit the members of the British public struggling with mental health issues, from a country sitting even further along the spectrum and tackling the challenges head on.
It's difficult to look at mental health issues in Japan and not consider the impact of work. Therefore 'karoshi' was something I wanted to try and get under the skin of whilst I was here; yes, it's a hot topic in the media but what is the reality on the ground?
'I think it’s the sentiment that it’s ok to feel damaged a little for the greater good.'
The statement above came from a GP when asked if there was anything about Japanese life that potentially negatively impacts the mental health of the people. It followed the explanation that during the post war economic slump, an already conscientious workforce was encouraged to give yet more to the rebuilding of the country: to sacrifice themselves for the 'greater good'.
Whilst this historical context might account for the modern day intensity of the workplace, it is important to remember that elements of Japanese culture which give rise to such an ethos have existed for centuries.
During my first week in Japan I was taken to see the the city of Aizu Wakamatsu; a previous Samurai stronghold and home to the beautiful Tsuruga castle. It was really during this visit, whilst wandering the museum galleries, that I first became aware of the 'bushido' or 'Way of the warrior'. The Samurai code puts honour above all else and this, coupled with 'Wa', the Japanese concept of a peaceful unity and conformity within a social group, in which members prefer the continuation of a harmonious community over their personal interests, perhaps goes some way to illustrating how the path towards a dedicated and self-sacrificing workforce has been paved throughout history.
But what is the reality now?
Before coming to Tadami, I hadn't imagined I would be given such a thorough insight into small town Japan work life as I have been lucky enough to receive. It all began last Thursday evening with sake, copious amounts of sashimi and the agenda of recruiting people for interview via the local hydroelectric plant annual drinks party. Looking different luckily goes a long way here and very quickly the group's curiosity regarding the project was peaked. We were hoping for a few willing volunteers, what we got was an invitation to the plant the following day for a tour, lunch and a series of interviews with the workers. Off the back of this meeting I was also invited to participate in my very first Japanese karaoke experience but that's another story…
The following day brought with it the beginning of the rainy season or 'Tsuyu', but the weather didn't dampen our spirits as all of our geeky, 'physics-loving' desires were fulfilled on a tour of the plant complete with hard hats!
Japan is one of the biggest hydroelectricity producers in the world and following the Fukushima Nuclear power plant disaster in 2011, the area is relying more and more on this power source leading to concerns that the plants are being 'overused' and not rested adequately.
As the plant staff continued to take us and the project under their wing we were provided with our own conference room and a string of interviewees for the afternoon; I only hope they had volunteered!
'Young people at this company would go into town together'
'Who is my community? My colleagues at work'
'If we talk about time spent together, it’s my work colleagues.'
I began to hear how the company in question was for many, their community. Not only did the workers frequently speak about spending time with their colleagues outside of work, 4 out of 5 interviewees identified a work colleague as being a main confidante and the person they would turn to first on receiving bad news.
On reading about the concept of the 'salaryman' in Japan, the expected career choice for young men of joining a company on graduating and staying there his whole career, it is easy to imagine how a business could become one's family. When thinking, therefore, about work-related suicide it is important to not only consider the potential negative aspects of being a salaryman such as long hours and limited progression but also how losing the positive aspects of such a position, in the context of redundancy for example, might impact mental health.
'With regards to this company, there aren’t any pressures. I don’t think I’ve been under much pressure even after 26 years. For example in other companies; some places make you do overtime without logging it.'
'Some are here because they were being bullied at other companies and therefore came back.'
Many of the interviewees spoke positively about the company in question, alluding to the idea that it managed to escape many of the flaws of bigger and more urban businesses and provided a better work:life balance for its employees.
'Sometimes, in the past, we would finish work early and go for a beer but now I feel like I’m worrying about how other people see me.'
'I didn't feel initially welcome at the office. How long did it take to fit in? 6 months. '
'I feel watched 24 hours a day in a small town.'
However, it would seem that some of the negative aspects of work life in Japan have crept in in recent years and are perhaps exacerbated by the small town location of the plant.
'In November, there was a man who moved away for work and he died in February. I heard it was suicide.'
'Those are the times when I speak to my colleagues. At those times, if I discussed it with my wife or children they wouldn’t understand, we wouldn't connect.'
'My bad feelings before were due to work. When I was down about work, it felt like there was no escape route. I realised that if I was able to have a work:life balance and keep it 50:50 then if work was not too good I could rely on my homelife and vice versa.'
Even despite reading around the subject prior to the interviews, I was still surprised at how many of the workers opened up about either personal experience of mental health symptoms or about knowing someone who had suffered. There seemed to be a growing acknowledgement of the route of some of these problems and an awareness of the benefits of improving work:life balance. However, it was interesting to note that many revealed through the circle exercise that disclosing work problems to family members or anyone out of the workplace would still be unusual. Many spoke of how family 'wouldn't understand', that they felt 'disconnected' from them on this topic.
'I had my classes at work. They invited a specialist to come talk to us. I think that’s probably normal now. When they first did it here we all wondered why we had to listen to this but they went through what to do if you develop symptoms yourself or if you know someone else who does, so it was useful.'
'There’s more education on what not to say…they teach us not to say “try harder” which would feel normal but just adds pressure.'
'From the main office, there is an email once a year around May with a checklist to check your 'soul’s care'. If you’re only at 80% they may refer you to a psychiatrist.'
In this small office in rural Japan, I was seeing proof of the suicide prevention programmes I'd read about in national legislation and the effects they were having both in terms of changing habits but also attitudes. Not for the first time in Japan, I had a renewed sense of the power of discussing mental health issues and the possibilities that a new openness amongst people might bring.
I was impressed, on reading more about the goals of some of these programmes, to find that creating new spaces and forums for people to open up about their experiences is a priority. Not only for those suffering with mental health issues themselves, but for the families and friends of sufferers and those who are bereaved.
There's a message now being sent out to the people of this nation, one that is still fairly revolutionary but slowly and surely growing in volume, reaching even the small streets of Tadami: Japan, it's time to talk.
1) (World Health Organisation, http://www.who.int/mental_health/suicide-prevention/japan_story/en/)
(Enjoying the 'work:life balance' in Tadami. )