Tamaaoba psychiatric hospital visit

Today, Tuesday 28 July 2015, I had an appointment to visit Tamaaoba psychiatric hospital in Tokyo. Mari Yamamoto of the Japan National Group of Mentally Disabled People (http://www.jngmdp.org ) came to pick me up at 12.30. I didn’t do much before that time, only breakfast and some re-organizing of my bags. Mari and I took the subway and bus to the west of Tokyo, to Tamaaoba psychiatric hospital, which was located in a neighbourhood (not in a park). On the outside it was not a special building.
At 14.00 we had an appointment with Dr. Nakajima, who was also the vice president of the hospital. First we talked, and Dr. Nakajima explained the basic structure of the psychiatric hospital. On the ground floor was the outpatient care and day care, with facilities for occupational therapies. The second floor was staff and older persons, and at the third and fourth floor were the wards for persons with psychosocial problems. The wards were numbered, and ward 3 and 6 were the acute wards, and ward 4 and 5 were for long stay, of which ward 4 has more younger persons. Many persons are discharged after 1-3 months, and otherwise it is indicated as long stay. The placement of persons on the various wards also depends on the vacancies in the wards, and whether a shared room (up to 5 people) or single room was indicated. The wards are all closed wards, with a locked entrance, but the rooms were not locked. Medication appeared to be the main treatment-component, and only when the person is considered “ready”, he or she can move around in the hospital and go to the ground floor to join the activities (creativity, sports, karaoke) at the day care centre. At the wards there are no such activities, only table-tennis.

I then asked many questions to Dr. Nakajima, who was very open to answer them all. The number of patients on the wards was around 50 per ward. And there were about 120 staff-persons in the hospital. He didn’t know how many exactly in day shift, but night shift was 2 or 3 staff per ward. I asked what they did if someone needs support, and heard a classical story of “in case of emergency other staff comes to assist” (it sounded like classical forced interventions when persons have a hard time). This hunch was confirmed when we were guided over the wards, and I saw a tower of boxes with restraint belts (at least 12 boxes of belts in 1 ward…), which were placed close to the seclusion cells (they had several cells per ward, except none on ward 5). There were 14 seclusion cells in total. The belts appeared to be used on the wards in the (shared) bedrooms, and there was no set time limit of their use, and they can be combined with a shot of medication or an IV drip…. When we were guided around, the staff (15 on day time) were mainly all inside the office, and the patients were basically alone with each other on the wards. It was very painful to see this. When I asked whether they use ECT (electroshock-therapy), he said “no, but if necessary we sent the person to another hospital for receiving ECT, but this is very rare, maybe once in a few years”. Generally a personal crisis is answered with medication, sometimes there is discussion and if ‘necessary’ it is forced, also restraints or seclusion...

Then I asked many critical questions to Dr. Nakajima, such as: When you restrain or seclude a person in distress, and then walk away to occupy yourself with other things, how can you call this ‘care’ for the person? Dr. Nakajima said that he thought that restraints were effective. I then added that I know from experience, that being subjected to restraints is frightening and scary for the person, and it does not bring mental health or wellbeing, but it rather adds another trauma. And I added that tying a person up or locking them away is a practice that we know from Africa, and it is called abuse, but this is Japan (!), and in Japan there should be more professional mental health care. I saw that this was a painful new view for him, so I didn’t really push much further at this moment. I did offer to send him information on practical alternatives to prevent forced interventions, and he was open to receive that. I will do that in a few days.

I had seen the split up between the staff in the office and the patients on the wards (they even have separate smoking areas for staff), and there was not much communication or contact, nor care for the wellbeing of the persons. The patients just laid on the bed or sat in the “living room”, which was merely an open corner of the hallway, with chairs and tables and a TV playing. The nurses seemed occupied with paperwork in the office. I could not see how this can be called mental health care. It seemed like the patients had to heal themselves, as “waiting for recovery to happen”, tick tack tick tack. It seemed as if the nurses were just mainly guards, and only deal with the patients when something goes wrong, or for the practicalities like food and medication. I have seen this situation many times, and it is outdated. Real mental health care is not about chasing away the so-called illness and fighting symptoms, but it is about care and support for a person, and making him or her feel better. All reactions have a cause, and it’s a social job to support a person in finding ways to deal with feelings. But I did not see much of a social job done by the nurses at Tamaaoba psychiatric hospital. They seemed unaware, and just following the guidelines of the past century.

Dr. Nakajima had expressed at the beginning of the visit that “this hospital already has high standards” when it comes to the number of staff. And maybe it is indeed not the number of staff that needs to be changed (it’s now almost 1 staff on 3 patients during day time), but rather their focus. I will really send them some practical ideas, such as those listed in chapter 2.6 (page 37 and up) of the 2013-report on Torture and ill-treatment in mental health care in the Netherlands (see http://www2.ohchr.org/english/bodies/cat/docs/ngos/StichtingMindRights_Netherlands_CAT50.pdf )

During the visit, I noticed that the place was clean, but there was a lack of fresh air. Persons can use a public phone, but without any privacy (the public phone is located in the hallway next to the nursing office). Mobile phones are not allowed, because they don’t want any pictures being taken in the hospital, and nowadays all mobiles have camera’s so they are prohibited. Internet on public pc is available only in the day care centre, but many persons have restricted access outside the closed ward, so most inpatients have no internet access. And due to health- and safety regulations, living plants are prohibited on the wards, and there are also no living animals at the psychiatric hospital area at all (except for some wild cats maybe). The (lack of) quality of the food was a also well-known topic of discussion inside the hospital. And visiting hours for friends and family are limited, while at hard times one needs his/her loved ones the most. Altogether, inside the psychiatric institution, the quality of life is really stripped down and reduced.

The last part of the visit, we were allowed to talk with some persons who were hospitalized in Tamaaoba psychiatric hospital. I asked them what they would like to see changed, and they mentioned: the food, the nurses actions to be unified, because now there are differences depending on which nurse is involved, equality between doctors, nurses and patients, having mobile phones on the ward (and the camera isn’t necessarily a problem, they can deal with that), and abolishing isolation cells and restraints, because these only make things worse, and having attention for the persons to be able to improve themselves (and not wasting a life time by psychiatric hospitalization). These were very strong and concrete wishes.

I had also asked Dr. Nakajima before the tour how the hospital deals with complaints, and there appeared to be only a very formal procedure at a complaint board. I asked whether there was any mediation, or patient advocates to deal with complaints on a more practical level, but there was no such thing. I then explained, that I had learned about “Research and Development” during my studies, which means that companies try to improve their products and services by being sensitive to the level of satisfaction of the service users, and by learning from complaints or questionnaires as a cycle of improvement. Also this angle appeared to be new to Dr. Nakajima, and he admitted that they do not have such a cycle of improvement, and so far the main quality-investment is the training of staff, but he appeared interested in exploring this new idea.

Altogether, I found it quite heavy to witness all of this, all those marginalized lives... and the threat of forced intervention for whatever they call ‘wrong behaviour’ in the air. The cells and the belts... Personally I felt a bit like I was walking in my past, and it hit me to see that these harmful practices are really so widespread and a global problem. Yesterday I had felt like I was far away from home on a happy holiday, but today it felt not so far away from home… It made me somehow sad. I have seen (too) many places like this, where human beings are subjected to regimes. It’s a global problem of psychiatry, which is also one of the reasons why the UN Convention on the Rights of Persons with Disabilities is also explicitly including this domain, as can be seen in the CRPD General Comment on article 12, http://www.ohchr.org/EN/HRBodies/CRPD/Pages/GC.aspx and the CRPD Committee’s statement on article 14, http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=15183&LangID=E

But the talk and discussion with Dr. Nakajima was somehow still giving me a sense of hope. I could see I brought a new perspective to his mind, and when I asked how he felt about this visit he said it was “complicated”, so I think I planted a seed there, and I hope he will think about it, and hopefully bring some change.

After this visit, I was very tired. Mari and I travelled back to the centre, and Mari left, while Ryugan and later also Satani joined me for a visit to Tokyo Sky Tree, the highest tower in the world. We went to the 350th floor (350 metres high) to enjoy the nice panoramic view of Tokyo, with many lights in the dark. We didn’t have enough time to go to the highest top level, the 450th floor, because there was a farewell-dinner scheduled for me. So we made a quick visit up in the Sky Tree, and we even stood on the glass floor at 350 metres high looking down. That was cool and gave some relief after the hospital visit. Then Satani, Ryugan and me made our way to Shinjuku, very hungry and tired, and around 10 PM we arrived and had a nice cosy dinner with Mari, Yoshi, Reiko and Tokyo at the 29th floor of Shinjuku NS Building, again enjoying a nice far view with the many lights of Tokyo. And we had a great Japanese dinner of course (Japanese food is always great). We had a very nice evening.

And now it is late again. I will go to bed now. Tomorrow another visit to another psychiatric hospital, and some social events in the evening as well. It will be my last day in Tokyo. I don’t want to think of it as an end, but rather as a beginning. It is very special to be here. It was a great beginning.
Good night!