History of Japanese psychopathology: Portraits of the second‐generation psychopathologists (Takeo Doi, Yomishi Kasahara, Hiroshi Yasunaga, Tadao Miyamoto, Bin Kimura, and Hisao Nakai) and their relationship to psychiatric reform movement in Japan

ABSTRACT

This paper attempts to provide an overview of the history of Japanese psychopathology by presenting concise portraits of the second generation of Japanese psychopathologists, whose era is considered to be the heyday of Japanese psychopathology. Meanwhile, we also consider the historical background of the psychiatric reform movement in Japan that influenced many second‐generation psychopathologists. First, the paper briefly discusses the emergence of the first‐generation of psychopathologists through the adoption of German‐centered psychiatry after the Meiji era. In general, the first‐generation can be said to have laid the foundation for the independent development of psychopathology in Japan. Then came the second generation, at a time when the psychiatric reform movement was gaining momentum, with the Academic Chair System of the Faculty of Medicine (Ikyoku Kōzasei) heavily criticized, and psychiatric research itself halted temporarily. In order to continue the hampered academic research, workshops on “Psychopathology of Schizophrenia” were organized by the second‐generation psychopathologists, whose major figures include Takeo Doi, Yomishi Kasahara, Hiroshi Yasunaga, Tadao Miyamoto, Bin Kimura, and Hisao Nakai. The invaluable contributions of the second‐generation psychopathologists are essential to the development of Japanese psychopathology, and their close relationship with the psychiatric reform movement is worth reexamining, as it could be argued that the political tensions generated by the movement were the driving force behind their high‐quality work.

INTRODUCTION

Japanese psychopathology has not been adequately introduced to the Anglophone world. Only Bin Kimura (木村敏), ¹ who developed his own phenomenological‐anthropological psychopathology under the influence of the Kyoto School (京都学派, Kyōto‐gakuha) of philosophy, and Takeo Doi (土居健郎), whose major work is The Anatomy of Dependence, ² are widely known. Thus, this paper provides an overview of the thoughts, deeds, background, and history of psychopathologists in the second generation, which was the flourishing period of Japanese psychopathology. ³

The prehistory of Japanese psychiatry and psychopathology

Since the Meiji era, Japan has practiced mainly German medicine. ⁴ Beginning in 1882, Erwin von Bälz (1849–1913), a German physician, taught psychiatry (mainly pre‐Kraepelinian) at the (Tōkyō) Imperial University. Later, Hajime Sakaki (榊俶, 1857–1897), who specialized in psychiatry at the University of Berlin, returned to Japan as a professor and opened the psychiatry department at the university. In 1901, Shūzō Kure (呉秀三, 1865–1932), who wrote the book Actual Conditions of Home Confinement and Statistical Observations of the Mentally Ill (精神病者私宅監置ノ実況, Seishinbyōsha Shitakukanchi no Jikkyō), ⁵ became the professor of the department. After studying in Austria and Germany, Kure returned to Japan with an education in Kraepelinian psychiatry and research based on the Nissl staining method.

One of Kure's outstanding students, Noboru Ishida (石田昇, 1875–1940), studied at Johns Hopkins University in 1917 and specialized in American dynamic psychiatry. However, Ishida's mental state deteriorated while studying abroad, and he was arrested for murdering a colleague. After undergoing a psychiatric evaluation by Adolf Meyer, Ishida was sentenced to life imprisonment. ⁶ He returned to Japan in 1925 and spent the rest of his life at Matsuzawa Hospital. Had Ishida's studies been successful, dynamic psychiatry may have had a greater influence on Japanese psychopathology. ⁷

Thereafter, Yūshi Uchimura (内村祐之, 1897–1980), the professor at the Tōkyō Imperial University and son of the famous Christian thinker, Kanzō Uchimura (内村鑑三, 1861–1930), embraced a wide‐ranging approach to psychopathology, from the classical psychiatric theories of Germany and France to phenomenological–anthropological psychopathology. ⁸

The first‐generation psychopathologists were born around 1910 and included Tsunerō Imura (井村恒郎, 1906–1981), Katsumi Kaketa (懸田克躬, 1906–1996), Masashi Murakami (村上仁, 1910–2000), Shihō Nishimaru (西丸四方, 1910–2002), and Toshiki Shimazaki (島崎敏樹, 1912–1975). Nishimaru and Shimazaki were brothers and great nephews of the writer Tōson Shimazaki. Murakami graduated from Kyōto Imperial University, Kaketa from Tōhoku Imperial University, and the others from Tōkyō Imperial University. Kaketa was interested in not only psychopathology but also psychoanalysis, and he translated some of Sigmund Freud's works.

The first‐generation psychopathologists had several notable achievements. First, the Japanese Society for Psychopathology and Psychotherapy (日本精神病理・精神療法学会, Nihon Seishinbyōri Seishinryōhō Gakkai) was established in 1964, with Murakami serving as its first president. However, this society focused more on psychotherapy than psychopathology. For example, the society became a member of the International Federation for Medical Psychotherapy (now renamed the International Federation for Psychotherapy). Medard Boss was the president of the Federation at the time, and his recorded message was played at the first annual conference of the society. ⁹ Second, Eugène Minkowski's The Schizophrenia, which Murakami translated in 1946, and Karl Jaspers's General Psychopathology, which Uchimura, Shimazaki, Nishimaru et al. translated from 1954 to 1958, were published. Third, as a result of the rapid implementation of psychopathology abroad, the Lectures on Abnormal Psychology (異常心理学講座, Ijō Shinrigaku Kōza) (first series, 1954–1958), a comprehensive series of books, was published. The first generation established the foundation for the independent development of psychopathology in Japan.

Second‐generation psychopathologists and Japan's psychiatric reform movement

The second‐generation psychopathologists were born around 1930 and include Takeo Doi (1920–2009), Yomishi Kasahara (笠原嘉, b. 1928), Hiroshi Yasunaga (安永浩, 1929–2011), Tadao Miyamoto (宮本忠雄, 1930–1999), Bin Kimura (1931–2021), and Hisao Nakai (中井久夫, 1934–2022). These psychiatrists began their research activities in the late 1950s. During this period, Kimura and Miyamoto et al. translated Ludwig Binswanger's Schizophrenia (1959), and Kasahara et al. translated Boss's Psychoanalysis and Daseinsanalysis (1962). With a growing interest in phenomenological–anthropological psychopathology, Japan's own phenomenological discussion began.

However, a major problem occurred at the time. After World War II, criticism increased against the internship system that was established by the General Headquarters (also known as Supreme Commander for the Allied Powers), and criticism of the faculty of medicine's academic chair system (医局講座制, Ikyoku Kōzasei) began in the late 1960s. Embroiled in the student movement at that time, this criticism became a significant political movement. As will be mentioned later, under the pseudonym Tatsuo Nirebayashi, Hisao Nakai wrote the book Doctors of Japan (日本の医者, Nihon no Isya), ¹⁰ which served as a manifesto to criticize the faculty of medicine's academic chair system. Moreover, some groups of young psychiatrists recognized that psychiatric care was inadequate at the time and that the academic chair system of the faculty of medicine hindered medical reform and exploited and dominated the psychiatric hospital.

Consequently, in May 1969, at the 66th Annual Meeting of the Japanese Society of Psychiatry and Neurology (日本精神神経学会, Nihon Seishin Shinkei Gakkai; the largest academic society of psychiatrists in Japan) held at Kanazawa, there was so much serious dissension about the society that all presentations were canceled and only discussion meetings were held. The 6th Annual Meeting of the Japanese Society for Psychopathology and Psychotherapy, which was held October 5–6, 1969, also had only discussion meetings. Psychiatrists of the psychiatric reform movement (精神医療改革運動, Seishin'iryō Kaikaku Undō) made the following accusation:

On the one hand, by treating one person selected out of a hundred patients with “psychotherapy,” [psychiatrists interested in psychopathology] constructed the theme of “academic [i.e., phenomenological‐anthropological] research.” Yet, the same psychiatrists, on the other hand, imprisoned the rest of the 99 in a locked psychiatric ward, denying their freedom as their basic human right—the psychiatrist's two‐faced duplicity—the self‐contradiction should be now questioned by us. ¹¹

Revealing the dark side of Japanese psychiatry and psychopathology led to the dissolution of the Japanese Society for Psychopathology and Psychotherapy. Furthermore, during the psychiatric reform movement, the anti‐psychiatry of Ronald David Laing and David Cooper was introduced in Japan. Consequently, research in psychopathology became temporarily impossible due to the suspension of the society's activities.

The Psychopathology of Schizophrenia workshops and the reconstruction of the Japanese Society of Psychopathology

Thus, second‐generation psychopathologists had to conduct their research in private places rather than in professional societies. The venue for their work was the Psychopathology of Schizophrenia (分裂病の精神病理, Bunretsubyō no Seishinbyōri) workshop, which was the center of Japanese psychopathology. The workshop participants boarded together annually at a hot springs hotel, frequently in Atami, and engaged in lively discussions about the psychopathology of schizophrenia. The records from 1972 to 1986 were published each year as a book titled Psychopathology of Schizophrenia (分裂病の精神病理, Bunretsubyō no Seishinbyōri). ¹² Doi was the original organizer of this workshop. The background of the workshop posed the practical questions of how to activate the stalled psychiatry and psychiatric care again and how to land softly after a radical movement.

Consequently, the research activities of the second‐generation psychopathologists were revived. However, these individuals were not only critical of the psychiatric reform movement (or anti‐psychiatry) that rendered their research activities impossible; rather, they sought to respond to the movement. Kimura, who studied at the University of Heidelberg at the time, recalled that he “felt very close to Laing” and that schizophrenia is not a disease, but a distorted ‘way of being’ in relation to others. This perspective has been self‐evident within me for a long time.” ¹³ Furthermore, Kimura began the paper he presented at the first workshop by stating, “Needless to say, the concept of ‘schizophrenia’ needs to be radically re‐examined today.” ¹⁴ Although not directly stated by Kimura, the underlying message was that the concept of schizophrenia needed to be updated in response to the anti‐psychiatry movement. In addition, Nakai explained the following about the workshop: “At that time, being in the midst of disputes in psychiatry, I thought it might be my first and last paper, therefore I decided to write what should be written, even if compressing intricate discussions into one line.” ¹⁵ Because of the circumstances, many second‐generation psychopathologists embraced this aspect of the response to the psychiatric reform movement (or anti‐psychiatry, which partially formed the basis of this movement).

Thereafter, the Roundtable on Psychopathology (精神病理懇話会, Seishinbyōri Konwakai), a similar workshop, began in 1978. In 1988, this workshop was dissolved in order that the Japanese Society of Psychopathology (日本精神病理学会, Nihon Seishinbyōri Gakkai) was newly established, led by Kasahara et al. The society changed its name to the Japanese Society of Psychopathology and Psychotherapy in 2004, but it changed its name again to the Japanese Society of Psychopathology in 2013. Currently, the society has more than 500 members, holds annual meetings, and publishes the Japanese Journal of Psychopathology (臨床精神病理, Rinshō Seishinbyōri) three times a year.

The next section examines the representative figures of second‐generation psychopathologists.

Takeo Doi: Psychoanalysis as self‐criticism (Selbstkritik)

Takeo Doi is a Japanese psychoanalyst world‐renowned for his theory of Amae (甘え, dependence) (Table 1). ² After graduating from the University of Tokyo, Doi practiced at the Department of Psychiatry and Psychosomatic Medicine of St. Luke's International Hospital. He became a professor at the University of Tokyo in 1971 and at the International Christian University in 1980. He received his training analysis in Japan and the United States and organized a group seminar on psychotherapy titled Wednesday Group (水曜会, Suiyō‐Kai). The Catholic faith consistently guided Doi's thinking, ¹⁶ dating back to his time as a student.

Table 1.

Timeline of Takeo Doi

1920	Born in Tokyo
1942	Graduates from University of Tokyo
1946–49	St. Luke's International Hospital (Internal Medicine)
1950–52	Studies at Menninger School of Psychiatry, USA
1955–56	Studies at the San Francisco Psychoanalytic Society and Institute, USA
1956–71	St. Luke's International Hospital (Psychiatry)
1961–63	Invited to National Institutes of Health, USA
1971–80	Professor at University of Tokyo
1980–82	Professor at International Christian University
1983–85	Head of National Center of Neurology and Psychiatry
2009	Dies

Doi's representative concept of Amae is an everyday Japanese word that means “enjoying the feeling of oneness with a familiar person who takes care, especially a mother.” Doi noted that Amae is reminiscent of the love for the Virgin Mary in Catholicism and that it roughly corresponds to Freud's concept of identification. He also used Amae theory to analyze the works of Sōseki Natsume, one of the greatest modern Japanese writers. ¹⁷

At the height of the psychiatric reform movement, Doi led a series of Psychopathology of Schizophrenia workshops. He rescued Japanese psychopathology and psychotherapy from the identity crisis caused by the movement. Doi's Amae theory is well known in the Anglophone world, but his association with the reform movement is less known, which is explained below.

In English‐language articles, such as “Amae: A key Concept for Understanding Japanese Personality Structure” ¹⁸ and “Giri‐Ninjō: An Interpretation,” ¹⁹ Doi discussed the characteristics of Japanese people using the concept of Amae. According to Doi, Amae provided the backdrop for Japan's expansion from the Meiji Restoration to World War II. After the war, the Japanese were exonerated by the post‐war Tokyo Trials, so they blamed the war on the emperor and optimistically believed that they had nothing to do with pre‐war Japan. However, Doi observed that the Amae of the Japanese people did not disappear after the war. On the contrary, the collapse of imperialism and Japan's Special Higher Police system, which had suppressed the Amae of the Japanese until the war ended, exposed their Amae. Consequently, modern Japanese leftist students wandered around looking for people on whom they could depend (Amaeru) and objects with which to identify. Thus, Doi criticized left‐wing students for merely identifying themselves with the supposed victims of society.

Doi also analyzed the left‐wing students using the concepts of victim mentality (被害者意識, Higaisya‐Ishiki) and perpetrator mentality (加害者意識, Kagaisya‐Ishiki). ²⁰ On one hand, the left‐wing students at Japanese universities inflicted significant harm on their professors and classmates. On the other hand, the students evoked a perpetrator mentality, which compelled them to engage in self‐criticism. However, it was evident that this forced self‐criticism was insincere. Moreover, the left‐wing students’ self‐criticism was inadequate because they identified themselves with the supposed victims of society and denied their own perpetrator mentality or sense of guilt. Modern society was sick, as the students claimed, but the students were also sick because they continued to stay in dark buildings and inflict violence on each other. When the students stated that they would be cured only when society was cured, they were depending (Amaeteiru) on society by avoiding their personal problems and subordinating them to social problems. Therefore, the students had to project their criticism of others onto themselves, overcome their victim mentality, and bear real guilt. Stated differently, Doi asked the students to engage in additional self‐criticism. In fact, Doi expressed in several of his writings that for him, psychoanalysis was self‐criticism (Selbstkritik), as he believed that a person could become a true human subject only through self‐criticism.

Thus, according to Doi, psychiatrists must engage in self‐criticism. In his paper, ²¹ Doi stated that young psychiatrists who identify themselves with the mentally ill, while claiming to act for the patient's benefit, actually act for themselves. Identifying with the patient and empathizing too much with the patient's problems are common mistakes of novice psychiatrists, and these psychiatrists never succeed in their treatment. Psychiatrists must correct the common Japanese error of identifying with victims (patients) by using thorough self‐criticism and treat patients in the true sense of the word.

There is an overly optimistic misconception in the anti‐psychiatry movement that if only social injustices were corrected, appropriate medical care would naturally follow. Unfortunately, prejudice will not easily disappear from our society. Therefore, we must use this inevitable prejudice in our treatment of patients. Here, the contrast between Doi's concept of secret (秘密, Himitsu, Geheimnis) and Freud's concept of the homely/uncanny (heimlich/unheimlich) ²² is notable. In the first volume of the Psychopathology of Schizophrenia series, ²³ Doi explained that the nature of schizophrenia, which is characterized by thought broadcasting, thought withdrawal, and the experience of influence, is that patients’ secrets are always already lost. Patients believe that they have no secrets because other people always broadcast and manipulate their thoughts and behaviors. Therefore, Doi explained that when patients recover from schizophrenia, they should be told the following: “Don't tell others that you were schizophrenic because other people are likely to be prejudiced and discriminate against you. Instead, you should cherish your memory of illness like a precious treasure and keep it a secret.” ²³ This statement indicates that Doi intended to give patients a new secret, which was the very thing they had lost. Doi's psychotherapeutic approach contains a valuable warning against the recent trend that encourages people to show off their illnesses.

Yomishi Kasahara: Daseinsanalysis, dynamic psychiatry, and anti‐psychiatry

Yomishi Kasahara graduated from Kyoto University and studied psychopathology under the guidance of Masashi Murakami (Table 2). In 1972, Kasahara became a psychiatry professor at Nagoya University and trained many successors. During the mid‐1970s, Kimura and Nakai became psychiatry professors at the nearby Nagoya City University, and psychopathology research became popular in the Nagoya region.

Table 2.

Timeline of Yomishi Kasahara

1928	Born in Kobe
1952	Graduates from Kyoto University
1958–	Kyoto University Hospital
1968–72	Associate Professor at the Health Administration Center in Kyoto University
1972–91	Professor at Nagoya University
1991–98	Professor at Fujita Health University

In Kasahara's early years, he showed an interest in Daseinsanalysis, beginning with Binswanger. He was also interested in the dynamic psychiatry that developed in the United States, particularly in the psychotherapy of schizophrenia (his doctoral dissertation related to this topic). Kasahara was skilled at reviewing articles and wrote a comprehensive review of the psychotherapy of schizophrenia and the theory of delusion, as well as social phobias (対人恐怖, Taijin‐Kyofu). ²⁴ The outline of Kasahara's theory of social phobia has already been abstracted in English. ²⁵

As a unique result of Japanese psychopathology that derived from these studies, Kasahara's concepts of “set out (出立, Shuttatsu)” and “incorporation (合体, Gattai)” became widely known. ²⁶ Kasahara continued to refer to studies on the psychological factors of endogenous psychoses (schizophrenia and manic‐depressive psychosis/endogenous depression, that is, depression with melancholic features) and the triggers or conditions (Vorfeld in German) that precede the onset of endogenous psychoses. Kasahara argued that such diseases arise in the anthropological sense of meaning inherent in each person. Schizophrenia refers to a pathological condition in which a person who is ready to “set out” for a new life fails to move forward in this direction. This is supported by the fact that schizophrenia is often triggered during life events that mark independence and autonomy, such as entering further education, starting work, getting married, or becoming a parent.

On the other hand, manic‐depressive psychosis/endogenous depression refers to a pathological condition in which one is frustrated in the direction of the meaning of “incorporation.” For example, people who value the order of their families and regional communities are incorporated into this order. When this order, which is highly regarded, does not function well, it often triggers manic‐depressive psychosis/endogenous depression. From an anthropological perspective, such a direction of meaning not only explains the pathogenesis of endogenous psychoses, but also prevents relapse during treatment and helps to find better pathways of adaptation.

Furthermore, Kasahara emphasized clinical practice, and he specifically advocated for minor psychotherapy (小精神療法, Shō Seishin Ryōhō) during the outpatient treatment of depression. ²⁷ Minor psychotherapy involves the following activities:

• informing patients at the outset that depression is an illness and not laziness

• urging patients to rest as soon as possible

• clearly explaining when patients will be cured

• making patients promise to the doctor that they will not commit suicide

• instructing patients to postpone decisions about major life events

• informing patients that their conditions will progress and regress during treatment

• communicating the importance of patients taking their medications and the concomitant symptoms of the autonomic nervous system.

This type of minor psychotherapy, which is based on the examination of psychopathology previously described, is easily understood by general practitioners and remains an extremely important principle in the clinical practice of depression in Japan. Kasahara also wrote a paper in English in 1987 on the work environment and depression among middle‐aged people. ²⁸

During the 1970s, Kasahara translated most of the books of Laing, who is known for his anti‐psychiatry work, into Japanese. In particular, Kasahara's translation of The Divided Self (1971) was so influential that many people aspired to become psychiatrists after reading the book. Kasahara's translation of Cooper's The Death of the Family (1971) was also published. In addition, Kasahara wrote a comprehensive review of anti‐psychiatry ²⁹ in which he methodically summarized the theories and trends of anti‐psychiatry, providing a critical perspective of them and a balanced discussion of the opposing arguments of anti‐psychiatry. Kasahara believed that responding to the questions that anti‐psychiatry raises about existing psychiatry was crucial. To some extent, Kasahara's view was shared with other contemporaries, and it is an important feature of second‐generation psychopathologists.

The psychiatric reform movement was also associated with the student movement, which led Kasahara to focus on the psychopathology of adolescents, partly because he worked at the Health Administration Center of Kyoto University during the student movement and examined many students with apathy. According to Kasahara, ³⁰ the student movement was a rebellion of young students against existing authority, but it was also similar to the rebellion of children against their parents. The movement was most active around 1968–1969, when significant changes occurred in the relationships between parents and children and between adults and adolescents, which affected the psychopathology of adolescence.

Hiroshi Yasunaga: Pattern reversal and Phantom Space Theory

After graduating from the University of Tokyo, Hiroshi Yasunaga worked mainly at the branch hospital of the University of Tokyo Hospital (Table 3). Because of the psychiatric reform movement, the Department of Psychiatry at the University of Tokyo was divided into the outpatient faction and the ward faction after September 1968. (This separation aligned with the reform movement. In 1994, the clinical practices of both factions were united, and the separation ended in 1996 with the unification of the clinical departments.) At that time, the branch hospital served as a neutral zone between the two factions. When Yasunaga was the medical director of the ward at the branch, Nakai was recruited as a research student. He had already resigned from his post of virus researcher and aspired to become a psychiatrist. Yasunaga ³¹ explained that the sensibility of the younger generation involved in the psychiatric reform movement is essential because if it disappears, the entire psychiatric profession will collapse altogether. However, according to Yasunaga, this sensibility is also dangerous because it may be linked to decadence. Yasunaga's neutrality made the clinical practice and research of psychopathology possible at the branch hospital.

Table 3.

Timeline of Hiroshi Yasunaga

1929	Born in Kyoto
1953	Graduates from University of Tokyo
1962–	Lecturer at the branch hospital of the University of Tokyo Hospital
1971–89	Associate Professor at the branch hospital of the University of Tokyo Hospital
2011	Dies

Yasunaga is well known for developing the phantom space theory (ファントム空間論, Fantomu Kūkan Ron), ³² which is a systematic theory that explains almost the entire range of psychopathology. The basis of Yasunaga's theory is his 1960 doctoral thesis, ³³ which referred to the work of the unknown British philosopher Oswald Stewart Wauchope, Deviation into Sense: The Nature of Explanation (1948), and began with the point of view of pattern and pattern reversal (the former is Wauchope's concept, and the latter is Yasunaga's own one).

The pattern refers to the pairing of self–other, quality–quantity, and whole–part, with the idea that the former is first and foremost self‐evident and that the latter is the negation of the former. Life–death is also a pattern, just as “legends about living people who never die” are intelligible, but “legend about some people who were always dead and never came to life” is unintelligible. The former term always comes first and is directly intelligible. ³⁴ For example, “self” comes first, so “other” can only be understood as something that is not self. Thus, in the A–B pattern, the comparison of A ＞ B always holds.

According to Yasunaga, all fundamental experiences of schizophrenia are manifested as a reversal of this pattern with A < B. For example, in human perception, A is the subject who sees, and B is the object that is seen, as in A > B. However, in schizophrenic hallucinations, the object B is the first thing that appears as if imposed from the outside on subject A, which can be described as A ＜ B. Similarly, in the ego disturbances of schizophrenia, the relationship between the A that is conscious and the B that is made conscious is reversed so that a passivity experience occurs. The phantom space theory, presented successively in Volumes I, ³⁵ II, ³⁶ and III ³⁷ of Psychopathology of Schizophrenia, is a hypothetical system for describing how pattern reversal occurs. Pattern reversal is an illusion caused by the discrepancy between the spatial schema experienced by humans (e.g., body schema, which can be as detached from reality as a phantom limb, hence the name “phantom space theory”) and the actual physical distance. Although Yasunaga's theory is characterized by an extremely difficult and highly logical writing style, he is aware of the affinity of his theory with neuropsychology and experimental psychology. Perhaps by introducing Yasunaga's theory in English, it may be possible to compare it with the findings in the neurocognitive research related to schizophrenia. ³⁸

Tadao Miyamoto: Psychopathology of space and language

Tadao Miyamoto graduated from Tokyo Medical and Dental University (Table 4). He studied psychopathology under Shimazaki, a psychiatry professor at the same university. In 1973, Miyamoto became the professor in the Department of Psychiatry at the newly established Jichi Medical University and trained many young people in the northern part of the Kanto region, where Jichi Medical University is located.

Table 4.

Timeline of Tadao Miyamoto

1930	Born in Saitama
1954	Graduates from Tokyo Medical and Dental University
1967–	Associate Professor at Tokyo Medical and Dental University
1968–69	Studies at University of Heidelberg
1974–95	Professor at Jichi Medical University
1999	Dies

Although Miyamoto's theory of mixed states in mania and depression has been introduced in English, ³⁹ his starting point was second‐person psychopathology. To some extent, Miyamoto appreciated Jaspers's first‐person psychopathology, which emphasizes the patient's subjective experience and contrasts it with the third‐person psychopathology, which relies on objective observation and measurement of the patient's behavior. The first‐person psychopathology is, however, problematic because the pathology of schizophrenia is often understood as if it was only a negative form of loss or breakdown of something (e.g., Wolfgang Blankenburg's concept of loss of natural self‐evidence ⁴⁰ or Binswanger's concept of breakdown in the consistency of natural experience). ⁴¹ On one hand, relationships with others and the common world are impaired for schizophrenics, which can be seen as a loss or breakdown of some function. On the other hand, schizophrenics problematize other people and the world in their hallucinations and delusions. This is clear because schizophrenic patients usually find more meaning in the gazes of other people they encounter on the streets than they do in non‐human entities, such as rain, wind, or animals. In other words, the second‐person relationship between “I” and “you” does not disappear with schizophrenia but undergoes a specific shift.

Miyamoto began his own research on psychopathology with his 1959 doctoral thesis, ⁴² which examines the symptoms of vivid physical awareness (leibhaftige Bewusstheit) explained by Jaspers ⁴³ from this second‐person psychopathology perspective. Miyamoto found it problematic that this concept had not been sufficiently explored phenomenologically or anthropologically after Jaspers, so he provided a phenomenological–anthropological analysis of many cases that showed vivid physical awareness.

Vivid physical awareness is a subjective phenomenon that “is not vivid in the concrete sense but is for all as an equally forcible deception” as hallucinations. For example, “when a patient [feels] someone always walking next to him or rather obliquely behind him,” the patient “[has] never seen or heard him and [has] never felt him nor touched him and yet he [experiences] with an extraordinary certainty that somebody [is] there.” ⁴³

According to Miyamoto's analysis, the other felt in vivid physical awareness is mostly positioned in the space behind (後ろの空間, Ushiro no Kūkan). For human beings, the space in front is the place of confrontation (Gegenüber), the space to the left and right is the place of coexistence (Miteinander), and the space behind is the blind spot, where the sudden appearance of the other makes patients feel watched or feel that they are the object of rumors. No matter how hard the patients try to escape, they cannot escape from the other in the space behind. Furthermore, in terms of the relation to the common world, the space in front is open to the world (Weltoffen), and the space on the side is close to the world (Weltnahe). Both spaces form the living space (lebender Raum), but the space behind is nothing but a dead space (toter Raum). The presence of an uncanny other (i.e., an unnamed other who cannot constitute a common world with the patient) in the space behind is an early symptom of schizophrenia.

In addition, according to Miyamoto, the other gradually becomes a specific third‐person other, and this other persecutes the patient through various hallucinations, delusions, and “made” phenomena, such as thought‐insertion and delusion of control. This other eventually reverts to an anonymous, impersonal other, as reflected by the fragmentary delusions of the chronic phase. In sum, Miyamoto argued that vivid physical awareness, when analyzed phenomenologically, forms the basis of many other symptoms, enabling the process of schizophrenia. Thus, this symptom is central to the symptomatology of schizophrenia.

In addition, Miyamoto left many writings about artists, which are referred to as “pathography” or “病跡学, byōsekigaku” in Japanese. The most famous is Miyamoto's research on Edvard Munch (1863–1944), the results of which were published, among others, in the third volume of Psychopathology of Schizophrenia. ⁴⁴ Munch suffered from hallucinations, including auditory hallucinations, and was committed to a psychiatric hospital between 1908 and 1909.

After reviewing numerous documents and paintings, Miyamoto ⁴⁵ diagnosed Munch as a schizophrenic and examined the spatial features in Munch's work. In works such as The Scream (1893), Anxiety (1894), and The Voice (1895), Munch painted many eerie landscapes and nameless figures in the space behind that serves as the background and included a projection of himself as a foreigner in the center. Thus, Munch's work represents how schizophrenics perceive themselves as the center of the world, watched and commented on by others behind them.

However, Munch placed the sun at the center of the canvas in The Sun (1911). According to Miyamoto, this was a turning point, as Munch began to concentrate on painting natural landscapes and animal life. There are cases in clinical practice in which the sun is painted during the recovery phase of schizophrenia, when patients become interested in the activities of people in their surroundings and return to the common world.

Compared to other psychopathologists, Miyamoto had little interest in political movements, but he was attentive to the structuralist movement that was at its height in France at that time. Referring to structuralist theory, Miyamoto explained that the pathology of language is revealed in schizophrenia. As was the case with the sickness experienced by Roquentin, the protagonist of Jean‐Paul Satre's novel Nausea, in schizophrenia, a real thing that is inexpressible in words suddenly appears. With this type of experience, the signifier (word) and the signified (meaning) are separated. Miyamoto ⁴⁶ described this as a language crisis (言語危機, Gengo Kiki). According to Miyamoto, the delusions seen in schizophrenia are delusional signs created to reconnect the signifier with the signified to stabilize these anxiety‐provoking experiences (as in the Saussurean context, a sign is made of a signifier and a signified).

Miyamoto was one of the key figures who introduced the work of the French psychoanalyst Jacques Lacan to Japan. Miyamoto translated Lacan's doctoral dissertation and some articles from his Ecrits. Miyamoto's work enabled the subsequent generation of psychopathologists to lay the groundwork for the development of psychopathology influenced by Lacanian theory, which is characteristic of Japanese psychopathology.

Bin Kimura: Phenomenological‐anthropological psychopathology of life

Bin Kimura, a Japanese phenomenological‐anthropological psychopathologist, is well known to foreign psychiatrists and philosophers for his various concepts, such as “in‐between (あいだ, Aida),” ^{47 , 48} “self‐consciousness (自覚, Jikaku),” ⁴⁹ “Self (自ら, Mizukara),” and “Nature (自ずから, Onozukara)” ⁵⁰ (Table 5). After graduating from Kyoto University, Kimura worked at private psychiatric hospitals in Shiga prefecture and studied at the University of Munich and the University of Heidelberg. He became a professor at Nagoya City University in 1974 and a professor at Kyoto University in 1986. Throughout his life, Kimura devoted himself to the study of psychopathology and clinical philosophy (臨床哲学, Rinshō Tetsugaku).

Table 5.

Timeline of Bin Kimura

1931	Born in Korea
1955	Graduates from Kyoto University
1959	Kyoto University Hospital
1961–63	Studies at University of Munich
1969–70	Studies at University of Heidelberg
1970–	Associate Professor at Nagoya City University
1974–86	Professor at Nagoya City University
1986–94	Professor at Kyoto University
1994–	Adviser at Kyoto Hakuaikai Hospital
1995–2001	Professor at Ryūkoku University
2008–	Head of the Kawai Institute for Culture and Education
2021	Dies

Similar to his personal friends Binswanger, Blankenburg, Hubertus Tellenbach, and Dieter Janz, Kimura sympathized with phenomenology, especially Martin Heidegger's Being and Time (Sein und Zeit). Simultaneously, Kimura introduced to phenomenological psychopathology the ideas of Japanese philosopher Kitarō Nishida, the founder of the Kyoto School of philosophy inspired by Zen Buddhism. For example, by considering the forms of being of endogenous psychoses from a temporal perspective, ⁵¹ Kimura named the temporal structure of the schizophrenic “ante‐festum,” the depressive “post‐festum” (Psychopathology of Schizophrenia, Vols. V ⁵² and VIII ⁵³ ) and the epileptic “intra‐festum.” ⁵⁴ In addition, Kimura also reinterpreted Heidegger's concept of ontological difference (ontologische Differenz) from the perspective of life in the same manner as Nishida ⁵⁵ : Kimura regarded schizophrenia as a pathological phenomenon of biological difference (biologische Differenz) between βίος (individual lives by Kimura's definition) and ζωή (life itself by Kimura's definition). ⁵⁶

Among Kimura's numerous publications, The Structure of Abnormality (異常の構造, Ijō no Kōzō) ¹³ is the most notable for its relationship with the anti‐psychiatry movement. In this book, Kimura expressed great sympathy for the anti‐psychiatry movement and referred to Laing's ideas. However, at the end of the book, considering the standpoint of his life‐oriented psychopathology, Kimura criticized the anti‐psychiatry movement for negating life and posited his views against anti‐psychiatry, that is, “anti‐antipsychiatry.” Although many of Kimura's writings have been translated into German, French, Italian, and English, this early work has not been translated. The following section presents an overview of this literature.

The Structure of Abnormality begins with the declaration that nature is irrational and contingent. As the cornerstone of modern society and everyday life, natural science considers nature rational and lawful. According to Kimura, this rationality of nature is nothing more than fiction, and lunatics expose this fiction ontologically. He then shifts to the notion of common sense, which Blankenburg ⁵⁷ also highlighted, for it is common sense that underlies our scientific and rational world. After studying Aristotle's concept of common sense (κοινὴ αἴσθησις), Kimura argued that in psychotic patients, particularly in schizophrenics, common sense is always already lost, and the irrationality of nature, which should be conquered by our rationality, is revealed. Simply stated, in the first half of this book, Kimura defines the essence of schizophrenia as a trouble of common sense.

In the latter half of the book, Kimura explains that the everyday world of normal people, where common sense is retained, consists of three principles: (1) individuality of the individual, (2) identity of the individual, and (3) singleness of the world. Thereafter, Kimura philosophically integrates these three principles into the world formula of 1 = 1. In contrast, Kimura states that the delusional world of schizophrenic patients can be expressed by the formula 1 = 0. Kimura characterized the world of normal people by the equation 1 = 1 and the world of abnormal people by the equation 1 = 0. Kimura also argued that 1 = 1 is the formula for life, while 1 = 0 is the formula for anti‐life. Incidentally, just as rationality cannot exist without eliminating irrationality, life cannot exist without eliminating anti‐life. Thus, the fact that the basic formula of life (1 = 1) tries to exclude the anti‐life formula (1 = 0) is deeply rooted in life itself. Therefore, Kimura believed that to be serious about the discrimination of normal people from abnormal people, we need to rethink life ontologically. Consequently, in the last chapter of the book, Kimura distinguishes philosophically two kinds of life: “the fact of individual lives” and the “true reality of life in general.” ¹³ The latter seems to be the irrational nature described at the beginning of the book. Regardless, Kimura believed that the anti‐psychiatric claim ultimately depends on the anti‐life formula of 1 = 0 because the anti‐psychiatry movement affirms the delusional world of patients. However, as long as we live, we cannot completely abandon the life formula of 1 = 1. Hence, Kimura ultimately concluded that his position should be called “anti‐antipsychiatry,” although he once expressed partial solidarity with the anti‐psychiatry movement.

Let us summarize the above. Firstly, Kimura partially agreed with the anti‐psychiatry movement in his book, stating that psychiatry based on natural science ignores the natural irrationality exhibited by psychotic patients. Secondly, using the perspective of life, he also redefined the psychopathological concept of common sense. Furthermore, the difference he refers to between the “fact of individual lives” and the “true reality of life in general” would correspond to the biological difference between βίος and ζωή, which are terms he later uses. In sum, Kimura tried to provide a philosophical basis for life‐oriented psychiatry by examining the ontological problems about life and death using Nishida's approach. These ontological problems are more fundamental than the sociological ones with which the anti‐psychiatry movement is preoccupied.

By the way, because the 1 = 0 formula that Kimura ultimately rejects at the end of his book is close to the Zen Buddhism concept of “Life Is Death (生即死, Sei Soku Shi)” taught by Nishida, Kimura in later years would have agreed with the concept more. ⁵⁸ In fact, in his later writings, Kimura came to state that life called ζωή is also death itself, referring to Freud's concepts of repetition compulsion or death instincts ⁵⁹ and Victor von Weizsäcker's sentence: “Life itself does not die; only the individual living beings die.” ⁶⁰ Kimura's later years were marked by a growing interest in death. Thus, we can also summarize that in The Structure of Abnormality, on one hand, Kimura was somewhat attracted to the idea of 1 = 0, but on the other hand, he hesitated to speak positively about the 1 = 0 formula because of his self‐definition as a psychiatrist.

Hisao Nakai: From political struggle to the theory of remission

Hisao Nakai had a diverse academic background (Table 6). He first enrolled in the Faculty of Law at Kyoto University, and after being temporarily treated for tuberculosis, he transferred to the Faculty of Medicine. After graduation, Nakai conducted virus research and later became a psychiatrist. He worked at the Institute of Virus Research at Kyoto University, and under the pseudonym of Tatsuo Nirebayashi, he fiercely criticized the medical faculty's system in The Doctors of Japan (1963) ¹⁰ and What is a Resistant Doctor? (抵抗的医師とは何か, Teikōteki Ishi Towa Nanika, 1964). ⁶¹ As noted herein, these objections spilled over into the field of psychiatry, triggering the psychiatric reform movement. Although Nakai criticized the medical faculty's system, he did not participate in the subsequent series of psychiatric reform movements because he believed that “if we examine patients with regret, even patients who could be cured might not be cured.” ⁶² In other words, Nakai believed that if he considered psychiatry in a negative light, he might hinder treatment.

Table 6.

Timeline of Hisao Nakai

1934	Born in Nara
1953	Enters the Faculty of Law, Kyoto University
1955	Transferred to Faculty of Medicine
1959	Graduates from Kyoto University
1960–66	Institute of Virus Research at Kyoto University
1966–75	Branch hospital of the University of Tokyo Hospital
1969–	Aoki Hospital
1975–	Associate Professor at Nagoya City University
1980–97	Professor at Kobe University
1997–2004	Professor at Konan University
2004–07	Head of the Hyogo Institute for Traumatic Stress
2022	Dies

When Nakai became a psychiatrist, one of the books he relied on was Klaus Conrad's The Beginnings of Schizophrenia (Die beginnende Schizophrenie), ⁶³ which provides a detailed Gestalt analysis of the pathogenesis of schizophrenia. However, Nakai was dissatisfied because the psychopathologists, including Conrad, only discussed the pathogenesis of schizophrenia and explained little about the remission process. Consequently, Nakai created his own theory of treatment by closely observing the remission process for schizophrenia. His theories on the remission process were published in Volumes II, ⁶⁴ III, ⁶⁵ and V ⁶⁶ of Psychopathology of Schizophrenia.

While studying the remission process for schizophrenia, Nakai relied on drawing therapy to treat patients admitted to the psychiatric unit who did not speak much and who had difficulty understanding when they did speak. ⁶⁷ These patients, who were considered chronically ill, drew paintings rich in variation over time. Nakai noticed that “despite being in the midst of simple and highly repetitive daily life, their conditions continue to change to a great extent every day.” ⁶⁶ Therefore, schizophrenia should be perceived as a metastable state, which allows the possibility for constant change and leaps, rather than as a process that ends only in a state of dementia (Verblödung). This allowed Nakai to focus on the minor changes in the remission process of schizophrenia that are usually overlooked, including the physical symptoms, and to aim for recovery from schizophrenia.

Among the drawing therapies that Nakai employed, the Landscape Montage Technique (LMT) is particularly well known. Nakai invented LMT ⁶⁸ in 1969. It was originally conceived as a preparatory test for sandplay therapy, but because of its unique benefits, it became an independent drawing therapy. Unlike sandplay therapy, which requires specific configurations, LMT requires only a blank sheet of paper and a pen to begin therapy. In addition, unlike the given frameworks in sandplay therapy, this technique provides greater security to patients by allowing them to draw their own boundaries on paper. After drawing the boundaries, patients must follow a specific sequence for drawing. For example, the first stage of drawing may include large landscape groups, such as river, mountain, field, and road. The second stage of drawing may include medium‐sized landscape groups, such as house, tree, and person, and the third stage of drawing may include supplementary items, such as flowers, animals, rocks, and whatever the patient feels is lacking. After completing the drawing, the patient may color it with crayons or pencils. The overall duration of the process is 15–25 min. The therapist then interprets the constitutive representations expressed in the structural space within the frame. This technique is contrasted with the Rorschach test, which only involves interpretations of the projected representations.

Nakai never participated in the psychiatric reform movement, but he held Laing in high esteem and considered him to be a colleague. Nakai believed that he faced a situation similar to Laing, even stating that Laing was an “ordinary psychiatrist.” ⁶⁹ In fact, in a paper published in the ninth volume of Psychopathology of Schizophrenia, ⁷⁰ Nakai seems to have adopted the theory of the schizophrenic voyage that Laing proposed in The Politics of Experience as a theory dedicated to rehabilitation into society. Laing argued that while schizophrenics may be disrupters of the ordinary formation, the ordinary formation itself may be insane and that it is important for patients to grasp something in their voyage and return from the other world to this one. ⁷¹ Similarly, Nakai believed that schizophrenics are the minority. Therefore, rehabilitation into society does not mean that they can fit into the world of the majority; instead, as the minority, schizophrenics should invent to live the way they are. By using this approach, the ordinary world in which most people live can be viewed from a different perspective.

In 1975, Nakai became an associate professor in the Department of Psychiatry at Nagoya City University, which was around the same time that Kimura became a professor there in 1974. In 1980, Nakai became a professor in the Department of Psychiatry at Kobe University, where he trained many successors. ⁷²

On January 17, 1995, the Great Hanshin‐Awaji Earthquake hit Kobe, where Nakai lived. Nakai and his colleagues at the medical faculty were actively involved in the psychological care of survivors and Nakai translated into Japanese a large amount of literature on war, trauma caused by the disaster, and post‐traumatic stress disorder issues, including Judith Herman's Trauma and Recovery (translated in 1996), Allan Young's The Harmony of Illusions: Inventing Post‐Traumatic Stress Disorder (translated in 2001), and Abram Kardiner's The Traumatic Neuroses of War (translated in 2004).

In addition, Nakai translated many works of writers for connoisseurs, such as Michael Balint of the Budapest School of Psychoanalysis, Harry‐Stack Sullivan, and Henri Ellenberger. The translations of Sullivan's work are excellent, and because of Nakai's translations, Sullivan's theories, which are sometimes difficult even for American psychiatrists to understand, are well understood by Japanese psychiatrists. Nakai was also a person of letters and translated poems by Paul Valéry and Konstantinos Petrou Kavafis.

CONCLUSION

This paper provides to the Anglophone readership concise portraits of Japanese psychopathologists of the second generation, which is considered the height of Japanese psychopathology. This paper explains that Japan rapidly embraced German‐centered psychiatry after the Meiji era, from which the first generation of psychopathologists emerged. The second generation of psychopathologists became active at a time when the psychiatric reform movement was in full swing and psychiatric research was considered evil. Subsequently, the Psychopathology of Schizophrenia workshops, which were initially organized by Doi, became a major venue for second‐generation psychopathologists.

However, the second‐generation psychopathologists were not merely critics of the radical movements and anti‐psychiatry. These scholars took different positions as they struggled to confront these movements while still affirming psychopathology. Doi was critical of the movement, but Kasahara, Kimura, and Nakai held somewhat positive attitudes toward Laing's ideas and developed their theories using his ideas. Yasunaga and Miyamoto rarely mentioned the movement, but the characteristics of Yasunaga's workplace (i.e., the branch hospital of the University of Tokyo Hospital) cannot be understood without the political background, and Miyamoto introduced the structuralist movement, which was at its height in France at that time. The political tensions engendered by the radical movements were the driving force behind the high‐quality work of these second‐generation psychopathologists.

Due to space limitations, we have no choice but to write another paper on the third generation that leads to our current era, but we expect this paper to increase interest in Japanese psychopathology and propagate the research and history of Japanese psychopathology to the Anglophone world.

AUTHOR CONTRIBUTIONS

T.M. designed the outline of the article. T.M. wrote the Introduction, Conclusion, and the sections on Yasunaga, Kasahara, and Miyamoto. T.M. and W.M. wrote the section on Nakai. K.S. wrote the sections on Doi and Kimura, and made the Tables. W.M. wrote the Abstract and prepared the English text. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS APPROVAL STATEMENT

N/A.

PATIENT CONSENT STATEMENT

N/A.

CLINICAL TRIAL REGISTRATION

N/A.

Supporting information

As a supporting information, we provide detailed information on papers in Japanese‐language among the references.

Matsumoto T, Shimizu K, Mo W. History of Japanese psychopathology: Portraits of the second-generation psychopathologists (Takeo Doi, Yomishi Kasahara, Hiroshi Yasunaga, Tadao Miyamoto, Bin Kimura, and Hisao Nakai) and their relationship to psychiatric reform movement in Japan. Psychiatry Clin Neurosci Rep. 2023;2:e111. 10.1002/pcn5.111

DATA AVAILABILITY STATEMENT

N/A.