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1. Nakamura leads us to think differently by challenging the medical model and showing how community, structure, and humor can create meaningful lives for individuals with psychiatric disabilities. She uses Bethel House for this, to truly express how individuals with schizophrenia and other disabilities are active, visible, and valued, rather than being hidden away and shamed. An example of this would be the individuals within Bethel. As they engage in daily meetings, self reflect on their mental and physical states, and even work jobs to have as socially acceptable of a life as they can. Nakamura also writes about how these individuals refer to their hallucinations as “Gencho-san” which helps show how they use humor to connect with their symptoms without feeling guilty.

3. Nakamura shows that Japanese culture is often viewed through the lens of shame and social stigma, which often leads to long-term hospitalization or isolation. Families in Japan often feel pressured to hide relatives with any kind of psychiatric disabilities to avoid embarrassment. An example of how culture plays a role in Bethel House is when Nakamura explains how schizophrenic individuals were “warehoused” in hospitals and very rarely discharged. Not because of medical need, but because of cultural discomfort.

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Impact of Personal Stories

The inclusion of personal stories like those of Kohei, Rika, and Gen in A Disability of the Soul adds emotional depth and reshapes how we view people with psychiatric disabilities. For instance, Kohei’s UFO story shared during the “Hallucinations and Delusions Grand Prix” isn’t dismissed as nonsense, but celebrated for how the community rallied around him. This shows how Bethel validates rather than erases delusions, reframing them as part of a meaningful social world. These stories make the book more than an academic study; they force the reader to see disabled individuals as storytellers, workers, and community members not just patients.

Culture and Mental Disability in Japan

Japanese culture plays a major role in shaping how mental illness is treated. For example, the concept of sekentei (social appearance or public image) often leads families to hide relatives with psychiatric conditions to avoid shame. This contributes to long term institutionalization in many cases. However, Bethel offers a contrasting model rooted in communal care and acceptance. Members like Gen, who lives openly with schizophrenia, participate in work, group therapy, and storytelling. Bethel’s approach challenges the cultural norm of hiding illness and instead fosters visibility, dignity, and mutual support ideas that push back against both Western and Japanese institutional models

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3. Culture significantly shapes how mental disabilities are perceived and treated in Japan, often emphasizing community support and harmony.

A) Community Integration: There's a strong emphasis on integrating individuals with mental disabilities into the community rather than isolating them in institutions. For example, community-based care homes and supported employment programs are common.

B) Family Involvement: Families play a central role in the care of individuals with mental disabilities. This can lead to strong support networks but also place significant pressure on family members.

C) Stigma: Despite efforts to increase awareness, stigma surrounding mental illness persists. This can affect access to treatment and social acceptance.

D) Unique Approaches: Some unique approaches include incorporating traditional arts and crafts into therapy, as well as emphasizing social skills training to help individuals navigate social situations.

4. Dr. Kawamura and the Urakawa Red Cross Hospital are unique because of their focus on community-based, patient-centered care that integrates social support and vocational training. In contrast, typical US psychiatric care often emphasizes medication and individual therapy, with less focus on community integration and social support, although this is evolving.

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2. Bethel, according to Nakamura, shows what it means to live in another culture and with mental illness in society. For instance, Kohei’s story shows how residents at Bethel are able to rebuild their lives and support one another because of its community. She recalled, “At first I didn’t understand… but everyone has their strong points and their weak points. And we each support each other with our strong areas” (p. 124). These stories humanize mental illness and show the value of community.

3. According to Nakamura, cultures similar to that within Japanese culture often associate mental illness with shame and embarrassment, suppressing the disease and those with it. Those who experience them are said to be “warehoused in hospitals” or are hidden by families altogether to “avoid bringing shame” to them (p. 17). At Bethel, terms such as “Gencho-san” or “honorable voices,” are used in reference to hallucinations, which helps people accept them. She wrote, [it helps members] “externalize the voices and treat them as separate” (p. 13). This shows a more recent shift within cultures toward acceptance, beginning the abandonment of shame/suppression.

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1. How does Karen Nakamura lead us to think differently about psychiatric disabilities such as schizophrenia, and disability more broadly? Provide specific examples.

Karen Nakamura helps us think differently about psychiatric disabilities like schizophrenia by showing that these conditions are not only medical but also social and cultural. She explains that people with schizophrenia in Japan often push for more independence and control over their own lives, instead of being forced to stay in hospitals. For example, some choose to live in group homes where they can make their own decisions, which challenges the idea that they always need to be under medical care. Nakamura also talks about self-advocacy groups where people with psychiatric disabilities can speak for themselves and share their experiences, instead of being spoken for by doctors or family. This shows that disability is not just about illness; it’s also about how society treats people and the rights they have. Her work reminds us to think about freedom, respect, and human rights when we talk about disability.

4. How are Dr. Kawamura and the Urakawa Red Cross Hospital unique? How do they compare to typical psychiatrists and hospitals in the US?

Dr. Kawamura and the Urakawa Red Cross Hospital are unique because they focus on giving patients freedom and independence instead of controlling them. Unlike typical hospitals, where patients with psychiatric disabilities might be heavily medicated or locked in, this hospital encourages patients to make their own choices and take part in daily life. For example, patients can go outside, work, and be part of the community, which helps them build confidence and responsibility. This is very different from many hospitals in the US, where patients are often kept inside, closely watched, and not given as much independence. Dr. Kawamura believes that trusting patients and letting them have control over their lives is more helpful than strict medical treatment alone. This approach makes the hospital feel more like a supportive community instead of a place focused only on illness.

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Prompt one:

One example from the first chapter is when they explained to her the hallucinations at Bethel were called Gencho-sans or honorable voices. The way they talked about these hallucinations made it seem like they were another person rather than auditory hallucinations. One resident used Winnie the Pooh characters to represent her voices. He also explained that he wanted members to externalize the voices and treat them as separate entities, rather than, having them believe it was all just in their head (pg.12). I think it is also interesting how those around her did not discourage her from talking to her hallucinations. Another example of a way they viewed psychiatric disabilities differently was, by not delving too much into the past. People are encouraged to empty their mental trash and get on with their lives and that their time at Bethel is cyclical, not linear (pg.24). There was also the way those at Bethel’s founder explained how to live with psychiatric disabilities explaining that people who have them are not abnormal and should live their life with the fullest energy (pg.33). There are also the 8 goals of SA/WA which I thought seemed to view mental illness as something that can be shared with others to raise awareness (pg. 73). It also explains that in Rita’s story many diagnosed with schizophrenia become isolated and don’t talk about their hallucinations out of fear or shame, in bethel people are encouraged to talk about hallucinations delusions. She recognizes that without community her symptoms would get worse (pg.81). Rather than just throwing a medication or multiple at individuals Bethel tries to cultivate a sense of community around shared experiences and makes sure there is a sense of community support available for everyone.

Prompt 3:

Culture plays a huge role in how people in Japan with psychiatric disabilities in the beginning its talked about that since the 1900s those with severe physical, Psychiatric, or intellectual disabilities were put into nursing homes or institutions for their entire lives (pg.4). Those diagnosed with mental illnesses are often put away for long periods of time with little interaction with community or they simply are isolated (pg.7). There is a lot of shame felt if a family member has a mental illness, and it usually isn’t something shared with the outside world. While patients can now technically check themselves out of a hospital families will put pressure on hospitals to keep their relatives safely warehoused away. While you are recovering you are expected to do everything you can to focus on getting better. While on the outside life moves on you can only focus on getting better which is what makes mental illness so disabling in Japan (pg. 68). There is also a lot of bulling involved for example Rika talked about how she had rumors spread about her and her psychiatrist didn’t seem to take her seriously and the bullying and mean things came back as auditory hallucinations (pg.77). She became shut-in and lived in anguish because she didn’t know what was happening and had never got to interact with someone experiencing the same things since it was almost like a taboo subject (pg.78). In Japan, you legally become an adult at the age of 20 and expected to fulfill responsibilities, unless you are ill. It can be shameful for those with mental illnesses because they cannot function sometimes and fulfill society’s expectations for “normal individuals.” Japanese culture focused more on trying to treat the illness with medicine and contain it rather than keeping community support strong for those with mental illnesses.

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1. How does Karen Nakamura lead us to think differently about psychiatric disabilities such as schizophrenia, and disability more broadly? Provide specific examples.

She does it in a great way by talking about Bethel, but also how it is commonly mentioned throughout the book, even from the very beginning. She has  a great writing style/perspective as from the beginning it already makes the reader realize how normal it is and most likely, depending on them, forget their own influences from their culture while reading this in regard to prejudice towards mental illnesses. Simply by stating how there was a festivity/market where people were selling clothes/merch of hallucinations they have had from schizophrenia, etc., it introduces how they didn’t view it as ‘bad/negative’ but rather a simple fact and looked on the positive sides of it and even the humorous aspects of it (Nakamura , 2013, p.1). Then another instance that allowed you to see how normalized it was by how common the protest she walks upon, and many other similar instances throughout the book (Nakamura, p. 4, 2013). Yet, what really made me see how she writes to make us think differently was the moment when Nakamura is in the hospital and after she declares she’s not a patient (despite noting that no one is identified as a worker or patient) the 3 women dance around her while they sing a song that declares that mental illnesses are not bad and that you/they, as a person, are gifts from God, despite being different (Nakamura, p.7). Again, this showcases how they know they have a different condition than the average person might face, but it doesn’t make them ‘bad’ or ‘unworthy’ and that they are proud of it and proud to be alive and themselves! Which of course is a beautiful take that the rest of the world should take as well.

5. Disability and old age are often seen as impediments to "a meaningful life." How does A Disability of the Soul urge readers to question what a meaningful life means and what it might look like, especially for disabled and old people? Provide specific examples.

This book and the different stories and perspective it gives really deconstruct what a ‘meaningful life’ is supposed to be/look like. It does this by showcasing different lives of people with disabilities and how they break that stereotype by having happy and meaningful lives. For example, the introduction to the book and culture as I mentioned above, simply on pages 1 and 7, reveal how they are not ashamed of their conditions and that it doesn’t deteriorate them, their lives, or their worth ( Nakamura, 2013). Then it goes into the overview of Japan’s outlook on mental illnesses, where it states how there can be romanization due to the glorification of shamans in the past that had seizures or schizophrenia, etc., but that doesn't bring to light the negatives with this romanization (Nakamura, p. 35, 2013). This continues to go through a chronological order of entering the 90s to 2000s of how most of the institutions are privatized, but they hold long-term care for the patients, and the medicine/approach is not seen as different from Western medicines (Nakamura, p. 35, 2013). Overall in recent years, they have decreased their stays, but many families wouldn’t take their family members back due to more social reasons (Nakamura, p. 40, 2013). Due to this past history, Bethel takes an approach of having engagement, acceptance, and adaptation, like how they use dolls or art to showcase their hallucinations or other conditions (Nakamura, pp.10 & 40, 2013). Again, through these approaches, it allows the patients and hospital to reshape everyone’s outlooks on expectations of their health and societal expectations, so they create a meaningful life and find connection, support, and a life they enjoy! They do this again through their therapeutic approaches, which are discussed in more detail in chapter 6 with the peer support systems and roles in the community (Nakamura, pp. 170-180, 2013).

I would like to note in the first question response that I am referring to the protest and other references, that my responses is that Japan isn't accepting of psychiatric illnesses, but Bethel is!

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2. Karen Nakamura’s work incorporates personal stories from Bethel residents, such as Kiyoshi, Rika, Kohei, and Gen, between each chapter. The inclusion of these narratives has a significant impact, adding emotional depth and highlighting how the Bethel community shapes individuals' lives. These stories are crucial because they challenge the stereotype that individuals with schizophrenia are dangerous, unstable, or incapable.

Nakamura changed my perspective on schizophrenia and psychiatric disabilities by providing a glimpse into the daily lives of people living in Bethel House, a unique community in Urakawa, Japan. One of the most striking aspects of Bethel’s approach is its treatment of symptoms, particularly hallucinations. Rather than viewing these symptoms as shameful or solely something to be treated with medication, Nakamura reveals how communities like Bethel cultivate spaces for healing, growth, and connection. Members share their experiences with symptoms openly; for instance, they discuss the voices they hear, referred to as Gencho-San (which translates to “honorable voices”), and utilize tools like drawings or dolls to express their experiences (Nakamura, 2013, p. 12). According to the reading, “He wanted the members to be able to realize the voices and treat them as separate from themselves” (Nakamura, 2013, p. 12). An example of this is Asami, who used dolls to represent her hallucinations, which over time evolved into symbols of her support system (Nakamura, 2013, pp. 12–13). These creative and community-based approaches facilitate expression without shame.

Bethel also applies humor in powerful ways. During a morning meeting, members performed a choreographed welcome song that humorously referenced schizophrenia, self-harm, and alcoholism. Lyrics like, “Isn’t schizophrenia terrible? (PAPAYA) / With its hallucinations, voices, and delusions?” (Nakamura, 2013, p. 18) demonstrate how Bethel promotes openness and connection instead of isolation. Humor becomes a means of sharing difficult realities, transforming them into collective experiences that are less isolating.

The personal stories between chapters describe the genuine experiences of individuals within the Bethel community. For example, Kiyoshi's narrative is both heartbreaking and hopeful; he describes a difficult childhood marked by abuse, institutionalization, and feelings of worthlessness. However, after joining Bethel, he was able to live, work, and reconnect with others (Nakamura, 2013, pp. 23–30). Eventually, he became a leader who supported new members, emphasizing that recovery from psychiatric conditions is not solely about medication, but also about being seen, valued, and embraced by a community.

These personal accounts are important for helping readers understand psychiatric disabilities from an internal perspective. Instead of relying on abstract clinical descriptions, Nakamura shares voices, emotions, relationships, and real transformations. Readers discover that individuals with schizophrenia are not merely patients; they are friends, artists, caregivers, and unique individuals with dreams and a sense of humor. Together, these stories help us see schizophrenia not as something to be hidden or feared, but as a condition that can be lived with, particularly when people have support, dignity, and a sense of belonging.

3. In A Disability of the Soul, Karen Nakamura highlights how culture profoundly impacts the treatment of individuals with psychiatric disabilities, particularly schizophrenia, in Japan. She observes that Japanese society has traditionally viewed mental illness through a lens of shame, silence, and concealment. As a result, families often keep relatives with mental illness at home to avoid embarrassing their family name. Those diagnosed with psychiatric conditions are frequently institutionalized for extended periods, sometimes for decades (Nakamura, 2013, p. 17). According to Nakamura, Japan has one of the highest rates of institutionalization in the developed world, along with elevated levels of psychiatric medication use, reflecting a deeply medicalized and isolating approach to treatment (Nakamura, 2013, p. 17).

In this context, Bethel House, located in Urakawa, stands out as a significant departure from traditional cultural norms. Bethel encourages individuals to live openly with their psychiatric conditions, promoting community rather than hiding in shame.

Language and social traditions also influence the discussion about psychiatric illness in Japanese culture. Nakamura explains how members at Bethel refer to their hallucinations using the term Gencho-san. “Gencho” means hallucination, and the honorific “-san” adds a sense of respectful identity to the voices (Nakamura, 2013, p. 13). This small cultural and linguistic shift allows members to discuss their symptoms more openly and with less self-blame. As Nakamura states, “Hallucinations were called Gencho-sans (‘honorable voices’). According to the Bethel founder, “Mr. Mukaiyachi wanted the members to be able to externalize the voices and treat them as separate from themselves” (Nakamura, 2013, p. 13). In contrast, negative internal thoughts are referred to as Okyaku-sans, or “honorable visitors,” which helps to differentiate between symptoms of illness and an individual’s identity.

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1.        Reading Karen’s  small portion of her book “A disability of the Soul”, it is pretty clear that she portrays the challenges and “heartbreaks” mental “disabilities a lot more extensively. This was nice because I got a to see them from different perspectives. She explores the social and cultural methods to see the sense of community for individuals with mental distress or “illness”. She talks about the bethel community and challenges the traditional medicalization of diagnosis’. She has an emphasis on the expression of community and self- understanding within the bethel community and they enable to let individuals within the community be themselves.

2.        The impact of including these stories of the bethel community encourages and leads by example for individuals to develop a certain empathy and understanding for individuals that have mental “illnesses”. She challenges stereotypes by sharing personal narratives and including personal stories by diving deep into those who are effected mentally by schizophrenia and explains how they are more than capable to live a normal life, work, and form meaningful relationships within the community. It becomes a more humanized experience for people with mental disabilities to live in a society that can recognize them as normal citizens rather than “crazy” or “dangerous” individuals.

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3. How does culture play a role in the treatment of people with mental disabilities in Japan?

In Japan culture has a really big impact on how people with mental disabilities are treated. A lot of families feel ashamed if someone in their family has a mental illness, so they usually try to hide it from the outside world instead of talking about it. They place a stigma around it. For example in Kiyoshi’s story, his family didn’t really want to talk about his schizophrenia and they seemed even embarrassed to be talking about it. Japanese culture really values group harmony as well, so people are expected to act a certain way and when someone has a mental disability, they can be seen as different. This makes it really hard for them to be accepted even in their own families. Kohei’s story is an example of this because it shows just how he struggled to live his own life especially when society kept trying to make him be quiet about it. Another thing is that Japan used to lean a lot more on long term facilities for people with mental disabilities, instead of keeping them around family. Like they were expected to just be out of sight and out of mind, which is sad overall, but it shows the pressure to not stand out.

4. How are Dr. Kawamura and the Urakawa Red Cross Hospital unique? How do they compare to typical psychiatrists and hospitals in the US?

Dr. Kawamura and the Urakawa Red Cross Hospital are really different from most mental hospitals in Japan. Instead of just keeping people locked away and out of mind, they actually help them get involved in the real world. The patients there are encouraged to have jobs, to be more independent, and even talk about their experiences with their disabilities. Which we know that this is not a normal thing in Japan, a lot of people with disabilities in Japan with mental illnesses are kept in facilities for a long time to hide them. Dr. Kawamura also does not believe in solely using medicine for his patients. He really does listen to his patients and what they have to say. He wants them to know that they do have control over their lives and are worthy of being heard. That’s also different from some places in the U.S. too, some treatment in the U.S can still feel very cold and rushed as if the provider does not actually care. I think what makes this hospital special is that they take the time to try and understand each individual's background. In a lot of places, even still in the U.S, that kind of respect is still lacking. The U.S. might have more rights and services in place for people with mental illnesses, Urakawa focuses on helping people actually live, not just treating their symptoms.

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4. Dr. Kawamura and the Urakawa Red Cross Hospital are unique in their approach to treating and interacting with patients. The United States healthcare system (in addition to its many other flaws) is notoriously horrible with scheduling and seeing patients in a timely manner. Individuals with health issues can wait upwards of seven months for an appointment that lasts roughly 15 minutes. Hospitals in Japan commonly don't take appointments and instead operate on a first-come, first-served basis. (Nakamura, pg. 138). Dr. Kawamura, working in a small community, knows his patients well and works with everyone in Bethel. This allows for a greater sense of community among everyone, and less of an air of judgment and formality, since he is a community member as well. We see on pg. 149, that when Akiko (single mother) needed help, she had the support and cooperation of everyone who could possibly help. She had a meeting at the public health clinic, saying that she needed help. Dr. Kawamura came, along with other hospital workers, some public health clinic staff, school board members, a head teacher, a daycare adult, one of her friends, and a variety of other welfare and healthcare workers. They genuinely listened to her, provided the help she needed, and didn't overstep or pressure her about anything. In the small community of the hospital and the little town, they all work together and take care of each other. That is what community is. The phrase "It takes a village to raise a child" rings true not just in actual childcare but in supporting any community member who is struggling. Dr. Kawamura reduced the number of inpatient beds, provided different levels of outpatient care housing options, and created a supportive environment among his patients (Nakamura, pg. 143-146). He essentially created a realistic system of "rehabilitating" patients and getting them to points where they felt comfortable living independently. While the patients primarily chose to stay in Bethel/Urakawa instead of returning to their previous homes or workplaces, that does not mean they haven't succeeded in learning how to pinpoint reasons for flare-ups/reach out for help when needed. The decision to stay is the result of a supportive community with healthy communication. It is the result of previously living in an unsupportive, unaccommodating world that is ableist out of ignorance (and sometimes flat-out cruelty).

5. Readers are encouraged to reconsider what constitutes a "meaningful life" by being asked to look outside the box of "social conventions." Throughout all the excerpts of this book, we are shown how Bethel residents who struggle with disabilities and/or age were able to find and flourish in a community that doesn't subscribe to the nuclear-family way of living, and were able to live their lives, hold jobs, have friends and family, and be supported by everyone in their shared environment. Nothing is perfect; people will always struggle with things and fight over them. That is what life and being social are. "A life without struggle is not a life worth living" (Nakamura, pg. 153). There is no utopia, no way to get rid of chronic conditions. A meaningful life is getting to do things you enjoy, spending time with people you care about, and having the support to figure out how to live your "best life." The community in Urakawa and the philosophy of non-support are both excellent steps in the right direction, allowing disabled and aging people to have a community that doesn't hold them back from opportunities, and provides support as needed (Nakamura, pp. 154-155). (Ideally, it would not have to be specifically smaller communities, and we could reconstruct the whole system and get rid of agism, ableism, and all the issues, but we do not live in an ideal world, and there are far too many horrible people.) Nakamura pgs. 187-201 cover the life of Gen'ichi. We especially see in his story that although he struggled with his own (and family) health issues, he was able to become a successful public speaker and artist (Nakamura pg. 201). While his health issues certainly got in his way at times, he was able to do things he cared about, be happy, have a community, and not be restricted to a social box of expectations and/or involuntary in-patient care.

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Culture has a big impact on how people with mental disabilities are treated in Japan. Nakamura explains that Japanese values like shame, and fitting in with society often lead to locking people away in hospitals, instead of helping them live in the community. For example “Those who aren’t in hospitals are of- ten secluded in their own homes, prevented by their families from going outside and bringing shame to the family name.”(Nakamura pg. 19). There is an incredible amount of shame in Japan leading to people hiding there family members or them being locked away in hospitals, In japan there is a “Japan has some of the longest hospitalization/institutionalization rates in the developed world as well as the highest rates of pharmaceutical use.”(Nakamura pg. 19). People in Japan with mental illness are in hospitals for long stretches of time and take a lot of medication for there mental disabilities. This shows that in Japan, shame and pressure to fit in make it hard for people with mental disabilities to get real help. Instead of getting support, they are often hidden or kept in hospitals for a long time.

Dr. Nakamura and the Urakawa Red Cross Hospital are very different from most psychiatric care in Japan and even in the U.S. Instead of focusing only on medicine or locking people away in hospitals, they treat people with mental illness by helping them stay connected to their communities. They focus on building trust, giving patients more control over their lives, and supporting them as real people, not just as patients. “Since the early 1900s, people in Japan with severe physical, intellectual, or psychiatric disabilities had been warehoused in nursing homes and other institutions for their entire adult lives. At the protests, I watched as various grassroots organizations representing people with physical and psychiatric disabilities lobbied for greater funds to allow for more deinstitutionalization—the ability for people with disabilities to live independently in the community rather than in hospitals, nursing homes, and other long-term care facilities.”(Nakamura pg. 4). Urakawa Red Cross shows how disability rights groups are now pushing for more funding and support so people can live independently in their communities instead of being locked away in Japan. The US still struggles to create enough support systems especially in the community, leading to homelessness or incarceration instead of proper care. Dr. Kawamura and the Urakawa Red Cross Hospital show that mental health care can be about helping people live in the community with respect and freedom, instead of locking them away. This shows that both Japan and the U.S. need better ways to support people with disabilities so they can live better lives outside of hospitals.

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2. Nakamura includes personal stories of Bethel residents in between each chapter, such as Kiyoshi, Rika, Kohei, and Gen. What is the impact of including these stories? Why are they important and what does the reader learn from them?

Including the stories of Kiyoshi, Rika, Kohei, and Gen in “A Disability of the Soul” adds a deeper meaning within the story through personalization. Allowing readers to hear first-hand experiences of who individuals were before and after Bethel is a great way to use their voices as power. These narratives show how Bethel creates a space where people with schizophrenia can be social, expressive, and independent while receiving appropriate care.

This is such an impactful way of organizing a story because it shows Bethel’s approach to mental health care, eliminating isolation. For instance, Kiyoshi’s one of Bethel’s founding members talked about his trauma and family history and how it shaped his experience with schizophrenia, but also how Bethel turned his life for the better. In fact, Kiyoshi believes “I hadn’t met Dr. Kawamura, I would have most likely spent the rest of my life in a hospital or institution.” (Hayasaka, 24). Bethel gave him a sense of purpose through public speaking. Rika’s story focused on her journey dealing with trauma and bullying. For her, Bethel was her safe space welcoming her in with supporting hands and shaping the community for her by founding the Schizophrenics Anonymous. Kohei’s narrative showed how order and peer support helped him manage his hallucinations, delusions, and build a life outside of institutional walls. Gen’s story was a story of his drive to learn and research. After being hospitalized, Bethel became a home for him where he defied his odds and “became an accomplished artist and public speaker” (Nakamura, 201). The inclusion of each individual shows patients who made an impact of the early Bethel days, shaping their behavior and making a pathway of support for others.

3. How does culture play a role in the treatment of people with mental disabilities in Japan? Provide specific examples.

In Japan, people with mental disabilities are treated and taken care of differently in a more harmonic family-oriented manner. In other words, families make decisions for their loved ones when challenged by psychiatric disabilities practicing group autonomy versus individual autonomy. An issue with this type of approach is that when families aren’t able to care for their loved ones anymore, they turn to long-term hospitalization. In fact, “Japan has some of the longest hospitalization/institutionalization rates in the developed world” (Nakamura, 17). Once in hospitalized care, families keep their loved-one there due to “Hospitalization for social reasons, "which personal reasons may vary from not wanting to provide care because of households or not being able to.

Along with staying at a private psychiatric hospital, Japanese culture doesn’t practice talk therapy. Their approach is closer to their religion since “Buddhist and Shinto traditions have no option of the narrative confession of sins” (Nakamura, 67). With this, patients are given high doses of multiple medications because of roots relating to herbal medicine of China.

Cultural norms in Japan are the foundation of their mental health system. Although long-term hospitalization, lack of verbal therapy, and heavy medication reflect Japanese culture of family autonomy, they can also hinder recovery by violating patient autonomy.

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Brooke Fishback’s Answers for Questions 2 & 3.

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Brooke Fishback’s Answers for Questions 2 & 3.

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2. Nakamura includes personal stories of Bethel residents in between each chapter, such as Kiyoshi, Rika, Kohei, and Gen. What is the impact of including these stories? Why are they important and what does the reader learn from them?

By including these stories, it allows the readers to get a better understanding as to what residence went through to get to the Bethel house. By hearing their stories from having sick parents, to having hallucinations, to being hospitalized, and to seeing UFOs, these stories help people understand how they got the help they needed. The impact of these stories allows the people reading to feel connected with the patients and it understand how their daily lives work. It also helps the readers get exposure to what these mental disabilities can entail and can even relate to a reader to where it can help diagnose them with similar visions. By reading these stories, it has helped readers learn how the Bethel house was able to help these residents and the good work they are doing for them. As said in chapter 6, “Because Bethel is in the middle of nowhere, the members really have nothing to do but focus on their own issues and support each other. As one member notes in Bethel, you can’t die of starvation alone in your apartment in Urawkwa like you could in a big city. Bethel is also blessed by the lack of resources in the town, which has meant that they have had to be creative in their solutions. Nothing will happen unless people work together” (Nakamura, 2013 pg 186). By also adding these stories, it helps other residents see the possible outcomes they could have in their lives. In Kohei’s story it says, “His story became a legend, shared property of the community. It was raised as an example of everyone doing the River=get thing to save one of their peers” (Nakamura, 2013 pg 131). By adding these stories, it has impacted the way the Bethel house is seen to others and has helped teach readers or possible residents how unity towards a goal can help others in need.

3. How does culture play a role in the treatment of people with mental disabilities in Japan? Provide specific examples.

In japan, their culture didn’t really see mental disabilities as an important part of society. A lot of hospitals would try to prescribe medications to patients but wouldn’t take the time to get to know their struggles and how to fix them, until Dr. Kawamura. According to chapter 1, “Japanese law defines three types of disability; physical (for instance, being deaf or blind or having mobility issues), intellectual (developmental or learning disabilities), and psychiatric (mental and psychiatric disorders, including epilepsy and dementia)” (Nakamura, 2013 pg 16). However, now that mental disabilities are more known, the country started putting accommodations in society so patients could be involved with activities. They included “wheelchair ramps on buildings, Braille letters on ATMs, or sigh language interpreters in public. At schools and universities, we make accommodations for people with learning disabilities by providing tutors and alternate testing methods” (Nakamura, 2013 pg 18). its good to see Japan adding accommodations to society, but their culture hasn’t changed much. When someone has a psychiatric disability, they are often seen to be placed in private psychiatric hospitals and stay there to get antipsychotics. This culture is to “fix the problem” instead of how to help limit and teach ways to get help. Also, some people aren’t treated the same and having money could be an impact on that as well. In Rika’s story it says, “I never even had the opportunity to meet a social worker. I wish I had met one earlier in my life, maybe my life would have been different”(Nakamura, 2013 pg 80). By having an equal culture in the Bethel house, it allowed the residents to know that “everyone has their strong points and their weak points. And we each support each other with our strong areas” (Nakamura, 2013 pg 124). Seeing how the Bethel house has impacted these residents helps others in society see how their world can change for the better and implement the way their culture treats mental disabilities.

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1. How does Karen Nakamura lead us to think differently about psychiatric disabilities such as schizophrenia, and disability more broadly? Provide specific examples.

First, Nakemura leads us to think differently about Schizophrenia with his words. "...hallucinations were called Gencho-sans (“honorable voices”)," (Nakemura electronic page 14). Labeling hallucinations as honorable puts a more positive connotation of Schizophrenia. Also, "Okyaku-sans (or “honor able visitors”), which was the Bethel lingo for negative self-thoughts, and which were recognized as coming from inside yourself" (Nakemura electronic page 14). This act of positively labeling things like Schizophrenia and intrusive thoughts helps to create a more positive environment.

Nakemura recognizes that all mental health related concerns have downsides, but that with the right approach mental illness can be easier to manage. "Depression, schizophrenia, and bipolar disorders can all be very physically and psychically painful and can also lead to significant self-harming behavior. No discussion of mental illness in a cross-cultural or transhistorical context can be made without stating that being mentally ill can lead to considerable suffering if not properly treated. That being said, social accommodation of mental illness is both possible and necessary for recovery" (Nakemura electronic page 33).

Surprisingly, Nakemura says that "contemporary Japanese psychiatrists do not see themselves as participating in a tradition separate from Western psychiatrists and psychiatry" (Nakemura electronic page 34).

However, one thing Japan does do slightly differently is "If you were hospitalized in Japan with a serious mental illness such as schizophrenia, you could expect several things. First, you would most likely be staying in a private psychiatric hospital rather than a public one. You would likely have been admitted with your voluntary consent, although in some cases your family could involuntarily admit you or, in much rarer cases, you could be temporarily hospitalized against your will by a psychiatrist or by the government psychiatric review board" (Nakemura electronic page 35). Hospitalization of mentally ill patients is almost all voluntary making more people seemingly more willing to get help. People who are able to get help freely are more likely to get help then those who help is forced upon.

Nakemura reminds the readers of the many reasons why in general the population with Schizophrenia has grown. "The first is that the regimentation of daily life and increased stressors of modernity have led to a rise in various types of mental ill ness, just as changing diet has led to an increase in diabetes. 1 This is what you might call a biomedical or epidemiological perspective. Second, we can chart the ways by which psychiatry has come to understand and defi ne mental illness, especially in terms of its modernist fascination with the neurochemical underpinnings of schizophrenia and depression. We might call this a history of science or social constructionist perspective. 2 Finally, we can also try to recognize the complex interactions among individuals, their illnesses, and the larger social contexts in which these are all embedded. Behaviors and ideas that might have been tolerated in rural environments where the predominant form of social existence was the extended family or clan—these become seen as aberrant and dangerous through the mediating lenses of psychiatry and in the com munities of strangers found in modern society. This is what I would call a biopsychosocial perspective, as it incorporates an acknowledgement of the interplay among the biological, psychiatric, and the social or cultural" (Nakemura electronic page 32). Therefore, Nakemura is explaining why people are seeing a rise in mental illnesses such as Schizophrenia that doesn't just point to more people having it.

These are all different ways in which Nakemura describes Schizophrenia and other mental illnesses different from most authors.

3. How does culture play a role in the treatment of people with mental disabilities in Japan? Provide specific examples.

According to Karen Nakemura, "...Japanese mental illnesses are for the most part the same as American or French mental illnesses. Most Japanese psychiatrists now use either the American DSM system of diagnosing and classifying mental illnesses or the more prevalent International Classification of Diseases (ICD) published by the World Health Organization. These psychiatrists might acknowledge that there are some cultural differences that might cause some Japanese people to express symptoms differently or to be more susceptible to some forms of mental ill ness than others, but on the whole Japanese biomedicine is seen as the same as Western biomedicine. They see the Japanese brain as the same as the Western brain" (Nakemura electronic page 34). Even similar medications are used to treat their symptoms. So, in terms of the Japanese Psychiatrists compared to other psychiatrists there isn't a huge difference.

Compared to other countries however, "There is an incredible amount of shame surrounding mental illness in Japan. In addition, Japan has some of the longest hospitalization/institutionalization rates in the developed world as well as the highest rates of pharmaceutical use" (Nakemura electronic page 19).

One major difference is that "...polypharmacy in Japan may have its roots in the herbal medications of China, where it is very common for the herbal practitioner to mix his or her own special blend of herbs in the appropriate proportion for each patient" (Nakemura electronic page 38 and 39). Their pharmacies are based more around offering differing blends of herbs to each person.

"Japanese psychiatric patients also receive higher doses of medication than in other countries" (Nakemura electronic page 39). This could be attached to Japan's shame around the mentally ill. They might be trying to hide that their people have mental illness in the first place by providing enough medication.

Japan also doesn't normalize talking about their mental health as a form of helping mental illness. "There has never been a moment when a form of talk therapy has been predominant in Japan, whether Freudian or post-Freudian psychoanalysis or psychodynamic psychotherapy. 51 Perhaps this is because, unlike Christianity, the Buddhist and Shinto traditions have no notion of the narrative confession of sins. 52" (Nakemura electronic page 40).

"Patients in Japan are very much expected to play the sick role in hospitals, giving up their out side responsibilities and becoming a passive, compliant, and . . . patient" (Nakemura electronic page 40). The people of Japan are expected to act a certain way as a patient.

"The 1965 Clark Report not ed the lack of community-based mental health care programs that could serve to help integrate people with mental illness into their local com munities. This situation continued well into the 1980s" (Nakemura electronic page 41). There isn't a community support system for mentally ill individuals making to harder for these individuals to manage their symptoms.

So, despite the psychiatrists of Japan agreeing that they aren't all that different from other Western countries, there are a good many cultural differences in how Japan treats and views people with mental disabilities.

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Week Four Padlet

Due: Wednesday, June 11, 2025, 11:59 PM

4. How are Dr. Kawamura and the Urakawa Red Cross Hospital unique? How do they compare to typical psychiatrists and hospitals in the US?

Dr. Kawamura serves as the chief psychiatrist at the Urakawa Red Cross Hospital and occasionally takes breaks to work at the Kawamura Space Research Center (p. 75). He distinguishes himself with a compassionate approach that goes beyond the norm, listening attentively to his patients in every session and dedicating time to understand their unique stories and concerns. By reflecting on their feelings and experiences, he acknowledges their struggles and often shares relevant anecdotes that resonate with them (p. 67) . In addition to individual therapy, Dr. Kawamura promotes group activities that cultivate friendships among patients. He organizes workshops and social events to encourage connection and leads communication skills training workshops, emphasizing the importance of expressing feelings effectively. To enhance these skills, he frequently incorporates role-playing exercises into the sessions, helping patients articulate their thoughts and emotions while reinforcing the notion that emotional honesty can strengthen relationships and foster personal growth at Bethel. Believing in the importance of patient autonomy, Dr. Kawamura allows his patients to drive his car and encourages them to share whatever is on their minds (p.72). He is firmly convinced that patients need to take control of their recovery, stating that there is little he can do as a doctor if the patient doesn’t want to get better. This perspective contrasts with that of many doctors who may be psychologically dependent on their patients, fearing abandonment. Often, these doctors strive to be viewed as "good doctors" and "good people," feeling pressured to cure their patients through various treatments and drugs (p. 78). Dr. Kawamura revolutionized psychiatric care at Urakawa Red Cross Hospital. Every year, Dr. Kawamura invited Bethel members to his house to pound mochi rice cakes (p. 79). He does not take appointments (p. 82).

The Urakawa Red Cross Hospital, established in 1887, operates as an independent, nonprofit institution affiliated with the Red Cross. Compared to typical hospitals in the U.S., it has notable differences and similarities (p. 79). One significant distinction is the Urakawa Red Cross Hospital's specialized focus on psychiatric care, evident in its 60-bed psychiatric ward and the inclusion of various therapeutic interventions like gardening, sports, and art-based therapy (p. 105). While many U.S. hospitals have psychiatric units, the level of dedicated resources for mental health can vary widely. In the U.S., there is often a greater emphasis on emergency care services, which is a gap for Urakawa, as it lacks an emergency room. (p. 81). In terms of the tuberculosis ward, having four dedicated beds is relatively rare in many U.S. hospitals today, as such specialized units have largely diminished. Most hospitals tend to integrate treatment for tuberculosis within their general medical wards instead. Furthermore, the facility's allowance for leave privileges and unannounced visitor access in the psychiatric ward may reflect a more flexible approach to patient care compared to some U.S. institutions, where stricter visitation policies are common. While the Urakawa Red Cross Hospital employs nineteen doctors across five wards and averages 248 inpatients and 668 outpatients, it faces challenges in physician retention (p. 81). This issue is also prevalent in many rural and smaller hospitals in the U.S., where recruitment and retention of medical staff can be a concern. Overall, while there are similarities in patient care philosophies, the Urakawa Red Cross Hospital’s commitment to providing specialized psychiatric services and its historical background set it apart from the typical hospital experience in the U.S.

5. Disability and old age are often seen as impediments to "a meaningful life." How does A Disability of the Soul urge readers to question what a meaningful life means and what it might look like, especially for disabled and old people? Provide specific examples.

“The Disability of the Soul” invites readers to contemplate what makes life meaningful, particularly for individuals with disabilities. Dr. Kawamura emphasizes the importance of letting go of the past, advising his patients against dwelling on past experiences, which he describes as rummaging through the "trash can of the soul" (p. 22). This guidance is especially crucial for disabled individuals who may struggle with feelings of loss or regret. By encouraging them to seize new opportunities in life and channel their energy into their current situation, he suggests that viewing life as a precious gift can lead to profound changes and offer a fresh perspective (p. 31). However, the concept of the “disability of the soul” can also manifest in older individuals, who often face emotional and psychological challenges. Feelings of isolation, a struggle to find meaning in later years, and loss of purpose can be exacerbated by physical disabilities. Cognitive decline and mental health issues like depression or Alzheimer’s further complicate their experiences. Despite these obstacles, the “disability of the soul” can be countered by engaging with the community, fostering relationships, and exploring new hobbies. Encouraging older adults to share their stories can also help them reclaim their sense of purpose. Conversely, individuals with disabilities frequently experience a “disability of the soul,” leading to feelings of disconnection from their environment and frustration. These emotions often stem from the challenges of managing their disabilities. To address this disconnection, participating in support groups, joining recreational activities, and acknowledging small victories can be effective strategies. Nurturing an environment where individuals feel encouraged to share their challenges and successes fosters resilience and helps restore their sense of identity. Overall, even during challenging times, Dr. Kawamura highlights that individuals with disabilities can find ways to connect with others and appreciate the beauty of life.

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1. How does Karen Nakamura lead us to think differently about psychiatric disabilities such as schizophrenia, and disability more broadly? Provide specific examples.

2. Nakamura includes personal stories of Bethel residents in between each chapter, such as Kiyoshi, Rika, Kohei, and Gen. What is the impact of including these stories? Why are they important and what does the reader learn from them?

3. How does culture play a role in the treatment of people with mental disabilities in Japan? Provide specific examples.

4. How are Dr. Kawamura and the Urakawa Red Cross Hospital unique? How do they compare to typical psychiatrists and hospitals in the US?

5. Disability and old age are often seen as impediments to "a meaningful life." How does A Disability of the Soul urge readers to question what a meaningful life means and what it might look like, especially for disabled and old people? Provide specific examples.

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1. How does Karen Nakamura lead us to think differently about psychiatric disabilities such as schizophrenia, and disability more broadly? Provide specific examples.

Karen leads us to think differently about psychiatric disabilities by presenting to us the biopsychosocial perspective that focuses on the biological, social, psychiatric, or cultural and is influenced by these factors (Nakamura, 2013, p. 35).  this is shown in the behaviors and ideas that could be tolerated in the rural environment because that's where the family or clan is and they were the ones that formed the their social interactions and was normal, but outside out of the family or clan this is seen as dangerous and unsafe in society as a whole (Nakamura, 2013, p. 35). She goes into the fact that the norm is that people with schizophrenia are expected to be healed or cured before going out in society; she talks about how they do not need to be cured before reentering society (Nakamura, 2013, p. 68). This viewpoint can make other possibilities come true as the change of society makes accommodations for people with these types of disabilities rather than helping fix them. Another thing she confronts is the idea that plagued people with psychiatric disabilities as they were shamans or spiritual leaders, but they were more just left to die (Nakamura, 2013, p. 36). There is an obvious lap in knowledge about psychiatric disabilities, and this leads to falsehoods or harmful stereotyping.

2. Nakamura includes personal stories of Bethel residents between each chapter, such as Kiyoshi, Rika, Kohei, and Gen. What is the impact of including these stories? Why are they important and what does the reader learn from them?

Including these stories of the residents of Bethel serves a major purpose. For example, the stories told humanize the experiences of people living with schizophrenic and other psychiatric disabilities. In the case of Kiyoshi, it reviles that he struggles with his mental illness and his resilience, and the importance of support specially form bethel (Nakamura, 2013, pp. 26-30). Another example is when we investigate the story of Gen and how the involvement of the community leads to growth, even with dealing with severe illness. He became an artist and speaker during hospitalization before moving into the Station House (Nakamura, 2013, p. 201). By telling these stories of these people I started to empathize their experiences and questioned some of the stigma that is associated with mental illness. This also shows that these people can live a meaningful life with proper support.