This chapter explores the treatment of alcoholism in post-World War II Japan, focusing on drug treatment, rehabilitation programmes and self-help groups. It looks at hospital-centred medical approaches as well as patients’ and their families’ initiatives in dealing with alcohol-related problems, such as Alcoholics Anonymous (AA), and Japanese-style treatments such as Danshukai and Naikan.

Alcoholism does not appear to have drawn much government and medical attention until the second half of the twentieth century, despite the fact that early Christian missionaries had brought temperance ideas to Japan during the early 1880s within the context of the modernisation drives of the Meiji period (1868–1912), followed by short-lived Buddhist temperance initiatives.¹ Only a small number of patients with alcoholism were reported in official records before World War II. Sakaki Hajime, who had studied psychiatry in Berlin from 1882 to 1886 and became the first university professor of psychiatry in Japan, talked about the state of psychiatry in his homeland at a conference in Berlin in 1884. He held the view that alcoholism was ‘relatively little known’ and that the Japanese ‘in general can tolerate little alcohol, and that’s why they take little’.² He thought that this was due to racial differences in biological sensitivity to ethanol. Most Japanese people and other Asians lack the enzyme related to alcohol metabolism, which makes for low alcohol tolerance.³ His contention seemed to be validated by the annual reports of one of the oldest public mental hospitals in Japan. In Matsuzawa Hospital in Tokyo, alcoholism was diagnosed in only 1 per cent of cases from 1920 to 1924.⁴

Other pre-World War II reports also indicated that the number of patients diagnosed with alcoholism was very low.⁵ Whether alcoholism was a factor among patients with other diagnoses is difficult to ascertain. The situation changed when alcohol consumption increased markedly after World War II, in tandem with economic growth, a rise in national income and changes in lifestyle. More attention came to be paid to alcohol use disorders across the country, within the context of wider anxieties about the family during this period.⁶ The traditional large Japanese family was supplanted by small nuclear families, which played a major role in rapid post-war economic growth, and new eugenic legislation, introduced by government to stem population growth, led to a declining birth rate.⁷ Alcoholism was seen to jeopardise the stability of the new nuclear family structure, which had come to consist of a working man, his housekeeping wife and their children. Alcoholism emerged not just as an individual illness, but as a family malady and as a symptom of social anxieties.

The Drunkenness Prevention Act, 1961

In post-World War II Japan, drinking and alcoholism were deeply embedded in the Japanese family and gender structure and were sometimes accompanied by poverty and violence. More attention was paid to the issue of alcoholism after a murder that occurred in Tokyo in 1958. According to a newspaper article, two young daughters, thirteen and sixteen years old, strangled their alcoholic father on Fathers’ Day.⁸ They lived in a slum in the Adachi area. The article stated that the father was frequently inebriated and often hit his wife, and that he was unemployed and used any money earned by his family for liquor. His wife was a day labourer, the elder daughter worked at a sōzaiya or Japanese delicatessen, and the younger daughter worked illegally as a housemaid (this was illegal because she was still required to be in compulsory education). There were three sons in this family, but they had run away from home. On 14 June the mother left home and did not return, saying that she was disgusted with her husband. According to the article, the daughters decided to kill their father in order to save the family.

Tragedies such as this directly influenced activists who were fighting to improve the position of women and children in Japanese society. Kōro Mitsu, a woman elected to the National Diet (Assembly) in 1946 – at the first general election since women’s suffrage was granted – attempted to introduce legislation for the prevention of similar cases.⁹ In 1961 Kōro and twenty-three other Diet members, mainly women, submitted a bill on the regulation of disruptive acts and violence to the general public caused by drunkenness (the Drunkenness Prevention Act). At the committee meeting in the Diet she explained the rationale underlying the suggested legislation:

One of the concerns discussed was that Article 6 of the bill allowed the police to enter the homes of alcoholics who tried to assault their family members. Kōro explained that the aim was to prevent a drunken husband or father from causing pain to the family at home. Adding to her explanation, Kashiwamura Nobuo, Commissioner General of the National Police Agency, stated, ‘although we do not like the fact that the police will enter private houses, we hope that Article 6 will become a warning for all men’.¹² Some Diet members held that Article 6 was unnecessary, for the Police Duties Execution Act of 1948 had already stipulated that the police could enter houses to protect personal life and property. But Kōro asserted that including Article 6 in this new law on drunkenness and increasing public awareness of alcoholism would make alcoholics themselves reflect on their drinking habits and the occurrence of family tragedies would be reduced.¹³ The Drunkenness Prevention Act was enacted on 1 July 1961. The law was aimed at the protection, punishment and treatment of alcoholics. An additional resolution of this law by the National Diet stipulated that the government should take budgetary measures for establishing institutions to treat alcoholism as soon as possible.

National Kurihama Hospital

As a result, in 1963 the government began to build a special men’s ward with forty beds for alcoholic patients in National Kurihama Hospital, located on the coast in the suburb of Yokosuka near Tokyo.¹⁴ It was the first national facility for the psychiatric treatment of alcoholism. The hospital in Kurihama had originally been established in 1941 as a branch of Yokosuka Kaigun Byōin (Yokosuka Naval Hospital). After World War II it was mainly used for tuberculosis patients under the administration of the Ministry of Health and Welfare, but when the number of those patients decreased, it was converted to a psychiatric ward.

The patients participated in a three-month rehabilitation-oriented programme based on group activities such as meetings, occupational therapy and kōgun or long-distance walking. These therapies were strictly controlled, being incorporated into the patients’ daily, weekly or monthly routines. A jichikai, or patients’ autonomous organisation, was established in the ward. This programme, called the ‘Kurihama method’, was new to psychiatrists at the time and was taken as the model for the treatment of hospitalised alcoholics in Japan.¹⁵ The psychiatrist and essayist Nada Inada (real name Horiuchi Shigeru), who had worked at ‘Tōroku’ or Ward East 6, dedicated to alcoholic patients since it opened, described the previous treatment regime: it was thought that there was no effective therapy for alcoholism, and alcoholic patients were accommodated in closed wards together with patients with other mental illnesses.¹⁶ But it should be noted that even after the ‘Kurihama method’ became famous around the country, the treatment of alcoholics remained underdeveloped in other mental hospitals. For instance, a newspaper article from 17 June 1969 reported that thirty-four alcoholic patients escaped from the closed ward of a mental hospital in Hachiōji in Tokyo after negotiations with the hospital staff to improve treatment had broken down.¹⁷

Nada was appointed as a ward doctor at Tōroku in 1963 (although the ward was still under construction). Shortly afterwards he went to Europe for a year in order to gain more knowledge of alcoholism, and experienced first-hand the extent to which the background and treatment of alcoholism varied from country to country. He was conducting research in order to find a treatment model that could be suitable for the new ward established at Kurihama. Despite learning much about group therapy in Great Britain and northern Europe, he was unable to identify an appropriate model that could be transferred to Japan. He concluded that he would need to start from scratch, and in 1964 he returned to Japan and began to develop a treatment programme together with another psychiatrist, Kōno Hiroaki: the ‘Kurihama method’.¹⁸

This new approach was based on the medical management of alcoholic patients in a hospital setting. Nada and Kōno agreed that it was crucial that patients continued to live soberly after leaving the hospital. Given the need for supportive rehabilitation measures for recovering alcoholics, they decided to collaborate with the self-help group Danshukai, as discussed below. The underlying premise was that ‘the only way to recover from alcoholism is to continue complete abstinence’.¹⁹

It is clear that the debates surrounding the new legislation resulting from the Drunkenness Prevention Act drew on the image of an idealised family, composed of a working man, his housekeeping wife and their well-educated children, during a period of high economic growth in the 1960s. Within this context, a family that consisted of an alcoholic man, and a wife and children abused by him, was recognised as a social problem. The ward in Kurihama was expected, as a national institution, to have a social (and national) role of changing a problematic family to the ideal image of a family by isolating an alcoholic man from his family, giving him a variety of therapies and discharging him from the hospital back to his home within three months. Hospitalised patients originated from a variety of social backgrounds. Many of those who had caused family conflicts wished for the ‘normalisation’ of the family and not just for their own successful recovery. For example, the ‘Tōroku elegy’, which is said to have been sung for a long time by hospitalised patients in the Tōroku ward, expresses patients’ regret and deep attachment to their families. Some of the lyrics are as follows: ‘On account of alcohol, I am isolated for three months in the hospital at Kurihama, the place people don’t like. My lovely wife must be lonely.’ Or: ‘I had a dream about my child, who wished me to do my best. Then I awoke and heard the waves from the coast. Suddenly tears sprang from my eyes.’²⁰

As the ‘Tōroku elegy’ indicates, patients did not only harbour regrets about ending up hospitalised but were also hopeful for their lives after leaving hospital. After discharge, many were involved in self-help groups to maintain recovery and assist rehabilitation.

Medical approaches to alcoholism: pharmacotherapy

Shortly after the end of World War II, pharmacotherapy for alcoholism was practised in Japan for the first time by Geshi Takamaro, a pioneering psychiatrist who was actively committed to the medical treatment of alcoholism. Born in 1914 in Kōchi, Shikoku, in south-west Japan, he studied medicine at Okayama Medical College, where he specialised in psychiatry and physiology, and became medical director at Seikaen Mental Hospital in his home town in 1947. He founded Geshi Hospital in 1959. His understanding of the reported rise of alcoholism was that:

Because earlier treatments for alcoholism, such as persuasion, confinement in mental hospitals and electroconvulsive therapy, had little effect, he began to use emetine and disulfiram (trade name Antabuse). Although at the time it was difficult for doctors in Japan to obtain these drugs, Geshi was able to get emetine from the US military. He also asked a Japanese pharmaceutical company to produce a sample of disulfiram.²²

The emetic drug emetine was used as a stimulus to produce an aversion to alcoholic beverages. This Pavlov-style ‘conditioned-reflex’ treatment for chronic alcoholics had first been applied by Walter Voegtlin and his colleagues in a sanatorium in Seattle, Washington, during the 1930s.²³ Voegtlin found the secret of success to be proper timing. The onset of nausea from emetine had to occur at the same time as the alcoholic drinks were consumed. As was shown in an article by Voegtlin and William Broz in 1949, over a period of ten and a half years conditioning procedures caused 85 per cent of the 3,125 of patients diagnosed as chronic alcoholics at the institution to remain abstinent for six months or longer; 70 per cent remained abstinent for over one year.²⁴

Geshi knew about and referred to Voegtlin and Broz’s article and practised emetine aversion treatment with 343 alcoholic patients between 1950 and 1951.²⁵ According to Geshi, the approximate dosage was 0.04 grams of emetine per san shaku masu (a wooden cup for sake, which has a capacity of about 54.1 ml). The drug was given once a day after a meal for ten consecutive days. It seems that the patients did not know that the alcohol they drank contained emetine; most of them vomited within thirty minutes. Geshi reported the results of the treatment of 261 patients and concluded that more than half of the patients avoided alcohol for some time following emetine therapy. Geshi also practised disulfiram therapy on 154 patients and evaluated it positively.²⁶ When he presented the effects of pharmacotherapy (using emetine and disulfiram) at a medical conference in Kōchi in 1950, the event was reported in the mass media and brought to public attention.

Disulfiram was the first medicine for the treatment of alcoholism that made use of the action of alcohol metabolism. It was invented in 1948 by the Danish physician Erik Jacobsen and his colleagues in their laboratory in Copenhagen.²⁷ Disulfiram produces unpleasant effects when taken with alcohol because the drug inhibits the oxidation process of alcohol. In the 1950s medicines for alcoholism such as Temposil and Cyanamide were developed, and they had similar effects to Antabuse. Temposil was developed in North America, while in Japan, Cyanamide was the drug of choice, having mainly been developed by Japanese doctors.

Despite their apparent success, from the 1950s onwards Geshi came to believe that there were limits to the usefulness of drug treatments in alcoholism cases unless they were accompanied by further interventions.²⁸ During this time Geshi met an alcoholic patient, Matsumura Harushige.²⁹ Matsumura was born in 1905 as the second son to a family working in agriculture and forestry in an economically deprived village in Kōchi Prefecture. In his twenties he served as head of seinendan, a local young men’s association that existed in almost every rural community before World War II. He was also involved in a socialist group in Kōchi until it was made illegal under the wartime regime. Then, in 1939, he went to Pusan in Korea, which was under Japanese rule at the time, and worked at a shipping company, where he developed what was then described as alcoholism.³⁰ After the war he returned to Kōchi and became an active member of the Socialist Party, but he was severely dependent on alcohol and was hospitalised repeatedly. His doctor, Geshi, treated him with emetine therapy, but it was all in vain, and Geshi gave up on him as a completely hopeless case upon his fifth hospitalisation. However, at that moment, when Matsumura saw his doctor’s face full of empathy and despair, he realised for himself that he should stop drinking alcohol.

On the basis of his encounter with Matsumura, Geshi began to attend the regular meetings of Danshukai in Tokyo, a self-help group of patients suffering from alcoholism. Geshi had realised that there was a need for the continued support of patients and for rehabilitation measures after their discharge from hospital.

Nihon Kinshu Dōmei, Alcoholics Anonymous and the rise of Danshukai

Danshukai was modelled on AA. AA was first introduced to Japan by the temperance association Nihon Kinshu Dōmei, which was established in 1898 and aimed at ridding society of alcohol.³¹ One of its leaders, Yamamuro Buho, was seemingly the first Japanese person to participate in an alcoholism treatment workshop held at Yale University in 1952. In the same year, Ōtsuji Kimiko was sent to the USA as an abstinence ambassador by Nihon Kinshu Dōmei and visited the head office of AA. AA describes itself as ‘a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism’.³² It dates back to the 1935 encounter in Akron, Ohio, between two people then experiencing alcoholism: the surgeon Bob Smith and the stockbroker and entrepreneur Bill Wilson.

In 1953 Nihon Kinshu Dōmei formed an AA group, but it closed after about four years. It is assumed that the failure of AA at this time was due to problems associated with the cultural transfer of an American-bred model as well as organisational problems.³³ The reappearance of AA had to wait until 1975, when, as a result of interaction with AA members within a US military base in Japan, an AA meeting was held at a Christian church in Kamata, Tokyo.³⁴ Shortly before this, Tanaka Michio, the Japanese priest of the church, who himself was an alcoholic, had met John Meaney, the American priest of Maryknoll Mission in Japan, who was an active AA member. The latter had become an alcoholic during his stay in Japan, had been treated in the USA and subsequently returned to Japan with the aim of helping others experiencing alcoholism. In the early years, many of the AA members in Tokyo came from the US military base. Later, meetings also began to be held in other parts of Japan. Unlike Danshukai, which will be discussed below, AA was thought to be useful for alcoholics who lived alone, away from their families. From the 1980s to the 1990s, when AA groups spread nationwide, it was common for hospital and welfare staff in the Tokyo area to refer individuals who received public assistance and lived alone to AA. AA Japan General Service estimates that in 2018 there were more than 600 AA groups and over 5,700 members in Japan.³⁵

Danshukai became active in the late 1950s as a new organisation, using AA as a model. Geshi Takamaro often visited the Danshukai meetings in Tokyo and was impressed by them. As at AA meetings, individuals who had been formerly diagnosed with alcoholism talked about their experiences. Geshi lent his support to this non-directive approach to group psychotherapy. Unlike temperance groups, Danshukai did not aim at a wholly sober society, but simply supported those who had experienced and were experiencing alcoholism in their quest to abstain from drinking completely. In 1956 Geshi visited the USA for three weeks as a member of a mental hospital inspection team from Japan.³⁶ This inspection was significant for him, as he had previously been interested in American group psychotherapy, and he tried to position Danshukai as such. He was impressed by the fact that patients with alcoholism were well treated in the state mental hospitals he visited, and by the recreational and group activities. The inspection visit convinced Geshi of the effectiveness of Danshukai. He started collecting information on AA and the treatment of alcoholism with the help of Sawamura Eiichi, an English literary scholar at Kōchi University, who had previously won a Fulbright Scholarship in the USA.³⁷

In January 1958 Geshi encouraged his patient Matsumura to establish a Danshukai group in Kōchi in order to help others to deal with their alcoholism.³⁸ In November 1958, inspired by an earlier lecture by Koshio Kanji, a leader of Nihon Kinshu Dōmei, Geshi and Matsumura founded Danshukai (Kōchi-ken Danshu Shinseikai).³⁹ The organisation gradually expanded nationwide. In 1963, at the fifth anniversary meeting held in Kōchi, Danshukai in Kōchi and Tokyo cooperated to set up a national organisation of Danshukai called Zen Nihon Danshu Renmei (Zendanren).⁴⁰ Matsumura was appointed first president of Zendanren. By the end of the twentieth century, it had grown into Japan’s largest self-help organisation for alcoholism, with more than 10,000 members.⁴¹

The feasibility of abstinence rather than moderation in drinking became a major issue of debate. Complete abstinence from drinking seems to have been the aim for the treatment of alcoholism shared by Danshukai and medical doctors at the time. For example, Erik Jacobsen, the above-mentioned pioneer of pharmacotherapy, spoke about the ideal and the reality of the treatment of alcoholism as a guest speaker at the fifteenth General Assembly of the Japanese Association of Medical Sciences held in Tokyo in 1959:

However, there were some who thought that complete abstinence was not the only possible approach to alcoholism. For example, the psychiatrist Mukasa Hiroshi, who founded the mental hospital in Nakatsu, Ōita, doubted the practicability of complete abstinence and opposed Jacobsen’s view. He contended that:

Mukasa had developed Cyanamide, an alcohol-deterrent drug, and insisted that it would be possible to moderate drinking by means of pharmacotherapy. On the basis of the results of 200 individuals with alcoholism, he observed that it was better for them to maintain their social lives by drinking a little than to abstain from alcohol completely. Mukasa’s favourable view of the use of drugs contrasts with that of Geshi, who focused on the Danshukai approach rather than pharmacotherapy.

Like Mukasa, Tsukue Ichirō, the director of a private mental hospital in Hiroshima, regretted that many psychiatrists did not expect pharmacotherapy to be efficacious and that they had become predominantly interested in Danshukai, with its emphasis on the social adaptability of alcoholics who would commit to abstinence, exchange their experiences with other Danshukai members and maintain a sober life. Tsukue believed that there was still much room to conduct research into the pharmacotherapy of alcoholism, both in Japan and in the West.⁴⁴ As in Western countries, so too in Japan, psycho-pharmaceuticals were used widely from the 1950s onwards in the treatment of alcoholism and mental illness.⁴⁵ But, despite the possibilities of pharmacotherapy envisaged by authors such as Mukasa and Tsukue, and because many others held the view that it would be impossible for individuals to control or moderate their drinking, the treatment of alcoholism was (and still is now) based predominantly on the principle of complete abstinence.⁴⁶ Danshukai was widely thought to be indispensable for the care of alcoholics within the community, as its regular meetings were believed to help them remain sober outside hospital.⁴⁷ At the beginning of each Danshukai meeting, members declared their pledge to remain abstinent. They were expected to speak of their own experiences regarding their alcohol-related problems, share their feelings with members and deepen their insights into the disease (see Figure 9.1).

Although Danshukai was inspired by AA, there are notable differences.⁴⁸ While the abstinence pledges and the ‘Twelve Steps’ (a set of guiding principles for recovery from alcoholism) are similar, AA refers to God or a greater power in the recovery process. In contrast, Danshukai does not invoke any religious notions. As Chenhall and Oka have suggested, it is thought that AA’s Christian principles ‘do not correspond with Japanese understandings of recovery from alcoholism’.⁴⁹ Another important difference is that, unlike AA, Danshukai is based on the non-anonymity of its members.⁵⁰ While AA has a horizontal organisational structure, Danshukai is ‘top-down’ and all relationships are vertically organised. What is more,

Figure 9.1 The twentieth anniversary meeting of Yokosuka Danshukai, held in 1987

Chenhall and Oka note that in Danshukai ‘recovery is not an individual journey but is inclusive of the family in the therapeutic process’.⁵²

In order for Danshukai to gain wider acceptance in Japan, some principles, such as compatibility with existing Japanese family and gender structures and values, had to come to the fore. This focus was not limited to Danshukai. It had also been important in regard to the kind of treatment pursued at Kurihama and had been a vital aspect of the discussions of the murder case in the lead-up to the Drunkenness Prevention Act. It is therefore vital to explore the changing relationship between alcohol problems and the Japanese family and gender structure. Ideas about alcoholism in post-World War II Japan typically appeared at first in the guise of narratives that tended to focus on a drunken and violent husband who was to be punished, and an abused wife and children who were to be rescued. However, the premise of such a narrative about alcoholics and their families changed once the idea of ‘alcoholism as a family disease’ spread more widely, by the 1980s at the latest.

The psychiatrist Saitō Satoru, who had worked in Kurihama, asserted in his 1985 book that when a person developed alcoholism they were, in his words, ‘born’ as part of a family problem, and the stress produced by the ‘birth’ of that person would make the problems even worse.⁵³ This suggestion had some affinity with Joan Jackson’s studies of the mid-1950s, conducted on the partners of AA members and excessive drinkers in Seattle.⁵⁴ Saitō explored the complex relationship between the recovery process from alcoholism and the changing family roles of husbands and wives. He pointed out that the husband’s recovery from the disease and his subsequent resumption of the traditional role as the head of the household could threaten the stability of the family and even lead to the wife becoming mentally ill. In the text used during the 1980s for the family education programme on alcoholism at Tokyo Toritsu Seishin’eisei Sentā (Tokyo Metropolitan Mental Health Centre), in which Saitō was referred to, the notion of ‘alcoholism as a family disease’ was emphasised.⁵⁵ The assumption was that when a husband developed alcoholism, the family dynamics changed, with the wife taking on the husband’s previous domestic and social roles. The wife, according to this model, depended on the children (especially the eldest) to support her in this like a husband. Children who took on these responsibilities were, it was thought, forced to grow up too fast. Mental health guidance recommended that the family should not let itself be ruled by the person with alcoholism, but should return responsibilities to him and focus on their own recovery.

Because Danshukai kept a close relationship with medical institutions, it took on board the idea of alcoholism as a family disease. This is demonstrated in the newsletter of a Tokyo Danshukai group.⁵⁶ A woman wrote a short essay about her memories of when her alcoholic husband was hospitalised in January 1983. When the doctor said to her, ‘You are also an alcoholic, or an alcoholic patient who never drinks’, she was puzzled. However, following the doctor’s advice, she joined Danshukai in the Setagaya area and attended the regular meetings. At first, she was not interested in what other people attending the meeting said, as she was strongly conscious that she herself was not experiencing an alcohol dependency. But, as time passed, she noticed that her efforts to help her husband not only were in vain but were exacerbating his condition. She gave her essay the title ‘A silly wife and mother’. Thanks to her involvement with Danshukai, she realised that her role as ‘rescuer’ had maintained undesirable family dynamics and encouraged her husband’s continued role as that of the ‘patient’. She asserted that changing her own role in the family led to her husband’s recovery.

With the aim of spreading the idea of alcoholism as a family disease, Danshukai published a booklet for the wives of those with alcoholism titled ‘Madam, there is something you can do!’⁵⁷ According to the booklet, alcoholism involved the whole family, and therefore all family members were implicated in the patient’s and the family’s recovery process. Attendance at Danshukai meetings was important not only for alcoholic husbands but also for their wives. Once the husband had recovered, it was expected that the role as the head of the family (shujin), which the wife had assumed during his illness, must be returned to him as soon as possible. As the booklet shows, in the context of Danshukai alcoholism as a family disease seems to be narrowly defined as occurring only in marital settings.⁵⁸

It is however important to keep in mind that the phrase ‘alcoholism is a family disease’ makes sense only if the family is not yet broken. Danshukai in Tokyo published an essay written by a member who had joined the group after his family’s collapse.⁵⁹ This individual, who worked as a cartoonist and had drunk heavily for twenty years from his twenties onwards, had been hospitalised repeatedly, presenting with hallucinations and delusions. He eventually lost his family and his job. After the last hospitalisation, in 1986, he began to attend a Danshukai meeting. The extent to which the concept of ‘a family disease’ was relevant to his recovery is difficult to ascertain. However, in his essay, he still expressed his regrets to his divorced wife and children and his hopes for a continued sober life.

While recent studies have shown that a considerable number successfully recover from alcoholism by attending Danshukai meetings together with their spouses, there has been a decline in the number of Danshukai groups.⁶⁰ According to Zendanren, the umbrella organisation of Danshukai, the total number of members continues to decrease, having fallen to around 8,500 in 2012.⁶¹ Despite an increased alcohol intake among women in the general population, the number of female members has not increased. Furthermore, Danshukai is little known to the younger generation.⁶² The members are ageing, and in 2012 the proportion of existing members over the age of sixty was close to 60 per cent.⁶³ Moreover, the proportion of members who were over sixty when they entered Danshukai reached 25 per cent in the same year.⁶⁴ Zendanren suggests that these trends are due to the fact that the treatment of alcoholism has tended to depend more and more on medical institutions and, as a result, the age when people enter Danshukai has increased. The organisation is concerned that its treatment, which it considers vital for maintaining continued abstinence, is no longer taken up in the earlier stages of life.

Shimmitsu Setsuko points out that Danshukai’s activities have stagnated despite the fact that its views on the treatment of alcoholism have continued to develop in tandem with changing medical approaches in institutional settings.⁶⁵ However, she notes that Danshukai does not favour abstinence that relies exclusively on medical treatment. It considers its comprehensive approach indispensable for the ‘real’ and sustained recovery of alcoholics. There is currently no agreement among those involved in the treatment of alcoholism on the extent to which medical staff and Danshukai members should work in unison. Sometimes these two parties even compete against each other.

Danshukai is similar to the ‘Hudolin model’ or the Club of Treated Alcoholics developed in Communist Yugoslavia, which is discussed in this volume by Mat Savelli (see Chapter 10). In both approaches, family participation is thought to be of immeasurable value in establishing and maintaining abstinence.⁶⁶ However, in the Hudolin model professional involvement is much stronger. Moreover, while Geshi Takamaro was influenced by foreign trends such as American AA and group therapy, he is unlikely to have had contact with ideas of preventive and social psychiatry which influenced Yugoslavian psychiatrists in the United Kingdom. There is also no evidence that Geshi and other Danshukai leaders had direct or indirect contact with colleagues in Yugoslavia.

Focusing on individual change: Naikan

Separate from group-oriented treatments, such as Danshukai and AA, an individual psychotherapy called Naikan also gained prominence in Japan. The Japanese word Naikan, if literally translated, means ‘looking inwards’. It was founded as a form of psychotherapy by Yoshimoto Ishin in the 1940s. Yoshimoto was born in Nara in 1916 as the third son of a farmer.⁶⁷ Under his mother’s influence he became deeply interested in the teachings of Jōdo Shinshū, a Buddhist sect. In the process of religious practice, Yoshimoto experienced mishirabe (looking into oneself thoroughly). According to Jōdo’s teaching, mishirabe leads to the conviction that a peaceful death is guaranteed. Yoshimoto adapted the practice and applied it to a popular technique of psychotherapy, in which one looks back on one’s relationships with others. The religious scholar Shimazono Susumu explains the essence of Naikan practice:

Some psychiatrists were interested in Naikan and applied it to the treatment of alcoholism from the end of the 1960s onwards. In 1967 the psychiatrist Suwaki Hiroshi visited Yoshimoto’s dojo (space or centre for immersive teaching or meditation) and participated in the Naikan training.⁶⁹ Suwaki was convinced that, since those experiencing alcoholism clearly caused their families worry, Naikan would motivate individuals to deal with their disease and remain abstinent. He introduced Naikan as a psychotherapy in some psychiatric institutions in Okayama.

Another example is the psychiatrist Takemoto Takahiro, who was based at Kagoshima Kenritsu Seishin’eisei Sentā (Kagoshima Prefectural Mental Health Centre) and became involved in the treatment of alcoholism in 1970.⁷⁰ Staff at Kagoshima had become increasingly concerned about patients with alcoholism because there was almost no medical treatment available for them at the time. Takemoto first set up a Danshukai group in 1971 and held its regular meetings in the health centre. However, many members withdrew from Danshukai and only few of them remained abstinent. Takemoto felt a necessity for a special ward for the treatment of alcoholism, modelled on the one at the National Kurihama Hospital. He proposed the idea to the director of the centre, but it was rejected. Takemoto therefore founded the Ibusuki-Takemoto Hospital for alcoholism. Initially the treatment was unsuccessful. Takemoto concluded that it was not enough to rely on the methods of Danshukai; crucially, for him, the failure of Danshukai methods was related to how members engaged with their past. Therefore Takemoto visited Yoshimoto in 1975 to undergo Naikan training. Since then, Naikan has been used as one of the psychotherapy programmes available at his hospital.

In 1978 Takemoto became a founding member, alongside others involved in psychiatry and psychology, and with Yoshimoto Ishin as an advisor, of the Japan Naikan Association, an academic society promoting Naikan therapy. According to the programmes of recent annual meetings, reports of research undertaken by domestic and international speakers – as well as clinical case studies – are presented, and Naikan training sessions held.⁷¹ Today, about twenty Naikan dojos have been established around Japan, and Naikan extends to Europe, the USA, South Korea and China.⁷² But seen in relation to the general trend of the treatment of alcoholism in recent years in Japan, Naikan does not necessarily surpass Danshukai. Takemoto’s preference for Naikan was based on his critical view of the group-oriented approach practised by self-help groups such as Danshukai, in which the participants were expected to talk about their experiences without specific focus on their past behaviour and its impact on their families and friends.⁷³ He was convinced that as a systematic individual therapy Naikan would lead to spiritual growth and behavioural change, and that it should therefore be applied more widely in the treatment of alcoholism. However, according to Miki Yoshihiko, a clinical psychologist and one of the founding members of the Japan Naikan Association, Takemoto also recognised the limitations of Naikan.⁷⁴ First, a one-week programme of Naikan is time-consuming for both the therapist and the patient. Second, Naikan tends to be misunderstood as religion, and some patients avoid it for that reason. Third, some people are averse to looking back on relationships with others that involve a sense of guilt, which constitutes the core principle of Naikan. Miki Yoshihiko suggests that these issues need to be addressed if Naikan is to flourish.

Conclusion

The mainstream treatment of alcoholism in post-World War II Japan consisted of pharmacotherapy, rehabilitation programmes in mental health hospitals and self-help groups. These treatments complemented each other, and practitioners across all three shared the understanding that the best treatment for alcoholics was to encourage them to become abstinent and remain abstinent for the rest of their lives, as the Danish physician Erik Jacobsen had declared before a Japanese audience in 1959. During the period of post-war chaos, views on alcoholism focused on its connection to family and gender dynamics, which were closely linked to poverty, violence and family tragedies. Early activists, who intended to improve the position of women and children, were involved in the passing of legislation that was aimed at the control of alcohol consumption and the treatment of alcoholics. The 1961 Drunkenness Prevention Act led to the establishment of a centre for alcoholism at the National Kurihama Hospital, where the first rehabilitation programme for alcoholic patients (the ‘Kurihama method’) was implemented. This was a place where married men experiencing alcohol dependency were isolated from their wives and children in order to take part in a variety of therapies before being sent home within three months.

Apart from medical programmes in psychiatric institutions, a variety of approaches to alcoholism such as AA, Danshukai and Naikan were available. The former two developed as group therapies and the latter as an approach that focused on the individual. These approaches, while being influenced by Western psychotherapeutic practices, developed alongside modernisation, Westernisation and social change during a period of rapid economic recovery in Japan after the war. The Japanese traditional family structure that supported industrial society and high economic growth also played a decisive role in the emergence and management of Danshukai. Danshukai, the most popular self-help group in Japan, was originally inspired by AA and group therapy in America, which emphasised a horizontal relationship between the participants. However, conforming to the Japanese socio-cultural context, Danshukai was based on vertical relationships between members and on the power structure of traditional family gender politics between husbands and wives. On the other hand, the Sapporo psychiatrist Saitō Toshikazu evaluated Danshukai’s wider societal and political influence in positive terms.⁷⁵ According to him, its close connection with the Nihon Kinshu Dōmei (Japan Temperance Union) and its power as a social movement facilitated the passing of important legislation, such as the Basic Act on Measures against Alcohol-Related Harm to Health in 2013.

Increasingly, some groups of psychiatrists began to pay attention to approaches that focused on the individual, such as Naikan. Naikan had been invented in the 1940s and applied to the treatment of alcoholism from the end of the 1960s onwards, but in the context of the recent worldwide boom of mindfulness, some authors refer to the similarities between these approaches.⁷⁶ A common goal is said to be to strengthen self-affirmation through self-insight. It is very probable that the current trend emphasising individual insight over group dynamics has influenced Danshukai’s loss of appeal, leading to its decline. The emphasis on individuals over groups is also seen in the change of medical programmes in the National Kurihama Hospital.⁷⁷ With the increase of patients who are not amenable to group activities, the focus of its rehabilitation programme has changed from the use of group dynamics to the treatment of individuals by means of cognitive behavioural therapy, for example.

Japan’s alcohol consumption peaked in the mid-1990s and since then has continued to decrease gradually.⁷⁸ However, according to estimates by the Ministry of Health, Labour and Welfare, the number of alcoholics treated both within medical institutions and in the community over the past thirty years has been stable, at around 40,000.⁷⁹ With Japan’s rapidly ageing population and changes to the family structure, such as an increasing number of single-person households, the approach to alcoholism has changed. Moreover, the worldwide upsurge in pharmacotherapy, in particular in the shape of Nalmefene, may make moderate alcohol consumption possible and change the focus on complete abstinence that has been so prominent among Japanese therapists and self-help groups.⁸⁰