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Psychologist Ayako Ishida Talks about Mental Health in Japan

Ayako Ishida has been a psychologist in Japan for eight years. Highly motivated in helping others, she works as a school counselor and as a clinical psychologist at a hospital. Through helping her clients on a personal level, she is also a witness of social issues and changes in Japan’s society. In 2020, on top of dealing with the consequences of the pandemic, Japan has seen its children’s suicide rate hit a record high. Read on to learn about Mrs. Ishida’s take on these events, what her job consists of, and the current situation regarding mental health in Japan.

Being a Psychologist in Japan

Can you explain the path that has led you to become a psychologist?

When I was a university student, at first, I was not interested in becoming a psychologist. Originally, I wanted to become a researcher in social psychology because I wanted to work inside a university, and I had some interest in this field. Later, I realized being a researcher is a hard job that requires solid knowledge of statistics. 

The main reason I started wanting to become a psychologist, though, comes from the fact I had to study many aspects of psychology. It led me to want to work directly with clients. My university had a great clinical psychology department, with many teachers who were actively working on the field. They had a great influence on me, especially a teacher from a seminar I attended, who became a role model for me. The way she was acting with us and how broad-minded she was resonated with me. She accepted us as we were, no matter what our values or our culture were.

When I was in elementary school and high school, there were no school counselors like today, and I did not have the experience of meeting a psychologist. But when I was a master’s degree student, I got sick and had to be hospitalized. There, a psychologist came to listen to me almost every day, and I realized I had made the right choice in pursuing a career as a psychologist.

In Japan, what are the certifications required to be a psychologist? 

I own two certifications: the clinical psychologist certification, and the licensed psychologist certification.

The Japanese clinical psychologist certification was created in 1988, about 30 years ago. About 40,000 people in Japan own it. It is a private certification, not a national one. However, since it has been around for about 30 years, it has gained trust and recognition. If you want to apply to jobs to work on the field, you will need it. To have the right to apply for this certification’s exam, you need to have studied two years for a master’s degree in psychology.

On Japanese television, you will often see people labeled as “psychological counselors” or “psychotherapists,” and the clinical psychologist certification proves that contrary to them, you have undergone training and passed an exam. It shows your knowledge and your experience.

The licensed psychologist certification started three years ago, in 2018. It is a national certification. They have made it easy for people to apply for this exam for the first five years, so the number of people who own it is already close to the clinical psychologist certification. I think there was a need for it, especially in medical care, welfare, and judiciary institutions. 

The idea is to support the clients so they can analyze their problems and figure out the best way to solve them by themselves.

What about the certifications for “psychological counselors” and “psychotherapists” that appear on TV?

Their job is different from ours. A certification for psychological counselors does exist, but you do not need to study for a master’s degree in university to obtain it. 

What is the difference between a psychologist and a psychiatrist?

It is a question I am often asked. The main difference is that psychiatrists are allowed to prescribe medication, while psychologists are not. Psychologists study about medication too, but do not have the right to prescribe it.

Psychiatrists are like physicians in the sense that their role is to cure the illness you are suffering from, for example, depression.

A psychologist’s job is not really to cure you. Their role is to help your self-actualization while respecting your set of values. Another big difference from doctors is that fundamentally, we almost never give advice or instructions. Because we do not believe there is only one proper answer to people’s problems. The idea is to support the clients so they can analyze their problems and figure out the best way to solve them by themselves. 

Taking Care of Kids and Cancer Patients

Portrait of Ayako Ishida

You work in two different environments: in a hospital and in schools. Can you tell me the common points and differences between the two?

The hospital I am working at is specialized in cancer. My clients are the patients of this hospital who suffer from cancer, their families, and sometimes the families of patients who have passed from their illness.

You may think most of my clients come to me because they are worried about their cancer. Of course, this happens, but most of the time, they need advice about their jobs, their hobbies, or their families that have been affected by their cancer. Family problems, especially, seem to come into light a lot when someone suffers from cancer, because the familial balance changes when one has to undergo treatment. I also help people for whom treatment is not possible anymore, to figure out how they want to spend the time they have left. When problems between siblings or parents and children appear in relation to the illness, my clients often ask me, “Can you hear me out about something else, too?”  They often come see me to talk about problems other than the illness itself.

I try to make my clients understand that their feelings are valid.

I would also like to talk about something I noticed regarding the family of people who passed away. You may think that people who have lost their lifelong partner come to me because they are devastated by sadness. However, in about half of the cases, this is not true. For example, some women have lost their husbands, but the latter was domestically abusing them. So, their loved ones keep telling them, “You must be so sad!”, when in fact, they feel relieved, and they do not know how to process these feelings. They tell me things like, “I have supported him until the end, but now I wonder where my life has gone.” 

Sometimes people are shocked by the discoveries they learn when they find notes written by the deceased, and it creates complicated feelings. It is easy to think that when someone dies you ought to feel sad, but I try to make my clients understand that their feelings are valid.

Regarding schools, I currently work in an elementary school and in a high school. 

In high school, the students come to me by themselves. It is extremely rare that their parents come for advice. Most of the time, it is about troubles with their friends, or the fact that they do not want to go to school. There are also kids who are concerned because they are not very good in class, or have trouble concentrating. Of course, there also are familial problems. If a kid asks me to keep some information from their parents, I make sure to respect that. I also ask for their permission to tell the teachers.

Kids in elementary school hardly come to my office. I go to every class and introduce myself so that kids know they have someone to talk to if they have a problem. They sometimes find me during recess, quickly talk about their troubles, and go back to playing [laughs]. Most of the time, the request comes from the kids’ guardians. They are worried about their kid’s development, or their behavior at home, for example, because they play video games too much, do not want to do their homework, or will not listen [laughs]. Some cases are about the kid not wanting to go to school.

The common point between my two working environments is that it is crucial to create bonds with the doctors and the nurses in one case, and with the teachers in the other case. I am at the hospital three days a week, but in each school only one day a week. The people who know the kids best are the teachers. I only have a partial view of who the kids are, so it is very important to have good relationships with the teachers so we can all support the kids together. 

However, I am making sure not to give instructions to the teachers, the doctors, or the nurses. I explain the situation to them and let them judge which is the best attitude to take.

The key is to use all possible resources to help this person feel better. For example, by looking for extra people or services to give them support.

Wooden statues representing two people are sitting on chairs. One is talking while the other is listening.

What are you especially careful of when listening to your patients?

I think all psychologists do this, but I make sure to be careful not only of the words my clients tell me, but also of the meaning behind their words, the tone of their voice, how they breathe, their facial expressions, their gestures, and attitude. We learn how to do this during our studies.

This is why counseling people on the phone or online is very difficult. For example, even if you can see the other person’s face online and they are smiling, they might be clenching their hands and you cannot see that on the screen. 

I also try not to be too affected by my clients’ sadness and suffering, because I get easily affected. Although, there are times when it is hard to hold back my tears. There are also times I feel anger towards my clients because they say things that I find shocking. This actually can help me understand my clients’ problems. For example, if they say, “People around me don’t understand me!”, I can guess that maybe it is because they express things in a way that is hard to accept for others. If I get annoyed when I listen to a client, chances are people in their circle are feeling the same. [laughs] I try to focus on the movements of my own mind too.

If we take the suffering of our client too much for ourselves, we tend to want to do everything alone for this person. I guess it is true for all jobs that aim to help people face to face. The risk is that by doing all the efforts alone, you end up being burned out. The key is to use all possible resources to help this person feel better. For example, by looking for extra people or services to give them support.

When I travel, I have a look at the local culture, especially at the relation with life and death.

In my everyday life, I try to be in contact with people as diverse as possible. It is not possible to do a good job as a psychologist if you have narrow-minded values. It is important to understand that there are diverse ways of thinking in this world. I have a lot of hobbies because I believe one’s field of vision cannot broaden by only working all day long and just doing chores. For example, I play music in an orchestra, I scuba dive, and I like to travel alone and meet people from diverse areas and countries. Thanks to that, I can hang out with people of all ages, cultures, social backgrounds, and occupations. When I travel, I have a look at the local culture, especially at the relationship with life and death, which is an important topic for me who is working in a hospital specialized in cancer. 

Interestingly, I have found out that there are some common points between counseling and when I play violin in an orchestra. When we play, we have to read our music sheet, but also listen to the other instruments, look at the conductor’s baton, all the while expressing the music. In a similar way with my clients, I also must be attentive at how the spectators listen to us, and try to read their feelings. In an orchestra, you do not only use your head, but also your heart, and it is a valuable experience that I am trying to apply in my job.

Skipping School and Suicidal Ideation: The Troubles Faced by Japanese Kids

Middle schoolers in school uniforms

Even if I go with them to the classroom door, they tell me, ‘I don’t know why, but I just can’t go in.’

You have mentioned the kids not wanting to go to school. What are the reasons behind this?

Before, we used to have this image of kids not wanting to go to school because they are being harassed, or because they are not good at studying. These were clear reasons that could be solved. Recently, the very worrisome problem is that even if we ask the kids why they do not want to go to school, they tell us they do not know why. They are very difficult cases!

Some high schoolers tell me they are not able to enter the classroom. Even if I go with them to the classroom door, they tell me, “I don’t know why, but I just can’t go in.” They are not being harassed, they have friends they can talk to, and they are not unable to study, but it is just impossible for them to go to school. They know they should be studying, and they want to, but they just cannot. They seem to not be able to put their suffering into words.

They must be feeling some sort of stress, but they have no clue why. Because of this, the teachers do not know what to do to help. They try a lot of different strategies, but with no success. With elementary schoolers, we can involve the parents and usually, we manage to solve the situation. It is much more difficult with high schoolers, which is a problem because if they do not attend classes sufficiently, they may not be able to graduate. In most cases, they end up having to give up on their studies. 

We could make kids write how they feel, make them learn to put it into words.

Maybe these kids are lacking the vocabulary to express their feelings. They use single-word expressions such as “darui” [I feel heavy] or “mendokusai” [it’s annoying]. These are ambiguous expressions, too, in a very typical Japanese way. I think kids should be encouraged to express their feelings more. I feel like Western kids are better at this. Japanese people are very bad at developing self-appeal [laughs].

We could make kids write how they feel, make them learn to put it into words. I do not want to blame social media, but when I look at the messages that Japanese teenagers send to each other through messaging systems, they are all shorter than one line, and often reduced to a single word. And apparently, they are not able to write emails. They are very good at expressing themselves with pictures and videos, which is a good thing, but words are lacking in their culture.

There are many children who have wrist cuts or have been abused who describe their body being cut or beaten as ‘not painful.’

Another factor that prevents children from being able to put their thoughts into words is the lack of experience in translating their own senses into words. When children are young and beginning to learn how to speak, it is helpful for adults to help them translate their senses into words. For example, if an adult says, “It’s fluffy,” when touching a dog’s fur or, “It feels good,” when bathing in the wind, the child will acquire words.

However, when sensations and words do not match, it becomes difficult for children to verbalize their own feelings. For example, when a child falls down on the street, we may say, “That hurt.” But when we say, “It doesn’t hurt! Hurry up and stand up,” the truth is that their mind and body are in pain, but they are being labeled as “not hurting,” so they gradually lose their sense of self. In fact, there are many children who have wrist cuts or have been abused who describe their body being cut or beaten as “not painful.” This is probably because they can’t protect themselves physically and mentally without doing so…

In today’s world, where we have fewer and fewer experiences with our five senses to begin with, it seems very difficult to get children to talk about their feelings when their language and emotions do not match.

Are there other cultural or societal problems you have noticed doing your job?

I do not know if it is specific to Japanese people, but a majority of people are having troubles with their family. It may be because there are fewer and fewer children in Japan, but the distance between parents and children is becoming too close. For example, even when some people are already adults, their mothers still tell them what to do, or what jobs they should be applying to even though they want to do something else. 

I have had a client whose mother was so worried that she went with them to their company’s entrance ceremony for new recruits! Some parents go with their kids to the company recruiting exams. This can create malaise for the children. 

I feel that parents who act this way have a thin emotional barrier with their children, want to know everything about them, and are not able to keep an appropriate distance. They mix up their own anxieties with their children’s anxieties, and talk about their own worries as if their children are supposed to worry about them. However, when you actually ask their children, they have completely different ideas from their parents. 

Though, when the children don’t act the way the parents want to, the parents themselves become anxious, which leads to interference. This may not be a problem when their kids are still young, but it becomes one when they are adults. In recent years, such parents have been labeled as “toxic parents,” and I feel that many people suffer from this kind of relationship.

Girl sitting in the corner of a room looking depressed.

2020 saw the highest rate of suicide among Japanese children. What could explain this tendency?

I was very surprised and saddened by this news, especially because the Japanese suicide rate as a whole is decreasing. I have talked about it with colleagues and doctors, and we agreed it is difficult to explain why this is happening.

However, maybe for kids, dying has somewhat become something easier. More generally, kids are taught that it is okay to run away when facing a difficulty. For example, they are told that even if they quit school because it is too hard, they will manage in life. In that specific case, I could agree, but children should be told that even if they want to run away, dying should not be an option. There seems to be this idea going around that dying will make you feel better.

I think adults need to convey the message of ‘It’s good that you are alive,’ more.

Also, in my experience, almost all children who complain of wanting to die say that they have no reason to live and that they are not needed. Many of them feel that their parents are not interested in them, that they are not necessary to them, that they are worthless, and that there is no one who needs them, so they feel isolated. They do not have the confidence to live without someone’s help, without being able to study, or without getting likes on social media. I think adults need to convey the message of “It’s good that you are alive,” more and more, instead of “You should be doing something.”

The kids tell me they have friends but are afraid to be seen as ‘heavy’ if they talk about their problems.

Kids’ resilience and power to solve hurtful problems are changing. Parents can be overprotective to make sure their kids succeed in life. However, once the kids face problems, they do not know how to manage and cannot think of anything else than to escape.

The same problem exists among young adults. We hear more and more stories of young recruits who quit after a few days of working because their superior told them a negative remark. It is important to learn to make mistakes from a very young age, and to be able to stand up again when you fall. If kids walk the road of life without encountering any pothole, they will not be able to deal with them later.

Kids also seem more isolated than before. Young people are connected with a lot of people through social media, they have hundreds of followers, but are having trouble finding someone to truly listen to them. Many of my clients tell me they have no one to talk to. They tell me they have friends but are afraid to be seen as “heavy” if they talk about their problems. They are worried their friends will become distant. If only they had one person to talk to, may it be a friend, a teacher, a family member, or a school counselor, things would change greatly. 

Many things in our world are not positive. It is important to understand that it is okay to feel negative emotions such as sadness, or even hate.

Lately, people in the West are becoming increasingly aware of toxic positivity. Do you think it may be one of the reasons why these kids do not dare open up about their negative feelings with their friends?

Maybe. If you look at social media, the content is very happy most of the time. It is very natural that people only want to share positive content. Teenagers may not be fully aware that the people they are looking at on social media are having their own share of troubles too. They may be unconsciously pressured to look happy all the time. On top of this, they may feel lonely and misunderstood, thinking they are the only ones to be suffering like this. 

Many things in our world are not positive. It is important to understand that it is okay to feel negative emotions such as sadness, or even hate. I wish society was more tolerant towards this, and that everybody can find ears that will listen to them attentively, without dismissing their feelings by saying things such as, “Do not say such depressing things!”

I do as much as possible, you could even say I do too much. But, thanks to this, none of the kids I talk to have crossed the line.

In Japan, there is a saying that people who say they want to die do not commit suicide. It is not true at all. It is their last way of asking for help. If someone says they want to die, you should listen to them closely and show that you acknowledge how they feel. You should not dismiss it by saying, “Don’t say such things!” Only then can we start to try to find a solution all together.

There are a lot of high schoolers who sincerely want to die, and even look for ways to kill themselves on the internet. When I talk with such kids, I tell them that it is okay not to think about anything else, but just concentrate on staying alive. I also make them promise me they will be there for our next appointment. I also ask for support from the teachers and the families. I do as much as possible, you could even say I do too much. But, thanks to this, none of the kids I talk to have crossed the line.

Mental Health in Japan Today

People walking busily in a train station

Even if Japan did not experience a strict lockdown like other countries, the pandemic has caused people to become isolated.

Mental health is degrading in many countries because of the coronavirus pandemic. What is the situation in Japan according to your experience?

Last year, from March to June, schools closed, and I was very worried about the consequences of this on the kids’ mental health. However, there were some good sides to it. Actually, I noticed kids becoming healthier because they could rest. Many kids who do not want to go to school do not like being in groups and participating in school events, so the stay-home period felt good to them.

First year elementary school kids often cry on their first day of school, but this time, none of them cried, probably because they had been able to spend a lot of time with their mothers. There was no harsh transition between kindergarten and elementary school.

However, even if Japan did not experience a strict lockdown like other countries, the pandemic has caused people to become isolated. It is especially true for elderly people, for whom social interactions are made mostly with friends of the same age. Elderly people cannot use online chat tools to keep in contact as easily as younger people. Feeling isolated, many of them have lost motivation and felt depressed. It is even more true for people who are usually very active socially. 

Some kids have seen their familial balance change drastically. In some cases, it is because one of their guardians has lost their job. In other cases, because of remote working, some kids have seen their father, who used to usually work at the office, be at home all the time. I personally was not too affected, but I have heard other school counselors say that their schedules were overbooked. 

After living in Japan for 10 years, I feel like that compared to the West, mental health issues are still sort of taboo in Japan. People do not openly discuss it or seem ashamed to say they are seeing a psychologist or a psychiatrist. Am I wrong?

About 20 years ago, it was very difficult to talk about mental health, but today it has become much easier. People are becoming more open about their mental health on social media. Celebrities, too, play a positive role. For example, a local boy band singer has recently explained that he stopped his activity because he was suffering from panic disorder. Thanks to this, young people are very willing to go and see a psychiatrist when suggested to. Many high school kids tell me they want to see one, but their parents will not let them.

There is a generational gap regarding mental health, and there is also a gap between people living in cities and people living in rural areas. In Tokyo, there are a lot of mental health clinics, almost one near each station. There is a huge number of psychiatrists and psychologists. 

In rural areas, there are fewer mental health clinics, and when someone goes there, it immediately becomes a rumor in town. In rural areas, especially for elderly people, there is still this image that people with mental health trouble are just “crazy people.” It is reminiscent of a time where such people would be locked up.

Many Japanese people think that you can overcome anything by having guts, and mind problems can be solved with mere fighting spirit.

Social media plays a positive role regarding mental health, but there is also a negative side. There is a phenomenon of young people who publicly display videos of wrist cutting or bloodletting on Twitter. Such people are called “mental cases” by others, and the Japanese slang for it is “menhera, which comes from the words “mental health.” So, there is this image that people who have mental health troubles, or those who go to see a psychologist or a psychiatrist, are messed up people who should not be approached.  

Culturally, Japanese people tend to avoid talking too openly about sad things. Many Japanese people think that you can overcome anything by having guts, and mind problems can be solved with mere fighting spirit. Because of this, many people think the problem is that they are too weak, or are ashamed to go and talk to a professional.

I hope that with time, more people will understand that mental illnesses can be cured just like body illnesses and should be treated the same way. 

A Message If You Are In Japan and Struggling

A man is talking to a psychologist

You do not have to deal with this alone.

What advice would you give to foreigners in Japan who feel they need help regarding mental health?

If you live in an urban area and there is a community of people from your country, it may be a good start to ask people inside the community for recommendations. It is always better if you can talk to someone from your country, not only because of the language, but also because they will understand you better culture-wise.

In Tokyo, many clinics offer services in English too. I have also seen clinics where they could speak Chinese, Korean, German, or Portuguese. Some clinics are even specialized in offering counsel to foreign nationals, and they are not necessarily more expensive.

If you have kids and they are attending a public school, the school counselor may speak your language, especially if a lot of kids from your community attend the school. School counselors who can speak another language are often dispatched to schools where kids from other nationalities may need them.

If you are a foreign student, try to see your school’s counselor. Most of the time, they can provide someone who speaks English. 

Since the pandemic, online counseling has developed a lot, so if you cannot find a solution near you, maybe someone living in your home country can offer you counsel online. 

If you are feeling bad or are suffering, please do not feel ashamed. These feelings do not lie. Please tell someone, anyone, about it. They will probably find someone to help you. You do not have to deal with this alone.

You Are Not Alone

During this interview, I could feel Mrs. Ishida’s dedication to her work and her clients. This deduction extended to me, as she thought very seriously before answering each of my questions, making sure to give the most accurate information possible. 

Mrs Ishida’s dedication goes further than her workplaces. During her travels, she works on ways to keep an open mind and understand other ways of thinking, and when she plays music she trains herself to read other people. I guess this is how you can recognize her path has led her to her vocation of being a psychologist. I felt grateful meeting someone who spends most of her time and energy helping others.

Since 2020, times have been harder than usual for a lot of people. A few months into the pandemic, I realized that many people in my inner circle were struggling—myself included. Things were especially tough for people who were already dealing with mental health or personal problems prior to that, and self-isolation did not help. 

In times of crisis, it is easy to feel disconnected from the local society, or misunderstood by the people around us. However, even if you feel like you are alone, be reminded that that is not the case. Professionals like Mrs. Ishida are here to lend you a careful ear, and to give you the tools to overcome the suffering you are facing. Do not hesitate to reach out. You are not alone.

If you are struggling, feeling suicidal, or worried about a loved one, you can reach out to these hotlines.

Born in France, I've been living in Japan since 2011. I'm curious about everything, and living in Japan has allowed me to expand my vision of the world through a broad range of new activities, experiences, and encounters. As a writer, what I love most is listening to people's personal stories and share them with our readers.