International Journal of Mental Health, vol. 41, no. 2, Spring 2012, pp. 8296.

2012 M.E. Sharpe, Inc. All rights reserved. Permissions: www.copyright.com

ISSN 00207411 (print)/ISSN 15579328 (online)
DOI: 10.2753/IMH0020-7411410208

Setsuko Hanzawa

Toward an Effective Family Support

System in Japan
From Research on Family Caregivers and
Schizophrenia Patients in East Asian Countries
ABSTRACT: Japan has the highest admission rate of patients with schizophrenia
in the world, thus emphasizing the need for building relationships between psychiatric hospitals and resources for community living. Confucian ideas and the
tradition of providing care to family members are central to cultures and these
socio-cultural beliefs regarding family care in East Asian countries may seriously
influence the experiences of family caregivers. This article reviews and draws
conclusions from three Japanese and Korean studies that found that patients with
schizophrenia are likely to isolate themselves from society, thus avoiding contact
with nonfamily members and that these behaviors are correlated to a greater
caregiver role and an increased caregiver burden. Japanese families of patients
with schizophrenia are likely to perceive a stigma from others and are also likely to
think that schizophrenia should be hidden from others in the community. Japanese
families tend to adopt resignation as a strategy for coping with the strong stigma
attached to schizophrenia. Additionally, Japanese families are more resistant to
allowing others to care for family members with schizophrenia. Hence, there is a
close tie between schizophrenia patients and their families. These findings suggest
that Japanese mental health strategies should favor providing effective support

Setsuko Hanzawa, RN, Ph.D., is at Jichi Medical University, School of Nursing in Tochigi,
Japan. This article was supported by a Grant-in-Aid for Scientific Research (KAKENHI) (B)
(22406036) (201012), The cognitive behavioral characteristics among family caregivers
of patients with schizophrenia comparison between Japan and Korea, from the Japanese
Ministry of Education, Culture, Sports, Science and Technology (MEXT).
82

summer 2012 83

for reducing caregiver burden and eliminating reliance on inappropriate coping

strategies (i.e., resignation and unwillingness to accept support from outside the
family) for family members of schizophrenia patients.
Since the introduction of community-based rehabilitation services, research has focused on caregiver burden among families of patients with schizophrenia to identify
factors in both patients and families that contribute to such burdens. Patient-related
clinical and psycho-sociological factors reported in the literature include clinical
characteristics of illness, severity of positive symptoms, number of hospital admissions [14], duration of illness [1, 3], social behaviors [1], social functioning [4,
5], frequent care needs [1, 3], occupational status [5], and patients awareness of
their mental disorder [6]. In contrast, family-related psycho-sociological factors
include living with the patient [3], expressed emotion [710], coping strategies
[11], family member awareness of the mental disorder [6], assistance from professionals and social support [1, 5, 12, 13], and insufficient social resources [14].
Several reports have described the burden of care as dependent on the relationship
of the family caregiver to the patient (i.e., parent vs. spouse) and the caregivers
gender [8, 6, 15].
Over the last several decades, Glanville [16] has produced two important lines
of research involving families of persons with severe mental illness: One focuses
on family burden and the experience of caring for an ill relative and the other
investigates family communication patterns and interactions (e.g., expressed emotion). These lines of research have led to the development and testing of clinical
models of family psycho-education. Certainly, some of the issues suggested by
previous research (i.e., family caregivers awareness of the mental disorder, more
positive attitudes toward the patient, patients awareness of the mental disorder
and improved social functioning) could be improved through patient and family
psycho-education. Other issues raised in previous research (i.e., increased social
support for caregiver families, fewer hospitalizations) [16] might not be improved
through psycho-education for patients and families alone.
In Japan, patient- and caregiver-related psycho-sociological factors have been
repeatedly reported as the primary factors associated with caregiver burden. Examples of such psycho-sociological factors are assistance from professionals and
social support [13], expressed emotion [9], insight and recognition of the disease,
caregiver gender [6], and insufficient social resources in the community [14].
Therefore, the family relationship and the environment of support around patients
and families in the community may be associated with caregiver burden and inappropriate family coping strategies.
In the east Asian countries, socio-cultural background (i.e., the caregivers
gender) seems to be related to caregiver burden. A Japanese study of east Asian
countries reported that mothers of persons with schizophrenia express their emotions
more strongly, are more likely to expect patients to act productively, and are more
negative toward patients leisure activity as compared to other family caregivers

84 International Journal of Mental Health

[17, 18]. Mothers often undertake the role of primary caregiver for their adult
children with disabilities, even if they are over 20 years old. Mothers may be more
likely to express emotion strongly because of traditional family gender roles (i.e.,
women are more suitable for the role of caregiver for a child or disabled person
than men), and it is typically a mothers responsibility to care for a family member
with schizophrenia even when there are not sufficient vocational rehabilitation
services in the community.
In the first caregiver burden study [19], the authors identified and evaluated
factors contributing to mother caregiver burden. Multiple regression analysis revealed that social interests and resignation as coping strategies among mothers
exerted significant and independent effects with respect to caregiver burden. Little
efficacy and hopelessness of social inclusion may exist among family members of
patients with schizophrenia.
East Asian countries (Japan, Korea, and China) based primarily on Confucian
ideas have traditionally emphasized the importance of providing care for dependents. Thus, familial caregivers are evaluated with regard to typical social and
cultural values. Persons without a familial caregiver are more likely to be evaluated
as a pitiable person, and thus a pitiable person living alone with a disability can
obtain social support in the community (i.e., home-help services and home-visit
nursing). For example, the family of a person with schizophrenia and an elderly
mother with dementia would be able to obtain home-help services if the mother
was unable to get around the home.
Interestingly, at present in Japan, two causes for involuntary hospitalization are
allowed by the Law Related to Mental Health and Welfare of the Person with Mental
Disorder. One is involuntary hospitalization for the purpose of treatment and care
for a person who is deemed likely to hurt himself or herself or others because of
mental disorder judging from abnormal behavior and other circumstances. The other
is hospitalization for medical care and protection, which is for the treatment and care
of a person who is judged to be mentally disordered, based on the examination by
the designated physician, who needs hospitalization for medical care and protection.
Hospitalization for medical care and protection, which requires the familys consent
instead of the patients, has been allowed since 1950 under the Mental Hygiene Law.
Furthermore, family caregivers are obligated to (a) protect the person with a mental
disorder, ensure treatment, and protect his or her proprietary interests, (b) cooperate
with the physician to ensure that the person with the mental disorder is correctly
diagnosed, and (c) comply with the physicians instructions to ensure medical care
for the person with the mental disorder. Therefore, family members of people with
mental disorders have experienced guilt related to involuntary hospitalization for
many years. Additionally, the family member with the mental illness often blames
the family for giving consent. Therefore, involuntary psychiatric hospitalization
leads to complex family relationships in Japan, especially when the patient has
little insight into the seriousness of the illness during the acute delusional stage of
schizophrenia and later forgets these situations.

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Regional and Socio-Cultural Differences in East Asian Cultures

Recently, the factors influencing the extent of caregiver burden have attracted attention, and patient variables, caregiver characteristics, and regional differences
have been identified as predictors of caregiver burden [20]. Caregiver burden can
also reflect regional differences regarding patients socio-economic situations and
family support in European countries [21] as well as the provision of rehabilitative
interventions for patients [22]. Roick, Heider, and Bebbington [23] reported that the
burden placed on family members of people with schizophrenia may be influenced
not only by patient and caregiver characteristics but also by national differences
in the provision of mental healthcare services. This assumption was evaluated by
comparing Germany and Britain, two northern European countries that differ appreciably in their provision of mental health services. Even after controlling for
patient and caregiver characteristics, British caregivers reported a significantly
higher level of burden than German caregivers [23]. In another comparison study,
a higher burden was observed in Italy and Britain as compared to the Netherlands,
Spain, and Denmark as a result of differences in the provision of mental healthcare services [24]. Differences in caregiver burden could be caused by cultural
characteristics, as cultures may differ in their appraisal of mental illness, ranging
in attitude from acceptance and integration into society to stigmatization. Religious
beliefs, beliefs regarding the origin of mental illness, and societys appraisal of the
caregivers role also play a part [24].
In addition, as the vast majority of previous studies have been conducted in
Western cultures, it has been difficult to apply their findings to family caregivers in
Asian countries. In a sample of caregivers of family members with schizophrenia
in Japan and England, Nomura Inoue, and Kamimura [25] reported that expressed
emotion did not correlate significantly with caregiver burden, and a decreasing
tendency in caregivers positive and negative emotional reactions toward family
members, particularly critical comments in the Japanese sample, was observed.
East Asian cultures based primarily on Confucian ideas have traditionally
emphasized the importance of providing care for dependents. Studies of Chinese
families in Malaysia have demonstrated that the stigma of relatives mental illness
has a strong and pervasive impact on family caregivers, and, as a result, family
caregivers often avoid talking about their relatives mental illness with extended
family or friends to protect their families from losing face [26]. In a recent study
on caregiver burden in China, families who perceived a higher level of caregiver
burden were found to have poorer functioning, a lower health status, and lower
satisfaction with social support, and social support was identified as the best predictor of caregiver burden [27]. These results are similar to those obtained from
the survey of Japanese families [28].
A cross-cultural and cross-national comparison of caregiver burden between
Japan and Taiwan showed that Japanese respondents perceived a significantly
stronger stigma for the parents and neighbors of a person with a mental illness

86 International Journal of Mental Health

presented in a vignette than the Taiwanese respondents [29, 30]. Haraguchi

Maeda, and Mei [31] reported that social distance, knowledge of mental illness,
and treatment (medication) for mental illness were all greater in Japan than in
China. The reasons for this finding include the fact that there are many advanced
mental health-care inpatient facilities as well as regional rehabilitation services in
Japan and that Japan formerly had a long-term hospitalization system and hospital
detention policy (people with mental illnesses could be admitted involuntarily to a
psychiatric hospital without violent behavior or suicide attempts) [31]. In contrast,
a recent study of Korea, Japans closest neighbor, indicated that, among relatives
of patients with schizophrenia, those with less knowledge exhibited more inappropriate coping strategies and higher burdens [32].
In Japan, where the institutionalization rate for schizophrenia patients is the
highest in the world, the number of psychiatric beds has not decreased. Meanwhile,
in Korea, a steady increase in the number of psychiatric beds has been observed
over the past 10 years [33]. However, in northeast Asian countries, little is known
about the correlation between caregiver burden and socio-cultural factors, which
may differ from country to country in the appraisal of the caregivers role and coping strategies. Therefore, it is important to compare Japan and Korea to identify
differences in socio-cultural backgrounds that could contribute to differences in
caregiver burdens in these two countries.
The following research points regarding intercultural aspects formed the focus of
the study. First, the tendency for Japanese families to exhibit decreased emotional
expression toward family members as compared to Korean families was explored.
Second, differences in religious beliefs and beliefs about the origin of mental illness and in appraisal of the caregivers role were identified through a cross-cultural
comparison of Japan and Korea, emphasizing their histories of hospitalization and
cultural differences.
In the second caregiver study [34], members of the Federation of Families of
People with Mental Illness in Japan and Korea were recruited and evaluated. Several
differences between patients in Japan and Korea were observed. For example, the
proportions of Japanese and Korean patients who were frequently hospitalized (at
least three times) were 34.3 percent and 59.8 percent, respectively. Clearly, Korean
patients with schizophrenia were hospitalized more frequently over short periods
of time. There were also differences between the two countries in social activities
over the past year and in the levels of living skills and care needs. Korean patients
had more opportunities to go outside during the day and exhibited less impairment
in the activities of daily living as compared to Japanese patients. However, Korean patients were hospitalized more frequently, and their families more strongly
encouraged social participation. A multiple regression analysis in a previous study
identified the number of hospitalizations in the previous three years and kinship
(mother/father/other) as significant predictors of caregiver burden [35]. The results
of the second caregiver study did not identify the total number of hospitalizations in
the previous year as a significant predictor in either country; however, the patients

summer 2012 87

social function and care needs were both identified as significant predictors of
caregiver burden in both Japan and Korea.
The results of the second caregiver study also suggest that, when compared to
Korean families, constraints on the choice of caregiver in Japanese families (I
want care to be provided only by family members as much as possible) was significantly greater. Furthermore, in both countries, the family caregiver burden was
significantly correlated with awareness of the fact that the individual seems to feel
uncomfortable with being cared for by someone outside the family. Thus, patients
with schizophrenia in both countries are likely to avoid contact with nonfamily
members and isolate themselves from society, and these factors are correlated to a
greater caregiver role and an increased family caregiver burden.
In a study comparing five European countries, regional differences were identified in caregiver burden and support inside and outside the family [11]. The results
of the caregiver study demonstrate slight differences in independent factors for
caregiver burden between Japan and Korea. In Japan, families who agreed with
the statement The individual seems to feel uncomfortable with being cared for
by someone outside the family were more likely to have a greater caregiver
burden.
In Korea, family members are more likely to reluctantly allow someone outside
the family care for them, and thus, their family caregiver burden is lower. In the
latest study, about 70 percent of Korean families did not have someone who could
provide care, which was a higher proportion than that observed in Japan. The results
from Korea suggest that, when other family members also think that a patient with
schizophrenia should be cared for by family, family members are more likely to
collaborate to reduce caregiver burden. It might be difficult for family members to
find caregivers who can provide care on behalf of the family, despite the fact that
Confucian ideas and the tradition of providing care to family members contribute
to the reduction of caregiver burden.
The present results demonstrate that, while caregiver burden is high in both
Japan and Korea, patients and family members have a strong desire to restrict care
to family members. This issue should be discussed further to reduce family caregiver burden, especially in relation to the quality of community mental health-care
services. For example, general practitioners, home-visit nurses, home-help service
providers, mutual support group members, other outreach services, and integrated
assertive community services should provide advice for families having difficulties finding treatment and should suggest coping strategies for patients, especially
during critical periods of relapse. Early intervention may be an effective form of
support for the first episode of schizophrenia.
Family Stigma and Caregiver Burden in East Asian Countries
The public endorsement of stigma affects many people, with four groups being of
special importance: people with mental illness, their families, service providers,

88 International Journal of Mental Health

and the general public. Perhaps of greatest concern is the harm that public stigma
causes people who are labeled as mentally ill, but their family members and friends
are also affected [36, 37]. Published research has reported on public stigma [38],
family stigma [39, 40], self-stigma (patient stigma) [41], and medical staff stigma
[42, 43].
In Italy, the country with the longest experience with community-based psychiatric treatment, in the 20-year period following the promulgation of the 1978
Psychiatric Reform Law, a study revealed fearful attitudes in most of the general
population toward mentally ill people. Twenty years later, a study of the coping
strategies of resignation and maintaining social interests of families with schizophrenia showed a higher burden of care [11], and now, approximately 30 years later,
respondents who believe that patients with schizophrenia are unpredictable more
frequently report factors such as the use of alcohol and drugs as being involved
in the development of the disorder [38]. The concept of unpredictability is likely
connected to the fear of violent behavior of patients with schizophrenia, and the
familys attitudes toward patients with schizophrenia may have a significant impact
on patients social adjustment and achievement of effective goals [40].
In Japan, the number of psychiatric beds has not decreased in the 20 years
since community mental facilities were implemented across the country; thus, it
is likely that attitudes regarding schizophrenia and its treatment have not changed.
Therefore, the public fear of assault from mentally ill patients has been expressed
through community opposition to the opening of psychiatric institutions, and the
general belief is that these patients should be admitted to asylums. Japan is one
of the few countries with almost no experience with psychiatric outreach treatment in the community for relatives of patients with delusional behavior, which
may occur during critical periods of schizophrenia. Previous research shows that
Japanese respondents perceived a significantly stronger stigma for the parents and
neighbors of a vignette case than Taiwanese respondents [40]. The strong stigma
reported among Japanese respondents may be a consequence of the limited experience of the general public with psychiatric patients in the community due to
Japans institutionalization rate for schizophrenia patients, which is the highest
in the world [29]. Although the number of psychiatric beds has not increased in
Japan, a steady increase in the number of psychiatric beds has been observed over
the past 10 years in Korea [33].
Few studies have investigated the relation between caregiver experience and
stigma in families with schizophrenia patients. For example, three out of every four
Mexican-American schizophrenia patients live with their families, and a study of
patient symptoms and attributes has shown a correlation between family care burden
and stigma perception [44]. However, the effects of social stigma perception on the
experience of families of patients with schizophrenia can vary among countries,
depending on socio-cultural environmental factors regarding mentally ill persons.
The relation between burden and stigma in families of patients with schizophrenia
remains unclear. No research has compared Japan and Korea with regard to the

summer 2012 89

burden of care, stigma, or social distance in families of patients with schizophrenia.

In the third family caregiver study, stigma and care burden in families of patients
with schizophrenia were compared in both countries [45].
Korean Caregiver Experiences
While no significant difference existed in the perception of patients being dangerous to others, which is a personal stigma parameter, the family care burden
exhibited a significant positive correlation in Korea. Furthermore, when compared
to Japanese families, Korean families are more likely to believe that schizophrenia
patients are unpredictable, another personal stigma parameter, and care burden is
great for Korean families with great personal stigma (i.e., People with a problem
like Johns are unpredictable and dangerous). Interestingly, in Korea, the family
care burden was great for families who thought that the person in the vignette
was discriminated against by others in the community and families who were not
willing to have the person in the vignette as their neighbor. Further, only in Korea, a significant positive correlation was seen between caregiver burden and the
survey statement If I had a problem like Johns, I would not tell anyone, which
corresponds to the respondents beliefs about other peoples attitudes toward the
person described in the vignette.
These results suggest that it will be necessary to provide support for lessening
the care burden for families with personal stigma in Korea. For example, chronic
schizophrenia patients are thought to be dangerous and unpredictable, and there
are those who are unwilling to live near schizophrenia patients. Additionally, it is
necessary to introduce family counseling programs and provide individual family
support to families who are likely to perceive social stigma, such as those who agree
with the statement If I had a problem of schizophrenia, I would not tell anyone
or families that believe people in the community would be prejudiced. At the
same time, the results in Korea suggest that strategies for lessening stigma in the
local community, such as that exemplified by the statement It is best to hide and
not tell anyone about family members with schizophrenia may eventually aid in
lessening family care burden.
Japanese Caregiver Experiences
When compared to Korea, the relation between stigma perception and care burden
among Japanese families is slightly more complicated. For example, Japanese
families tend to be embarrassed by the behaviors of schizophrenia patients and
report not feeling comfortable around a relative with schizophrenia as compared
to Korean families. In addition, Japanese families are more likely to resist allowing
people other than family members to care for schizophrenia patients and are more
likely to think that schizophrenia patients feel uncomfortable with others entering
his/her house and feel uncomfortable with being cared for by someone outside

90 International Journal of Mental Health

the family. Japanese families appear to be sensitive to schizophrenia patients

tendency of rejecting interactions with others and not wanting to be cared for by
others besides family members at home, which is their safe space. Japanese families
are also resistant to allowing others to take care of schizophrenia patients. Hence, a
close family tie between schizophrenia patients and their families is suggested. The
ratio of families who have access to people outside the family who could provide
care in Japan was greater than half overall; even if families can find someone to
provide care, Japanese families are more likely to care for schizophrenia patients
on their own because they prefer not to have nonfamily members providing care.
In contrast to Korean families, Japanese families tend to believe that other people
think chronic schizophrenia patients are unpredictable and dangerous and that
it is best to avoid them. Japanese families feel that if they had a problem with
schizophrenia, they would not tell anyone and that if a person had a problem with
schizophrenia, he or she would not tell anyone, thus suggesting that their attitude
is it is best to hide schizophrenia in family members from others.
In summary of the third caregiver burden and family stigma study, Japanese
families of patients with schizophrenia are likely to perceive a stronger stigma
from others and are more likely to think that schizophrenia should be hidden from
others when compared to Korean families. Because they are worried about what
relatives and neighbors might think, they are more likely to take care of schizophrenia patients on their own. These findings are in agreement with the cognitive
and behavioral characteristics of decision making by Japanese people (i.e., make
decisions to maintain harmony with others) [46]. However, the results of the latest study show that the differences between Japan and Korea in terms of family
nursing awareness and stigma perception by others do not significantly correlate to
care burden. Interestingly, Japanese families that agreed with the statement Want
to provide care from family members only, without using home help services
experienced lower degrees of care burden.
It is evident that the families of patients with schizophrenia have a more pessimistic view concerning stigma perception from the general public, especially
regarding the ideas that people with schizophrenia are dangerous, unpredictable,
and best to avoid than perceived stigma concerning personal stigma. The findings
of the latest study indicate that family stigma of schizophrenia patients differs
between Japan and Korea, especially regarding perceived stigma.
Family Stigma and Coping Strategies in East Asian Countries
With the current shift to community-centered mental health services, considerable
research on the family burden of caring for patients with schizophrenia has been
conducted in European countries [11]. It has been reported that family burden and
coping strategies can be influenced by cultural factors, and it has been suggested
that family interventions should also have a social focus, with the aim of increasing
the family social network and reducing stigma [11].

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Among northeast Asian countries, research shows that in Taiwan caregiver

anxiety is the highest of the five dimensions of primary family burden, followed by
dependency of the patient, and feelings of shame and guilt. In addition, home and
family provide a person with the strongest sense of belonging and a place to return
to throughout life in Taiwanese society. Therefore, psychiatric patients traditionally live with their families [47]. Similarly, a study reported that approximately 80
percent of psychiatric patients in Japan and Korea live with their families [45].
Pervasive negative attitudes and discriminatory treatment toward people with
mental illness have been well documented in northeast Asian countries, and in
Chinese societies, the particular manifestations of the stigma associated with
schizophrenia are shaped by cultural meanings based on Confucianism. These
cultural meanings are reflected in severe and culture-specific expressions of stigma
in Chinese societies [48]. Yang, Phillips, and Lo [49] recently reported that psychiatric stigma in China is particularly pervasive and damaging, with rates of highly
expressed emotion (family members emotional attitudes) that are generally lower
than rates found in Western countries.
In the second caregiver burden study [34], resignation and maintaining social
interests were identified as coping strategies for the burden of care among mothers
of patients with schizophrenia who were given the caregiver role by other family
members [19]. In Korea, recent research indicates that, among relatives of patients
with schizophrenia, those with less knowledge have more inappropriate coping
strategies and higher burden [32]. Both Japan and Korea are located in northeast
Asia and have cultures based on Confucian ideas, with the tradition of providing
care for dependents. In addition, Japan formerly had a long-term hospitalization
system and a hospital detention policy that involuntarily admitted people with
mental diseases to psychiatric hospitals. Thus, many inpatient psychiatric facilities exist today. Given the stronger tendency for institutionalism in Japan than in
other Asian countries [50, 51], few people with serious mental disorders live in
the community. Consequently, the general public has little chance of coming into
contact with patients with schizophrenia in everyday life [31]. One study showed
that Japanese respondents perceived significantly stronger stigmatization of the
parents and neighbors of a vignette case than Taiwanese respondents [29].
The fourth caregiver burden study compared Japan and Korea in terms of the
personal stigma and strategies for coping with a family member with schizophrenia based on the socio-cultural factors that affect the care experience of families
in northeast Asian countries [52]. The results clarified the similarities and differences in the characteristics of personal stigma toward a person with schizophrenia
described in a vignette and the coping strategies among families who belong to
family support groups in Japan and Korea.
Differences in the attributes of the patients and their families were observed between Japan and Korea, for example, the total number of hospitalizations (a higher
number of hospitalizations was observed in Korea), patients social functioning
and care needs (Japanese patients had poorer functioning and required more care),

92 International Journal of Mental Health

optimal social involvement (the highest level of social involvement was observed in
Korea), and an alternative caregiver in the family (fewer among families in Korea).
Therefore, although Korean patients have a high level of social functioning and
social involvement, they experience more hospital admissions. The results regarding coping strategies also suggest that patient social involvement with family is
better in Korean families and that there are more strategies for coping with patients
social involvement in Korea. In contrast, although the overall scores for personal
stigma were worse for Korean families, the personal stigma score for If I had a
problem like Johns, I would not tell anyone was worse for Japanese families.
Thus, Japanese families of patients with schizophrenia would be more likely to
hide their own mental illness from others as compared to Korean patients, which is
a factor that is correlated with their high degree of resignation as a family coping
strategy. Conversely, Korean families would be more likely to hide their mental
illness through avoidance of a family member with schizophrenia.
These findings are in agreement with the cognitive and behavioral characteristics observed in cross-cultural qualitative studies that have explored the mental
health beliefs and help-seeking attitudes of Korean American parents of children
with schizophrenia [53]. In the traditional Korean culture, a marriage signifies the
union of two families rather than two individuals. Therefore, families of patients
with mental illness worry about the marriage prospects for their other children if
one child has a mental disorder. Furthermore, research shows that Korean families
even object to visits by researchers out of fear that neighbors might recognize
the investigators, thus revealing their childs mental disorder [53]. Family shame
could be explained by the Confucian concept of filial piety, which states that no
person should bring dishonor to the family [54]. Children with schizophrenia are
incapable of following the principles of filial piety, thus risking shame and violating traditional Korean beliefs [53].
The results of the present correlation analysis demonstrate many differences
between Japan and Korea in terms of factors affecting personal stigma and coping
strategies. In particular, it is interesting to note that coercion and avoidance as family coping strategies are correlated with many aspects of personal stigma in Korea
but not in Japan. In contrast, the idea that it is best to avoid people with a problem
like Johns is correlated with almost all factors of coping in Korea.
Conclusion
Although the foundation of Confucian ideas and the tradition of providing care
to family members are central to both Japanese and Korean cultures, unexpected
similarities and differences between the two cultures are observed. In both countries,
patients with schizophrenia are likely to avoid contact with nonfamily members
and isolate themselves from society, and these factors are correlated to a greater
caregiver role and worsening of family caregiver burden. However, Japanese families of patients with schizophrenia are more likely to perceive a strong stigma from

summer 2012 93

others when compared to Korean families and thus are more likely to think that
schizophrenia should be hidden from others. Japanese families tend to cope with
the stigma associated with schizophrenia through resignation in contrast to Korean
families. Furthermore, Japanese families are resistant to allowing others to care for
a schizophrenic family member. Hence, a close family tie between schizophrenia
patients and their families is suggested.
These findings suggest that Japanese mental health strategies should focus on
providing effective support for reducing caregiver burden and eliminating reliance
on inappropriate coping strategies (i.e., resignation, unwillingness to accept support
from outside the family) for family members with schizophrenia inpatients and
outpatients. This support is especially important for outpatients and their caregivers,
as continued support from the early clinical stage through the chronic stage should
be emphasized. This issue should be discussed further in the context of community
mental health care. Integrated assertive community services should be provided and
are especially necessary during periods of relapse throughout the long stretches of
time that patients spend living with psychiatric illness.
References
1. Joyce, J.; Leese, M.; & Szumukler, G.I. (2000) The experience of caregiving
inventory: Futher evidence. Social Psychiatry and Psychiatric Epidemiology, 35(4),
185189.
2. Szmukler, G.I.; Burgress, P.; & Herrman, A. (1996) Caring for relatives with serious mental illness: The development of the Experience of Caregiving Inventory (ECI).
Social Psychiatry and Psychiatric Epidemiology, 31(34), 137148.
3. Tucker, C.; Barker, A.; & Gregoria, A. (1998) Living with schizophrenia: Caring
for a person with a severe mental illness. Social Psychiatry and Psychiatric Epidemiology, 33(7), 305309.
4. Veltro, F.; Magliano, L.; & Lobrace, S. (1994) Burden on key relatives of patients
with schizophrenia vs. neurotic disorders: A pilot study. Social Psychiatry and Psychiatric Epidemiology, 29(1), 6670.
5. Harvey, K.; Burns, T.; & Fahy, T. (2001) Relatives of patients with severe psychotic illness: Factors that influence appraisal of caregiving and psychological distress. Social
Psychiatry and Psychiatric Epidemiology, 36(9), 456461.
6. Sakai, Y.; Kim, Y.; & Akiyama, T. (2002) Burden on the families of patients with
schizophrenia: Relations to patients and families awareness of mental disorder. Seishin
Igaku, 44(10), 10871094 (in Japanese).
7. Barrowclough, C., & Tarrier, N. (1990) Social functioning in schizophrenia
patients: The effect of expressed emotion and family intervention. Social Psychiatry and
Psychiatric Epidemiology, 25(3), 125129.
8. Kuipers, L. (1993) Family burden in schizophrenia: Implications for services.
Social Psychiatry and Psychiatric Epidemiology, 28(5), 207210.
9. Oshima, I.; Ito, J.; & Yagihashi, M. (1994) The relationship between expressed
emotion and daily life functioning of families who take care of the schizophrenics members. Psychiatric and Neurology Journal of Japan, 96(7), 493512 (in Japanese).
10. Smith, J.V., & Birchwood, M. (1987) Specific and non-specific effects of educational intervention with families living with a schizophrenic relative. British Journal of
Psychiatry, 150(5), 645652.

94 International Journal of Mental Health

11. Magliano, L.; Fadden, G.; & Madianos, M. (1998) Burden on the families of
patients with schizophrenia: results of the BIOMED I study. Social Psychiatry and Psychiatric Epidemiology, 33(9), 405412.
12. Magliano, L.; Fadden, G.; & Economou, M. (2000) Family burden and coping
strategies in schizophrenia: 1-year follow-up data from the BIOMED I study. Social
Psychiatry and Psychiatric Epidemiology, 35(3), 109115.
13. Oshima, I. (1987) A study on family support system for the mentally disabled
from the perspective of its functions and resources. Psychiatric and Neurology Journal of
Japan, 89(3), 204241 (in Japanese).
14. Hata, A.; Aso, Y.; & Akiyama, N. (2003) Present use of and needs for social resources assessed by family members of patients with severe mental illness: Results from
a research for families of patients with severe mental illness. Seishin Igaku, 45(1), 5564
(in Japanese).
15. Gopinath, P.S., & Chaturvedi, S.K. (1992) Distressing behavior of schizophrenics
at home. Acta Psychiatrica Scandinavica, 86(3), 185188.
16. Glanville, D.N., & Dixon, L. (2005) Caregiver burden, family treatment approaches and service use in families of patients with schizophrenia. Israel Journal of Psychiatry
and Related Sciences, 42(1), 1522.
17. Ohta, Y.; Tanaka, G.; & Sugasaki, H. (1997) Comparison of features in the evaluation of symptomatology and social adjustment between mothers and other family members of schizophrenic patients in Japan. Acta Med. Nagasaki, 42, 1218.
18. Otsuka, T.; Nakane,Y.; & Ohta, Y. (1994) Symptoms and social adjustment of
schizophrenic patients as evaluated by family members. Acta Psychiatrica Scandinavica,
89(2), 111116.
19. Hanzawa, S.; Tanaka, G.; & Inadomi, H. (2008) Burden and coping strategies in
mothers of patients with schizophrenia in Japan. Psychiatry and Clinical Neurosciences,
62(3), 256263.
20. Roick, C.; Heider, D.; & Toumi, M. (2006) The impact of caregivers characteristics, patients conditions and regional differences on family burden in schizophrenia: a
longitudinal analysis. Acta Psychiatrica Scandinavica, 114(5), 363374.
21. Magliano, L.; Marasco, C.; & Fiorillo, A. (2002) The impact of professional and
social network support on the burden of families of patients with schizophrenia in Italy.
Acta Psychiatrica Scandinavica, 106(4), 291298.
22. Magliano, L.; Malangone, C.; & Guarneri, M. (2001) The condition of families
of patients with schizophrenia in Italy: Burden, social network and professional support.
Epidemiologia e Psichiatria Sociale, 10(2), 96106.
23. Roick, C.; Heider, D.; & Bebbington, P. (2007) Burden on caregivers of people
with schizophrenia: Comparison between Germany and Britain. British Journal of Psychiatry, 190(4), 333338.
24. Van Wijngaarden, B.; Schene, A.; & Koeter, M. (2003) People with schizophrenia
in five countries: Conceptual similarities and intercultural differences in family caregiving. Schizophrenia Bulletin, 29(3), 573586.
25. Nomura, H.; Inoue, S.; & Kamimura, N. (2005) A cross-cultural study on expressed emotion in carers of people with dementia and schizophrenia: Japan and England.
Social Psychiatry and Psychiatric Epidemiology, 40(7), 564570.
26. Chang, K.H., & Horrocks, S. (2006) Lived experiences of family caregivers of
mentally ill relatives. Journal of Advanced Nursing, 53(4), 435443.
27. Chien, W.T.; Chan, W.C.; & Morrissey, J. (2007) The perceived burden among
Chinese family caregivers of people with schizophrenia. Journal of Clinical Nursing,
16(6), 11511161.
28. Hanzawa, S.; Tanaka, G.; & Goto, M. (2008) Factors related to the burden for

summer 2012 95

mothers of patients with schizophrenia: The impact of professional and social support
network and family functioning on the burden. Japanese Bulletin of Social Psychiatry,
16(3), 263274 (in Japanese with English abstract).
29. Kurumatani, T.; Ukawa K.; & Kawaguchi Y. (2004) Teachers knowledge, beliefs
and attitudes concerning schizophrenia: A cross-cultural approach in Japan and Taiwan.
Social Psychiatry and Psychiatric Epidemiology, 39(5), 402409.
30. Shinfuku, N. (1998) Mental health services in Asia: International perspective and
challenge for the coming years. Psychiatry and Clinical Neurosciences, 52(3), 269274.
31. Haraguchi, K.; Maeda, M.; & Mei, Y.X. (2009) Stigma associated with schizophrenia: Cultural comparison of social distance in Japan and China. Psychiatric and
Clinical Neurosciences, 63(2), 153160.
32. Lim, Y.M., & Ahn, Y.H. (2003) Burden of family caregivers with schizophrenic
patients in Korea. Applied Nursing Research, 16(2), 110117.
33. World Health Organization. (2005) Mental health atlas 2005. Geneva,
Switzerland.
34. Hanzawa, S.; Bae, J.K.; & Tanaka, H. (2010) Caregiver burden and coping strategies for patients with schizophrenia: Comparison between Japan and Korea. Psychiatric
and Clinical Neurosciences, 64(4), 377386.
35. Caqueo, A., & Gutierrez, J. (2006) Burden of care in families of patients with
schizophrenia. Quality Life Research, 15(4), 719724.
36. Link, B.G.; Phelan, J.C.; & Bresnahan, M. (1999) Public conceptions of mental
illness: Labels, causes, dangerousness, and social distance. American Journal of Public
Health, 89(9), 13281333.
37. Phelan, J.C., Bromet, E.J., & Link, B.G. (1998) Psychiatric illness and family
stigma. Schizophrenia Bulletin, 24(1), 115126.
38. Magliano, L.; Rosa, C.D.; & Fiorillo, A. (2004) Perception of patients unpredictability and beliefs on the causes and consequences of schizophrenia: A community
survey. Social Psychiatry and Psychiatric Epidemiology, 39(5), 401416.
39. Grausgruber, A.; Meise, U.; & Katschnig, H. (2007) Patterns of social distance towards people suffering from schizophrenia in Austria: A comparison between the general
public, relatives and mental health staff. Acta Psychiatrica Scandinavia, 115(4), 310319.
40. Magliano, L.; Fiorillo, A.; & Rosa, C.D. (2004) Beliefs about schizophrenia in
Italy: A comparative nationwide survey of the general public, mental health professionals,
and patients relatives. Canadian Journal of Psychiatry, 49(5), 322330.
41. Watson, A.C.; Corrigan, P.; & Larson, J.E. (2007) Self-stigma in people with mental illness. Schizophrenia Bulletin, 33(6), 13121318.
42. Lauber, C.; Nordt, C.; & Rosseler, W. (2005) Recommendations of mental health
professionals and general population on how to treat mental disorders. Social Psychiatry
and Psychiatric Epidemiology, 40(10), 835843.
43. Nordt, C.; Rosseler, W.; & Lauber, C. (2006) Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophrenia Bulletin,
32(4), 709714.
44. Magaa, S.M.; Ramrez, G.J.I.; & Hernndez, M.G. (2007) Psychological distress
among Latino family caregivers of adults with schizophrenia: The roles of burden and
stigma. Psychiatric Services, 58(3), 378384.
45. Hanzawa, S.; Bae, J.K.; & Tanaka, H. (2009) Family stigma and care burden of
schizophrenia patients: Comparison between Japan and Korea. Asia-Pacific Psychiatry,
1(3), 120129.
46. Radford, M.H.B., & Nakane, Y. (1991) Ishi-kettei-koui:Culture and decision making behavior. Tokyo: Human TY (in Japanese).
47. Hou, S.Y.; Ke, C.L.; & Su, Y.C. (2008) Exploring the burden of the primary family

96 International Journal of Mental Health

caregivers of schizophrenia patients in Taiwan. Psychiatric and Clinical Neurosciences,

62(5), 508514.
48. Yang, L.H. (2007) Application of mental illness stigma theory to Chinese societies: synthesis and new directions. Singapore Medical Journal, 48(11), 977985.
49. Yang, L.H., Phillips, M.R., & Lo, G. (2010) Excessive thinking as explanatory model for schizophrenia: Impacts on stigma and moral status in mainland China.
Schizophrenia Bulletin, 36(4), 836845.
50. Kurihara, T.; Kato, M.; & Sakamoto, S. (2000) Public attitudes towards the
mentally ill: A cross-cultural study between Bali and Tokyo. Psychiatric and Clinical
Neurosciences, 54(5), 547552.
51. Warner, R. (2005) Local project of the World Psychiatric Association Programme
to reduce stigma and discrimination. Psychiatric Services, 56(5), 570575.
52. Hanzawa, S.; Bae, J.K.; & Tanaka, H. (2010) Personal stigma and coping strategies in families of patients with schizophrenia: Comparison between Japan and Korea.
Asia-Pacific Psychiatry, 2(2), 105113.
53. Donnelly, P.L. (2005) Mental health beliefs and help seeking behavior of Korean
American parents of adult children with schizophrenia. Journal of Multicultural Nursing
& Health, 11(2), 2334.
54. Sung, K.T. (1992) Motivations for parent care: The filial children in Korea. New
York: Baywood.

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