A New Idea and the Practice of Elderly Care in Japan
Reportage MIYOSHI HARUKI
Vol.39, No.6, MARCH/APRIL 2004
A new idea and the practice of elderly-care in Japan
There are various problems with the graying of our society. The most serious are the problems involving senile dementia. According to estimates by the National Center of Neurology and Psychiatry, Japan, of the Japanese aged sixty-five and over, 1,557,700 were suffering from senile dementia in 2000, which showed an increase of 550,000 people from a decade ago. Regarding the cause of dementia, there is not yet an established theory despite the strenuous efforts of medical experts around the world. And there is no specific cure for this disease, either. Besides, an effective medicine for the disease has not yet been found, although pharmaceutical companies are trying hard to develop one. Under these circumstances, hospitals, welfare homes, and households are fighting a hard battle against the disease through trial and error methods.
A sty is an eye disease. Likewise, dementia is generally considered a brain disease. In medicine dementia is defined as severe deterioration of mental faculties due to an organic disease of the brain in the course of lifetime. Roughly speaking, there are two types of dementia. One type is caused by injuries in the cerebral blood vessels, such as cerebral apoplexy and cerebral infarction. The other type, which is exemplified by Alzheimerfs disease, is mainly attributable to the contraction or degeneration of the brain. As mentioned above however there is not yet an established cure for dementia. In the case of those suffering from senile dementia, it is of great importance to care for them not only physically but also spiritually,
There is a Japanese who is opposed to the common idea of dementia. It is Miyoshi Haruki, who is himself engaged in the care of elderly people affected with dementia. "Dementia is no brain disease," he said positively "Hysteria used to be considered a disease unique to women who had trouble with their wombs. Today, however, we laugh at such a misunderstanding. Similarly, in ten years or so today's popular idea that dementia is a brain disease will become a laughingstock."
According to Miyoshi, the medical circles' claim that dementia is a brain disease is incorrect in that they mistake the cause for the effect. He thinks that the contraction or degeneration of the brain, which doctors say is the cause of dementia, is the effect of that disease. "Indeed there really exists dementia caused by an organic disease of the brain, such as Alzheimer's disease and Pick's disease." he said. "But the proportion of this type of dementia is much smaller than expected. Besides, contrary to expectation, there are quite a few people who escape from dementia even though they are suffering from the contraction of the brain or injuries in the cerebral blood vessels. And there are also a lot of cases in which it is the other way around. Considering these facts, I should say that it is unreasonable to simply ascribe dementia to the deterioration of brain functions."
If dementia is not a brain disease, what is it then? It is "relationship trouble," according to Miyoshi's wording. He explained as follows, "Human relationships can be broadly classified into family and social relationships. While the former is an emotional relationship involving kinship, affection, or friendship, the latter is contract-1ike and rational. In addition, there is the relationship with oneself, which is the key to senile dementia. "
Regarding an elderly person's relationship with himself, he should try to come to terms with the humiliating fact that he is forgetful, incontinent about urine, or weakened with age. Suppose he fails to come to terms with his senile self for some reason. He will try to deny and estrange his senile self. Then he will start to have trouble with the relationship with himself. As a result, his family relationship and social relationship will be destroyed, too. In the meantime he will contract dementia. "
To be specific, ashamed of his senile self, he will abhor going out and seeing others. As he confines himself to his room, his family relationship will be getting worse and worse. Before long amid the agonies of solitude he will fall into an abnormal state of mind. In the end, he will start to suffer from the contraction or degeneration of the brain. ... Such is often the case with a sufferer of senile dementia. It is not that he has brain trouble from the beginning. "
Dementia is relationship trouble unique to human beings, who are involved in various relationships. Therefore, what is necessary to an elderly person suffering from dementia is not treatment but care to help him regain his relationships."
Miyoshi's idea is based upon his long experience. He has seen many wonderful cases in which elderly people ruined by dementia regained a vivid life as they moved from hospitals to old people's homes, namely, places where they could receive humane care. And he himself has helped such people recover by caring for them. It is his firsthand experience that encourages him to reject doctors' common idea of the disease.
Miyoshi began to care for the elderly in 1974, when he was twenty-four years of age. Born in Kure City, Hiroshima Prefecture, he grew up as a policeman's only child. In his boyhood his family moved from place to place. He studied at Shudo Gakuen, a private junior and senior high school attracting the cream of the children of the prefecture. This intellectually precocious boy committed himself to a student movement, which was active at the time. As the president of the student council, he took the lead in staging demonstrations against the Vietnam War time after time. The school authorities considered him a dangerous student. In January 1969, when he was about to graduate, they forced him to leave the school on the grounds of his excessive political activity,
After leaving the school, he belonged to a radical left-wing sect. While hopping from job to job, he continued with his political activity in the two adjacent prefectures of Hiroshima and Yamaguchi. In the 1970s, when domestic strife among the radical left-wing sects was intensifying, he withdrew from the forefront of political activity. As a citizen he started to direct his efforts toward the reconstruction of social reforms under the influence of Yoshimoto Takaaki, a leading thinker for the radical left wing of the time.
One day an acquaintance of his requested him to work for a special elderly nursing home in Hiroshima Prefecture. (A special elderly nursing home refers to a public institution meant for physically or mentally handicapped people aged sixty-five and over who require nursing around the clock. Among the residents of the home are many who are suffering from dementia.) Although Miyoshi was not particularly interested in the care of the elderly, he accepted the request. As he began to work for that special old people's home, he saw a world different from the one he had turned his back on because of his aversion to worldly things.
"The public has the idea that those living in an old people's home are piteous. And I was myself imbued with that idea, too. But I found it totally wrong." he said. "The residents of the home I worked for were living at their own pace, displaying their individuality to the full. For example, an eighty-four-year-old woman who came of a good family firmly believed a female staffer to be her own maid. And an old man would write a love letter in an admirably cursive hand and give it to a chief female staffer. Besides them, a former political activist made it a rule to read the newspaper of Aka-Hata (the Red Flag) on his bed all day long, although he was suffering from general paralysis. Seeing them, I thought that if we are to live the rest of our lives in so many different ways, we should live in our own ways from youth. I felt relieved at that thought. In the eyes of the public, I am the one who strayed from the ideal course. As I met the residents of the home, however, I learned to reconsider my life from a fresh angle. They taught me that there are no rails in our lives, and that we differ from one another in course and destination."
Miyoshi was rescued by the elderly people he was to rescue. While working for the home day after day, he was confronted with the realities of the care and medical treatment of the elderly. For example, there was no expression on the face of a woman from an old people's hospital, where she had been diapered and given intravenous drip injections with her hands tied. To encourage her to go to the toilet in the home, he shortened the feet of her bed. As a result, she became able to walk to the toilet by herself. On the other hand, a woman who had been on her feet in the home became unable to walk while she was hospitalized for an examination of her disease. After a week's stay in the hospital she returned to the home, confined to a wheelchair. Even unable to answer the call of nature, she was diapered.
Such cases shook his belief in hospitals as a group of reliable experts. He observed as follows, "To encourage a bedridden person to find his feet, it is necessary to cut short the feet of his bed so that his feet can reach the floor. If his feet can reach the floor, he will become able to get up on his feet. And if he can walk to the toilet, he will become able to answer the call of nature again. In the meantime his eyes will start to shine as before. Technical books cover none of the things we, the staff of the home, are going through. I've found that the key to the care of the elderly lies in our daily experience."
When Miyoshi was twenty-eight, he entered Kyushu Rehabilitation College, where he studied for three years. After obtaining a physical therapist's license, he returned to the home. It worried him that conventional stoical rehabilitation was not as effective as expected. Before long he devised a new rehabilitation method adopting the idea of play or a game. As he applied the new rehabilitation to the people of the home, he found that it was considerably instrumental in animating them.
While undergoing such trial and error in the home, he came to realize where his strength lay, that is, what kind of work to do. And at the same time he determined to seek a new way of caring for the elderly while reconsidering the significance and methods of conventional care.
In 1985 he left the special old people's home and founded, in Tokyo, the Research Institute of Life and Rehabilitation. He devoted himself to publishing books about elderly-care and to giving lectures to the staff of old people's homes throughout the country. His books and lectures, which were based upon his own experience with elderly-care, were so lucid that they won the enthusiastic support of those working for the elderly. He also established the "Society to Remove Diapers," which is aimed to encourage the bedridden to go to the toilet instead of depending on diapers, and the "Society to Remove Tubes," which is intended to prompt the bedridden to eat food instead of getting injections of nourishment through tubes. (Actually, the members of each society meet together to learn how to achieve their purpose.) Through these unique activities he has gradually pushed his way to the position of a world opinion leader on elderly-care.
The main reason for his rise to such a preeminent place is that he has brought an exhaustively concrete and practical approach to the care of the elderly while respecting their situation. However, there is another reason for that, too. It is that he has given considerable thought to the meaning of elderly-care. "Whoever is engaged in the care of the elderly can be a philosopher more or less. It is the zest of this job," he said. "While I was caring for a man suffering from senile dementia, I wondered for what he was living. I asked myself the meaning of my involvement in his life. And I pondered over the meaning of his life. Such thought and philosophy are essential for elderly-care just as a concrete methodology is."
Regarding philosophy, Miyoshi has adored Yoshimoto Takaaki since his school days. In addition, Miyoshi has learned a lot from French structuralist philosophers, such as Michel Foucault and Claude Levi-Strauss. "As I read 'The Savage Mind' written by Levi-Strauss, I was impressed by primitive people's ways of thinking and production, which seemed to have much to do with the world of elderly-care," he said. "In the book Levi-Strauss said that primitive people's methods of doing things, which was called Bricolage, could be art, not science. On the night when I read that book of the modern philosopher's, I was excited, feeling that modern thought overlapped my way of caring for the elderly. I was wide awake all the night through."
As a matter of fact, Miyoshi's lucid idea of elderly-care is gradually exerting an influence not only on the world of welfare but also on its surrounding areas, including the worlds of philosophy and literature.
An active man, Miyoshi has given a lecture more than 170 times a year for the past several years. There is good reason for his great popularity as a lecturer. It is that he is a master storyteller. Although stories of the care of the elderly tend to be gloomy, he tells them very humorously, quoting surprising behavior of those suffering from senile dementia. As often as not, he moves the audience to laughter as if he were rakugo-ka (a professional raconteur who is supposed to make the audience laugh). His words are easy, even for the laughing audience, to understand. It is not merely because he has the gift of the gab. Behind it is also the fact that he has thought over the method of communication while taking care of the demented elderly, who are hard to communicate with.
He delivers his lectures in the belief that dementia is not a brain disease but relationship trouble. And the point of his lectures lies in the explanation of the care of the elderly suffering from dementia. He said to the audience as follows, "Dementia is trouble with relationships with society, family, and oneself. This means that there are at least as many cures as the cases of dementia. We should help each patient establish relationships with people he can accept. This is an essential part of the care of the sufferers from dementia.
"For example, a former geisha aged eighty began to treat her visiting helper as a thief. This was a delusion of persecution typical of senile dementia. How do you think the helper should cope with it?"
After having had the audience think it over for a while, he resumed the story as follows, "As the helper finished doing domestic chores for the old woman, she learned from this former geisha ko-uta (Japanese ballads) and dodoitsu (Japanese ditties), which were in her line. As a result, the woman was cured of her delusion. Why? Well, she was such an independent woman that she felt uneasy about being cared for by the helper. To wipe out her guilty feelings toward the helper, the woman had to have the delusion that the helper stole things from her. However, as she began to teach the helper ko-uta and dodoitsu, they got to depend on each other. Then the woman was relieved of her mental anguish. And she was also freed of her delusion of persecution." Hearing this, the audience gave an exclamation of surprise.
His lectures are not limited to these kinds of stories, though. Otherwise it would not attract as many as 70,000 professional carers of the elderly a year. His audience is daily confronted with the difficulty of taking care of the elderly, They feel sympathy toward his lecture because it is based upon realities familiar to them.
His audience wonders, for example, how to bathe the elderly who refuse to take a bath, how to keep the elderly from constipation, or how to bed down those who are chattering in the corridor because they cannot go to sleep because of anxiety. He is ready to help them solve these vulgar but pressing problems. Regarding their questions related to these kinds of problems, he answered as follows, "Even those who seem to be reluctant to take a bath actually want to do so. However, keep in mind that they do want to make believe they are forced to take a bath. And as for the means of keeping the elderly from constipation, it is of great importance to have them sit on toilet stools after breakfast. I have seem quite a few cases in which those cured of constipation got to refrain from problem behavior."
Miyoshi's words were that concrete and convincing. His audience could apply his advice to their work from the next day on.
"I give a course of lectures not for the purpose of enlightening the participants by conveying my knowledge to them," he said. "I want to deliver the kind of lecture in which I can recount the process I have gone through. I would like the participant to understand what is behind my thought or methodology, I make it a rule to stick to what I experienced or felt while tending the elderly, And I put such experience or feeling into words. The world of elderly-care is quite a new world without a manual. Having nothing to rely on, I should verbalize my own experience. The participants do not have to imitate my ways. They should just experience for themselves what I have undergone."
While viewing dementia as trouble with human relationships, Miyoshi also thinks that dementia is representative of a ruined modern self on the way back to nature. Civil society, which is founded upon independent individuals, is not good at dealing with the elderly suffering from dementia, or nature in the form of human beings. Doctors and carers try to rehabilitate them while administering medicine. Miyoshi says, however, that such doctors and carers are utterly wrong.
He has a habit of saying, "Whoever turns eighty is a living Buddha." According to him, elderly-care is meant not to improve their lives but to help them enjoy their present lives as much as possible. He is aware that there is something Japanese about such an idea of elderly-care.
In his book Rojin Kaigo Joshiki no Ayamari (Mistakes about Common Knowledge of Elderly-care) he observed as follows, "Viewed from the standpoint of modern individualism, one's relationship with himself is independent of society and his family. Consequently, even if society and his family give him the cold shoulder, he should remain himself.
"Among the Japanese, however, are very few with such strong selves. Particularly, the elderly seem to have a tendency to identify themselves with society and family This lays the Japanese open to the criticism that they are immature as individuals. I think, though, that Japan just has a culture different from any other country.
"Japan has a unique culture of the elderly. The elderly of Japan have ways befitting their age. Such ways were born of the culture of mutual dependence, which tolerates those not able to stand by themselves."
The care of the elderly is an urgent problem in Japan. It is not simply that Japanese society is aging. The main reason is the collapse of the Japanese families' long-standing custom to take care of their old folks in the wake of an increase in the population of those imbued with an individualistic education since the end of the Second World War. People who maintain their selves and have the power of self-determination dismiss sufferers from senile dementia, or those whose selves have been ruined, as aliens. However, a day may come when these individualists themselves will fall victim to dementia and be estranged from others. There is a possibility that the individualists, who place confidence in themselves, will undergo the severest relationship trouble. In other words, it is possible that the number of piteous senile-dementia victims will be further on the increase in the future. Miyoshi seems to suggest that we change our ideas of dementia and the elderly before the situation becomes that serious.
Although we tend to be pessimistic about the care of the elderly, Miyoshi sees in it something encouraging. Among the professional carers of the elderly are young people. At first sight they appear as if they are not Japanese. They dye their black hair brown. And they have their ears and other regions of the body pierced to wear rings. When it comes to work, however, they are very eager to help the elderly, trying hard to communicate with them. Miyoshi has often seen them tearfully weep over the death of those they had taken care of. "Young people of today have no illusions about 'modernity,"' he said. "Since birth they have taken for granted the existence of nuclear families, individualism, and the self-responsibility principle. To them 'modernity' is rather a burden. They have a strong yearning for, say, the extended family system of old Japan. Because they are free from the illusions about modern things, such as independence and individualism, they have no difficulty entering into the hearts of the elderly. This is encouraging. Most of these young people read none of my books, though."
It is three decades since Miyoshi entered into the world of elderly-care. This old hand is closely examining the issues surrounding it. Among these issues is death. In his lecture he says, in gentle tones, that he once caused an elderly person to die because of his own misjudgment. And apart from that case, he has attended the deathbed of quite a few elderly people.
He seems to see something dangerous about the perception of death in today's Japan. "Concerning Japan's dispatch of the Self-Defense Force troops to Iraq, Prime Minister Koizumi said, 'If an SDF official should die in Iraq, it would be an honorable death.' But I think it ridiculous," he said. "Death is a private matter. So the death of an SDF official should be above the evaluation of the government."
He also told of the death of an old man he had looked after in the old people's home many years ago. "He was such an ill-natured man that his funeral was attended by none of his family and acquaintances. At the time I thought that he met a miserable end. Now I think, though, that it may have been the most respectable death because it caused sorrow to none."
If dying unwept is the best form of death, what is the meaning of elderly-care, death or life? It will take Miyoshi some time to find an answer to that. It is certain, however, that he never forgets his ambition to establish collaboration new to Japanese society, This ambition will oblige him to frequently travel between the two worlds of elderly-care and modern philosophy.