Ikuyoshi MUKAIYACHI (Health Sciences University of Hokkaido)
"Bethel House and Non-assistance Theory -- A New Partnership between Doctors and Patients"

Traditionally, medical and welfare specialists have possessed specific knowledge and skills grounded in consistent values, and are expected to have high problem solving abilities. The foundation supporting this expertise has been “science”. People who learned scientifically grounded theories and knowledge through specialized educational processes were expected to fulfill the role of a doctor. In particular, in the medical world, disease leads the life of an ordinary person in an opposite direction. A patient’s time is stressful, may include being separated from their family and work and can include measures such as surgery. They are forced to endure shame and anxiety in the hope of preserving their life and recovering their health. Doctors and nurses use their exclusive knowledge and skills to provide treatment and care for these patients.

Recently, however, has seen the beginnings of a change in clinical medicine, with people asking a fundamental question: “What is a medical expert”? This is due to shifts in expertise and a change in relationships with patients, all with the advent of the “Age of Chronic Diseases” in the background. Having a disease or requiring care is no longer a special life event, but a rather common scenario that can affect anyone. Patients are given special regard by seasoned professionals in cases of unusual, special incidents. However, the fact that growing old or living with a disease has become routine has redefined medical care and aid as a “service,” and in a relationship with equal contractual rights between service providers and beneficiaries, the emergence of various supply organizations and the push to marketize these services have been promoted, especially in the healthcare field. In particular, the computerization of medical and welfare information spurred on by the spread of the Internet means that valuable knowledge, skills, and other information, which were in the past held exclusively by professionals, are now instantly accessible to anyone. At the very least, there is no disparity between professionals and the average person in terms of available information. Furthermore, in this “Age of Blogs”, people living with a disease or disability can themselves share their experiences and knowledge with many others like them or ordinary people in diary format. This is an era in which the experiences of medical treatment can be publicly shared and felt by many people instantaneously through the Internet. Patient knowledge has become another “second opinion”, and has gained increasing importance as information.

This structural change is slowly highlighting another area: changes in the view of the patient. A doctor assumes that a patient is ignorant and powerless, but a new trend is developing within the traditional doctor/patient relationship. It’s called “Non-assistance Aid: Helping without helping”, or “Assistance to self-assistance: Helping patients that help themselves”  a complete restructuring of the patient assistance relationship which puts the patient at the center. However, this kind of patient-based viewpoint is by no means new to the medical and welfare fields. The body’s latent natural healing powers that maintain health and fight diseases is a fundamental aspect of curing diseases, and the primary assistance in the welfare field also utilizes and supports the patient’s own recuperative powers. This is a very fundamental thing to be learned. It may, therefore, be correct to ask how medicine and welfare lost sight of trusting and utilizing the patient’s inherent powers. Some factors, which are felt to have facilitated these changes, are the positions of doctors authorized on the grounds of “science”, as well as further authorization based on expectations about a “supervisor” as a guardian providing the ethical and public safe protection that is implicitly required by society. This is especially true in psychiatric treatment, where the patient is viewed as a deviant from societal norms. Of course, so-called doctors are not comfortable with their positions of increased authority. Even as they face this dilemma, they accordingly strengthen their authority, creating a vicious cycle. In that sense, the doctor/patient relationship model in “non-assistance aid” developed at Urakawa was conceived through introspection by professionals already facing this dilemma. One of its terminus ad quem is the approach towards patient research based on the principle of “together, for your own self”.

A unique feature of this approach is that doctors take their positions with the idea that the very experiences of patient themselves, who have been going through their lives with mental illness, include important accumulated information in order to work out specific difficulties in their lives as well as how to live and make judgments. Then, these doctors respect their partnerships with the patients while examining, through research, new ways for them to live, experiencing the subjective world of fantasy and delusion from the patient’s point of view. The results have been remarkable. In an example from recent patient research, I was working with a man in his 30s suffering from schizophrenia during ‘research on riding ambulances’. This patient stopped attending school in his junior high school days and began abusing his parents who urged him to return to school. He destroyed public telephones, often rage and caused other problems. Though examined by a psychiatrist, he was dissatisfied with the doctor’s response and sent inordinate amounts of protest faxes to the hospital. About this time, he began calling for ambulances when he was away from home. When he was home, he frequently called the hospital for advice whenever he felt insecure, and staff members at the hospital had trouble dealing with the situation. The patient himself also considered his condition hopeless, and he begin receiving treatment. This continued for 15 years during which time he would repeatedly call ambulances when away from home, sometimes upwards of 20 times a month, asking to be taken to the hospital. In my research, I realized that whenever he was “starting to feel sick”, voices in his head would doggedly order him “Rest! Rest!” Based on the Urakawa method for dealing with patients who hear voices, whenever these voices started, he tried to ‘politely, gently, and patiently’ ask the voices to stop.  As a result, he has stopped calling ambulances, a ritual he had engaged in for more than ten years.

These results were brought forth by both the strength of the patient and the research group at Urakawa. I feel there is an important clue there in reforming the current situation  the fall of psychiatry into excessive protection and oversight under the glorified names of treatment and aid  well hidden in all the doctor-patient teamwork research done through the years.