Curbside Consult

Treating a Japanese patient with family pressures


Editors’ Note: This is the first installment of Curbside Consult, written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry.

Come back home

The patient is an unmarried Japanese man in his early 40s who presents with symptoms of social phobia. He was born and raised in Japan, and migrated to the United States to pursue a PhD. In Japan, he enjoyed middle-class status, but after immigrating to the United States, he has faced many financial difficulties. His language barriers have made him uncomfortable in front of his colleagues and supervisors and he has not been able to do well in his PhD program, ultimately leading to his expulsion. He does not want to go back to Japan, thinking he will not have a “good life” there. He believes that there is no respect for a person’s individuality in Japan. He is currently living in an urban location of New Jersey and works odd jobs. He states that his family does not understand his feelings about not returning to Japan, and instead they want him to support them. He has engaged in supportive psychotherapy and cognitive-behavioral therapy in the outpatient clinic along with psychopharmacological treatment.

Key questions

1. How is Japanese culture different from U.S. culture in terms of respecting a person’s individuality?

2. The expectations of the patient’s family are considered excessive by the patient. What is the role of Japanese culture in this situation?

3. In moving forward with treatment planning, what aspects of the patient’s culture should the clinician keep in mind?

Family perspective

This middle-aged Japanese man has had a challenging time since coming to the United States to study. He lives here alone. He has failed to achieve his goal of earning a PhD. He has had financial difficulties because of his job challenges. He has had the courage to seek mental health treatment, although the goals of his treatment are unclear. He is in contact with his family in Japan, who has asked that he come home, presumably to support his somewhat older parents. It is unclear who constitutes his “family.”

Dr. John Sargent

Dr. John Sargent

From a family perspective, it seems that the family/parents in Japan are expecting that family obligation will draw the man home while the patient is defying that expectation by seeking and building individuality in the United States. A family-oriented therapist would consider the patient’s relationship with his family and help him consider how to make his decision on where to live. The therapist also would support the patient in maintaining a connection with his family. The therapist would help the patient avoid both passively capitulating to his family and defiantly cutting off from them. This would entail discussing the role of family in the United States and Japan. It would be important to empower the patient to explore his reasons for wanting to stay in the United States, what he means by “a good life,” and what he senses as his obligation to his family.

The history of this man’s life in Japan, including recollections of his childhood and an understanding of the job history of other members of his family, will help the therapist understand this man and his experience of his family. The telling of the family narrative, from his perspective, may help the patient understand his wishes and his fears. Exploring his relationships with his mother and his father will help the therapist and the patient understand some of the problems he has had in the United States.

Given his current life circumstances, work, and social stresses, lack of social support, and problems functioning, he also should be clinically assessed for depression and any other significant mental health problems. Additional questions to explore include: Does he define himself as a “failure,” and what would it be like going back to Japan? Are there concerns about “losing face”? If his parents want him to support them, do they know about his financial situation? Would he be able to get a job in Japan, or would he end up living with his parents? Are their requests that he “come home” based on their need for support, or are they afraid that he really needs their help given his difficulties establishing a life here? As the patient explores these issues in more detail, he can begin the process of resolving his future.

Cultural psychiatry perspective

This case raises important cultural questions, which deserve further exploration in psychotherapy. Alternate approaches to evaluating culture in clinical settings have moved away from conceptualizing “U.S.” or “Japanese” cultures monolithically to understand how cultural dynamics matter to the individual.


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