Clin Eval 48

Suppl XXXVII 2021

Original article

Dubious justifiabilityof involuntary hospitalization:
A cross-cultural, system-dynamic analysis ＊1
Hanson Park 1）＊ 2

Takeo Saio 2）＊ 3

Ames Dhai 3）＊ 4

Chieko Kurihara 4）＊ 5

1）Department of Anthropology, College of Social Science, Seoul National University, Seoul, Republic of Korea
2）Department of Internal Medicine and Psychiatry, Fuji Toranomon Orthopedic Hospital, Shizuoka, Japan
3）Specialist Ethicist at South African Medical Research Council, Johannesburg, South Africa4）Bioethics Policy Study Group, Tokyo, Japan

Abstract
This study presents critical factors to avoid human rights infringements in psychiatric care and topromote the wellbeing of Persons with Mental Disorders (PWMD). We performed cross-cultural, systemdynamic analysis of mental health systems of South Korea, Japan and South Africa, in terms of legislation,
resource and outcomes and historical development. Our system-dynamic analysis derived two prerequisite
factors for overcoming human right infringements in psychiatric care: (1) increasing resource allocation forcommunity care instead of hospital-based care; (2) establishment of the recognition of that the justifiabilityof involuntary hospitalization is inherently dubious supported by journalism as well as reformation ofmental health law.
Key words
human rights, involuntary hospitalization, mental health act, system-dynamic analysis, journalism
Rinsho Hyoka（Clinical Evaluation）．2021；48 Suppl XXXVII：147−63.

＊1

＊2

＊3
＊4

＊5

This article was developed based on an agreement among the authors on the need to conduct a comparative analysis of crucially
important cases in each country, when the three of us participated in the 23ne Annual Conference of the Japanese Society ofTranscultural Psychiatry, in October 2016, held in Tochigi, Japan. It took some time until publication and the data has not been
updated since 2018, but the conclusions drawn from the system dynamics analysis in this paper remain unchanged.
Corresponding author: Hanson Park, M.D., Ph.D., Department of Anthropology, Seoul National University College of Social
Science, Seoul, Korea, 08826 Suite 105, Bldg 16-A, Seoul National University, Gwanak-ro 1, Gwanak-gu, Seoul, Korea
Tel: +82-2-880-8910; Fax: +82-878-8621; E-mail: hansonpark@snu.ac.kr
K&S Consulting Office for Occupational Mental HealthProfessor of Bioethics at the School of Clinical Medicine, and former Professor and Director of Steve Biko Centre for Bioethicsof University of the Witwatersrand, Johannesburg, South Africa
Specially-appointed Professor, Kanagawa Dental University− 147 −

臨 床 評 価 48 巻

別冊

2021

Korea, Japan and South Africa, in terms of legislation, resource and outcomes and historical development.

1. Introduction
Both Japan and South Korea are known for theirlong duration of hospitalizations for Persons with
Mental Disorders (PWMD) 1〜4). Japan, in particular, is notorious for its long hospitalization (average length of hospital stays: 300days, OECD2012 5). The rate of involuntary hospitalizations is
especially high in Korea (74% in Korea, WHO2014 6), more than 40% in both of Japan and South
Africa. See Table 1).
On September 26, 2016, the Korean Constitutional Court pronounced that the procedures of
involuntary hospitalization as defined in the
Korean Mental Health Act were inconsistent with
the Constitutional principle of minimizing infringements of human rights which made Korean government to reduce involuntary hospitalization 7).
Meanwhile, in Japan on July 26, 2016, 19 handicapped people were killed in a facility by a previous employee of this facility who was discharged 5months ago from 2 weeks of involuntary hospitalization 8) which resulted in the revised draft oftighten management scheme of PWMDs by
Japanese government.
On the other hand, in South Africa in 2017, it
was reported that rapid deinstitutionalization
caused more than 94 deaths of patients between
March 23 and December 19 in 2016 in Gauteng
Province, being transferred to 27 non-governmental organizations (NGOs) operated under invalid
licenses 9).
In reaction to these situations mentioned above,
we tried to present critical factors that could beinstituted to avoid human rights infringements in
psychiatric care and to promote the wellbeing of
PWMD.
We performed cross-cultural, system-dynamic
analysis 10) of mental health systems of South

2. Three different mental healthsystems
The mental health systems of South Korea,
Japan, and South Africa are widely different. Thus,
we first compared mental health systems of thesethree countries in light of their legal systems,
resources and outcomes, and historical development. Secondly, we reviewed the influence of various factors to mental health systems by means of
the human ecological system-based framework.
2.1 Problem spaces of mental health systemin the context: Legal system, resource
and outcome, and historical backgroundof mental health systems
Table 2 shows a summary of the legal system ofmental health of South Korea 11, 12), Japan 13, 14) andSouth Africa 15). Table 1 shows resources and outcomes of mental health of these three countries.
Followingly in the next section 2.2, we review
how these actual situations have been historicallydeveloped in the three countries.
A common process of development of legal systems is a shift from the public security model to thehealth care model, and now the social welfare
model, seeking for compatibility with international
human rights conventions: All human being areborn free and equal in dignity and rights 16); having
the right of self-determination by nature. Therefore,
all persons have the right to receive the best available mental health care, having the right to live andwork, as far as possible, in the community, and any
treatment should be based on informed consent,
except in the cases where the capacity to consent is− 148 −

Clin Eval 48

Suppl XXXVII 2021

Table 1 Comparison of mental health resource and outcome among South Korea, Japan and South Africa,
based on WHO reports
South Korea

Japan

South Africa

Total population

49,512,023

126,999,807

53,139,528

2011

48,500,717

126,995,411

50,492,408

Total health expenditure per person (USD 2013)

1,880

3,966

593

Recent Mental Health Policy

2014

2014

2013

Estimated mental health spending per capita (USD)

44.81

153.7

Not applicable

Total staff for mental health impatient care

16,490136,075

Not reported

Total staff for mental health outpatient care

2,717

12,622

Not reported

Psychiatrist/100,000

5.1

20.1

0.4

2011

5.12

10.1

0.27
Not reported

Mental health outpatient facility, total(/100,000)

1,353

5,739

1,138(2.35)

2,936(2.31)

3,460(6.85)

79

3,242

Not reported

2011-day treatment facility, total

55(0.11)

1,337(1.05)

80(0.16)

Mental hospitals, total(/100,000)

1,314

1,071

63

1,232(2.54)

1,072(0.84)

62(0.12)2011 outpatient facility, total
Mental health day treatment facility, total (/100,000)

2011 mental hospitals, total
Psychiatric units in general hospitals (/100,000)
2011 psychiatric beds in general hospitals

265

582

37

20,004(41.24)

92,857(73.12)

1,362(0.16)

Residential care facilities (/100,000)

197

1,422

37

2011 Community residential facilities

127(0.26)

1,992(1.57)

63(0.12)113.1/Not reported

200.3/199.5

22.7/ Not reported

Mental hospital beds/annual admissions (/100,000)
2011 Beds in mental hospitals

72,378(149.23)

259,580(204.4)

9,846(19.5)

General hospital psychiatric unit beds/annual admissions

54.5/Not reported

69.2/98.0

Not reported

Residential care beds/annual admissions

4.7/Not reported

15.3/11.6

Not reported

65,976302,156

Total number of inpatients
Admissions that are involuntary

74%

Discharged inpatients followed up within one month68%

Not reported

646,458

Not reported

63%/29%/8%

35%/29%/36%

Treated cases of severe mental disorder
Inpatients staying less than 1 year/1-5 years/more than 5 years

Not reported(More than 40% report 43% in 3 provinces
in Japanese)

Not reported

Italic: Data of 2011, shown compared to data of 2014.
Source: World Health Organization (WHO). Mental Health Atlas-2014 country profiles (Republic of Korea, Japan, South Africa)[cited 2017 May 1]. Available from: http://www.who.int/mental_health/evidence/atlas/profiles-2014/en/
WHO. Mental Health Atlas-2011 country profiles (Republic of Korea, Japan, South Africa) (shown in Italic) [cited 2017 May 1].
Available from: http://www.who.int/mental_health/evidence/atlas/profiles/en/
WHO; Ministry of Health & Welfare, Republic of Korea. WHO-AIMS Report on mental health system in Republic of Korea. 2006
[cited 2017 May 1]. Available from: http://www.who.int/mental_health/evidence/korea_who_aims_report.pdf?ua=1
WHO; Ministry of Health, South Africa. WHO-AIMS Report on mental health system in South Africa. September 2007 [cited
2017 May 1]. Available from: http://www.who.int/mental_health/evidence/south_africa_who_aims_report.pdf
WHO. Data and statistics: prevalence of mental disorders [cited 2017 May 1]. Available from: http://www.euro.who.int/en/
health-topics/noncommunicable-diseases/mental-health/data-and-statistics
Ministry of Health, Labour and Welfare, Japan. Reference. 2014 Mar 28 [cited 2017 May 1]. Available from: https://www.mhlw.
go.jp/file/05-Shingikai-12201000-Shakaiengokyokushougaihokenfukushibu-Kikakuka/0000046405.pdf− 149 −

臨 床 評 価 48 巻

別冊

2021

Table 2 Comparative Law of involuntary hospitalization/care for mentally ill patients:
South Korea, Japan and South Africa
South Korea

Japan

Description on humanrights in the Acts

Clearly described in the “fundamental
ideas”, in terms of: respect for dignity
and value of human being; rights toreceive optimum medical treatment,
protection, necessary education; nodiscrimination; voluntary hospitalization; unrestricted environment andfreely exchange opinions with othersfor hospitalized persons.

None
Clearly described in Preamble quoting(Limited descriptions in another Act on Constitution to prohibit unfair
Support for People with Disabilities)
discrimination of people;
Chapter III defines rights and duties
relating to mental health care users
with items of “respect, human dignity
and privacy”; “consent to care,treatment and rehabilitation andadmission to health establishment”;“unfair discrimination”; “exploitation
and abuse”; “determinations concerning mental health status”; “disclosureof information”; “limitation on
intimate adult relationship”; “right torepresentation”; “discharge reports”;“knowledge of rights”- Chapter VII defines obligations ofauthorities to provide services formentally ill prisoners.

Judgment of involuntary
hospitalization/care

Consents of 2 guardians and 1
psychiatrist (Since the time of
implementation of the revised Act,
diagnosis of 2 psychiatrists, one ofwhich is not affiliated to the hospital
comes to be needed.)Consent of 1 family member or legal
guardian and diagnosis from 1“designated mental health doctors”(governmentally certified psychiatrists
on involuntary hospitalization)(“hospitalization for medical protection”)

Judgment of involuntary
hospitalization/care, incase at risk of harmhimself/herself or others

Mental health specialist may request ahead of regional government (autonomous Gu and Si/Gun/Gu, if there isconsensus from 2 or more psychiatrists, may request hospitalization of
the relevant person.

Diagnoses by 2 “designated mental
health doctors”, ordered by a prefectural governor, being noticed by acitizen or police force.
(“administrative hospitalization”)

Application is made by defined family,
relatives etc.
A person must be examined by 2
mental health care practitioners

Board review

5-10 members composed of (1)psychiatrist, (2) lawyer, (3) mental
health specialists (4) Family membersof a mentally ill person, (5) person
having expertise and experience inmental health following defined items.

Notification of involuntary hospitalizations are reviewed by a board
composed of (a) a learned authority ofpsychiatric care (designated psychiatrist); (b) learned authority of mental
health or welfare; (c) learned authorityof law.

A Review Board, appointed by the
Executive Council of province,
consisting of (a) mental health carepractitioner; (b) magistrate, an attorney
or an advocate admitted in terms of thelaw of the Republic; and (c) member ofthe community concerned.

Commitment of Court orpolice in the decision
process (or notification
process)

In some serious cases, a person may be
admitted in an emergency hospital,
with the consent of a doctor and apolice officer

None (Police shall notify to theprefectural governor when they find aperson with risk of harming oneself orothers.)In some serious cases, the Court
decision is additionally needed.

Standards to evaluate
capacity, diagnosis, andrisk of harm

None
(Police force has its own practicalguideline)“Hospitalization for medical protection”: Admission to the psychiatricwards either to treat diseases or tosecure the patients’ mind and body arerefused by the patients of concern due
to their insight less to their own
diseases“Administrative hospitalization”: riskof harm to self or others due topsychiatric disorders,Defined in the legislation

Requirements for social
integration

Description about rehabilitation

None

Description about rehabilitation

Source: References No. 7〜11.

− 150 −South Africa

Clin Eval 48

insufficient, or if domestic legislation so provides,
having regard to the patient’s own safety or thesafety of others, under defined conditions, including the determination of qualified mental healthpractitioner 17, 18); all of which should be in accordance with the 10 principles of the World HealthOrganization (WHO) 19).
Especially, South African legislation had been
established directly based on the Constitution toprohibit unfair discrimination 20), as described in
the preamble of the Act. With regard to resource
and outcome (Table 1), South Africa is resource
limited, while, South Korea is of intermediate orsatisfactory status and Japan seems to be overresourced. Japan is much more resourced not onlyin terms of hospitalizations but also out-patient/day care facilities, however, its de-institutionalization activities have been on sluggish stagnation.
Here, we analysed more in depth the overallsummary of the three countries.
2.2 Historical Perspective on Comparative
Law: South Korea, Japan and South
Africa2.2.1 South Korea
The Korean Constitution was instituted in 1948.
It has been amended 9 times through several generations of autocratic Presidents. The Declarationof Democratization was adopted in its most recent
revision in 1987. The aim of the latter was peaceful success of Seoul Olympic in 1988. Until 1970,
psychiatric disorders had not been well recognizedsince individuals with these disorders had beentaken care of by their families and relatives in rural
areas 21). The rapid economic growth and nuclearization of families since the 1970’s led to increasing numbers of psychiatric patients being
hospitalized in unauthorized facilities and without
governmental action 22). In 1983 certain humanSuppl XXXVII 2021

right infringements at an unauthorized facility was
publicized by media and broadcast on national
television channels leading to the government, which
resulted in 1984 establishing a plan for mental healthimprovement. However, this plan was intended toincrease mental institutions to “secure society”
because South Korea was preparing for the Olympic.
Many homeless and poor people were hospitalized
into mental institutions to secure and “clean” thecities. At that time, several cases of deaths ofpatients were reported, and sometimes parents
were involuntary hospitalized which resulted indivestiture of property by their own children. There
was also an increase in the numbers of psychiatrichospitals and psychiatrists during this period.
In 1995, the Mental Health Act was passed inSouth Korea. It has been revised 6 times to improveand protect the rights of people with mental disorders and to rectify the tendency of long hospitalization. The legislation has mandated that mental
health policies are issued every five-years from1998 23). Although the Act has been revised tostrengthen human right protection, some citizen’s
groups have criticized this legal system and filed
several lawsuits claiming that the Act was unconstitutional which eventually came to unsuccessful.
The activities of the Korean Alliance of Mental
Illness (KAMI), a citizen’s group collaboratingwith lawyers, are most prominent. The pre-existing‘Mental Health Act’ was superseded by ‘the Mental
Health Promotion and Welfare Service Support
Act’ in 2016, which went into effect in May 2017.
Despite it defining the conditions and proceduresof involuntary hospitalization in a more democratic way than previously, the Korean
Constitutional Court in September 2016 ruled thatthe procedures of involuntary hospitalization as
defined in the pre-existing ‘Mental Health Act’
were not consistent with the constitutional principle by common assent of nine judicators 7). The− 151 −

臨 床 評 価 48 巻

別冊

2021

Constitutional Court decision reflects a maturationof the Korean society to accept such people in theircommunity.
Notwithstanding social efforts such as ‘thereform vision’, deinstitutionalization has been difficult to implement with the number of long-staypsychiatric beds being maintained, or in certain
facilities, even being increased. The lack of progress with regard to changes may derive from wrong
and insufficient resource allocation coupled withstrong public prejudices.
2.2.2 Japan 24)
The Japanese Democratic Constitution was promulgated in 1947 while Japan was still under
occupation of United States (US) after the defeatof Japanese imperialism. This Constitution remains
unchanged until now. The laws for private captivity and psychiatric hospitals were established in1900 and 1919, respectively. In 1964, the USambassador Edwin O. Reischauer was stabbed bya 19-year-old schizophrenic person. The bloodtransfusion for his emergency treatment caused
him hepatitis. The impact of this event was therevision of Japanese mental health law to strengthen
involuntary hospitalization of a person at risk ofserious harm to himself/herself or to others, accompanied by the rapid increase of public and private
mental hospitals.
The 1950 Mental Hygienic Law was revised in
1987 to the Mental Health Act and then revised
again in 1999 to the Act for Mental Health andWelfare of Persons with Mental Disabilities. In
mid-1980s, there were revelations of violence bysome private hospital workers resulting in deathsof patients at psychiatric wards. The Japanese
Mental Health Act was therefore revised to establish a system of “designated mental health doctors”
authorized for the decision of involuntary hospitalization, to prevent arbitrary decisions of hospital-

ization by unauthorized psychiatrists. However,this system increased indiscriminate involuntary
hospitalizations. Psychiatrists could obtain thislicense by means of submitting 8 case reports of
their experience with involuntary hospitalization.
Recently in 2015 and 2016, it was revealed thatmany of these case reports were “fake” reports(copy and paste of the same cases) 25). Accordingly,
the Japanese Ministry of Health and Welfare
revoked more than 100 qualifications.
The Mental Health Act in Japan was revised several times along with its mental health policies toimprove human rights protection and the social
integration of PWMD. However, violence to thepatients by their workers at some psychiatric hospitals have been repeatedly reported. Japan has
been continuously criticized by prestigious international organizations for its involuntary and longhospitalization along with physical restraint; aswell as polypharmacy of psychiatric drugs. In
2013, a suit on the unconstitutionality of involuntary commitment was dismissed.
In July 2016, 19 handicapped people were killed
and 26 were injured in a facility by a previous
employee of the facility who, in February 2016,
had in a letter to the Congress Chairman confessed
his plan of this massacre based on his belief of
eugenics 8). This was brought to the attention of thepolice. Moreover, a few days later he confessed
these beliefs at the facility then voluntarily terminated his job. Again, this was brought to the attention of the police, then the mayor ordered that two“designated mental health doctors” must assess theindividual for involuntary hospitalization. He wasthen hospitalized involuntarily. After two weeks,
he was discharged. This was then followed by the
July massacre. A Governmental committee was set
up to discuss this tragedy and issued a report inearly December stressing the necessity of continuous “support” (actually “monitoring”) to those− 152 −

Clin Eval 48

who are discharged from involuntary hospitalization. Eventually, revision of Mental Health Act tostrengthen such “support” was proposed in May
2017 but it has not passed yet.
Coincidentally in May 17, 2017, a young New
Zealand man, teaching English language in Japan,
suddenly died after being restrained to bed for 10
days in a psychiatric ward 26). He was then sufferedfrom bipolar disorder and admitted to a psychiatrichospital with manic episode. Cause of death isalleged due to deep vein thrombosis or adverse
effect of sedative by the bereaved family, quoting
from the doctor’s explanation though the autopsy
was inconclusive. This caused international voice
to review the use of physical restraints in Japanese
psychiatric treatment, where average time of physical restraint is 96 days, comparing several to tensof hours in other countries.
2.2.3 South Africa
Democracy was established in South Africa in1994 and its Constitution implemented in 1996,
thereby overcoming the notorious apartheid era
since 1948. Of note, the latter had, followed colonialism and segregation since the 17th century 27).
The first hospital for mentally deranged persons
was established in 1711, being followed by theprison colony on Robben Island in 1846. From thelatter half of 20th century “political criminals”
who struggled for freedom of black people were
imprisoned in Robben Island, and the mental hospital was converted into a hospital for chronicallyill patients 28, 29). Some other “lunatic asylums”
were established in the first half of the 20th century. These were regulated by the 1916 Mental
Disorders Act, and thereafter by the Mental Health
Act in 1973. Private hospitals made profit from thegovernment according to the number of patients.
These hospitals have used the labor of thesepatients for building and repairing their facili-

Suppl XXXVII 2021

ties 30). Especially in the era of apartheid, discrimination against black patients and political abuse ofpsychiatry were strongly criticized through theinternational investigations by the America Psychiatric Association and A Special Committee on
the Political Abuse of Psychiatry of the Royal
College of Psychiatrists in 1983 31).
Soon after transition to democracy, the, Mental
Health Policy was issued in 1997 32), and the current day Mental Health Care Act was passed in
2002, followed by the renewed national policy andplan for 2013 to 2020 33). Recognizing the negative
legacy of apartheid and its “vicious circle” of poverty and mental illness, this policy endorsed along-term vision of integrating mental health into
community-based, primary health care programs,
according to the World Health Organization(WHO)’s recommendations 34, 35). With South
Africa’s strong intention of implementing theUnited Nation (UN)’s Covenants on humanrights 36〜38) into their Constitution and the Mental
Health Care Act, the aim was to change discriminatory attitudes toward mental disability and todevelop advocacy strategies according to the WHO
guidelines 39). However, even now several serious
problems remain such as wide discrepancies ofresource among provinces; heavy reliance on psychiatric hospitals; rapid de-institutionalization
without enough development of community-based
services resulting in high numbers of homelessmentally ill. In 2017, the Health Ombud reported
that rapid deinstitutionalization under the “Gauteng
Mental Health Marathon Project (GMMP)”, withmisinterpretation of 2013-2020 policy, caused
more than 94 deaths of patients between March 23
and December 19 in 2016 in Gauteng Province,
being transferred to 27 non-governmental organizations (NGOs) operated under invalid licensed.
This tragedy highlighted the problem of “dualroyalty” conflicts of health professionals follow-− 153 −

臨 床 評 価 48 巻

別冊

2021

ing state policy, taking precedence over their
responsibility of protecting rights and welfare of
their patients 9).

3. Subsystems about mental health
Based on the above review, here we analyse ecological system of these three countries. In Fig. 1, a
Cultural Adaptation Template (CAT) 10) is translated
to apply more specifically to variables relevant tomental health system in South Korea, Japan andSouth Africa. There are some candidate variables
for applying specific analysis as below (Table 3) 40).
3.1 State of Cultural Paradigms: cultural
background
In South Korea, Confucianism philosophy promotes people of authority to act with benevolence
for the favour of vulnerable people, as well as

extended family system have given support to
PWMD. Japanese culture is in majority mixture of
religions of Shinto (belief in Japanese gods) andBuddhism along with Confucianism philosophy.
In South Africa, along with the majority of Africans
with traditional culture and beliefs, Westernizedculture had been established since the era of colonialism in 17th century; then they experienced
recent dramatic democratization overcoming
apartheid in mid-1990s, which contributed to revision of democratic mental health act and new mental health policy. This strong awareness of humanright is common in South Korea, overcoming
political suppression in 1980s. Also, Christianity
shared in 80% of South African and 40% of South
Korean may contribute to humanitarian attitude
toward PWMD, which are not shared in majorityof Japanese. Japan has not historically experienced
civil revolution, as their democratization was direct
result of defeat of World War II where ancientFig. 1 The CAT translated to a current mental health problem space diagram

In fact, variables about State of Community are not limited just ‘mental health act’.
Enforcement ordinances, enforcement regulations, authoritative interpretations andgovernment policies should be considered all together.
Abbreviations: CAT, Cultural Adaptation Template− 154 −

Clin Eval 48

Suppl XXXVII 2021

Table 3 Some variables about social integration and deinstitutionalization in South Korea, Japanand South Africa: Commonalities and variabilities
Acronyms of country names in parentheses are inserted when the item is specific to one or two of the countries.
A. Variables for promoting social integration and deinstitutionalization

B. Variables for impeding social integration and deinstitutionalizationi. State of Cultural Paradigm: cultural background (3.1)(Cultural background)High level of familial support and kin relationship for the cases
Traditional strong brotherhood
Strong community spirit in general(Religious and ethical background)
Healthy spirits and ethics with benevolence/beneficence in
Confucianism (K), Buddhism (J), African indigenous (SA), andChristianity (SA, K)(Background of modern society)Social awakening among intellectuals and social requirement forpolitical correctness(Recent historical background in terms of human right)
Strong human right awareness overcoming political suppression until
1880s (K) or apartheid until mid-1990s (SA).

(Cultural background)
Remnants of feudalistic classism
Faulty collectivism between groups
Firm social prejudice toward mental illnesses(Impact of modernization)
Poor neighbor support in urban areas
Secularism and materialism in modern society
journalism to sensationalize the aberrant behavior of PWMD (K)Ostrich policy of journalism never provide ethical analysis on
conflicting issues in mental health situation concerning (J)(Recent historical background in terms of human right)
Lack of human right awareness because of historical lack of civil
revolution (J)ii. State of Community: regulations and policies (3.2)(Regulations and policies)(Actual difficulties in implementation of legislations and policies)
Strengthened human right protection in recent mental health acts andPrevalent involuntary treatment (K, J, SA)
policies (SA, K, J)
Inadequate enforcement of guardianship and custody in law for
Mental Health Act in SA (2002)
PWMD (K, J)“Law Related to Mental Health and Welfare of the Person with Mental
Mental health policy insufficient for de-institutionalization (K, J)
Disorder” in 1999 and “Act on Support for People with Disabilities” inLack of social agreement about patient autonomy vs paternalism in the2005 (J)revised or newly enacted laws (K, J)
Mental Health Policy Framework and Strategic Plan 2013-2010 (SA)Wong application of governmental policy causing harmful rapid
Enactment of the Mental Health Promotion and Welfare Service
deinstitutionalization (SA)Support Act in Korea (2016)(Constitutional judgment)(Constitutional judgment)
The Judgement of constitutionality of preexisting Mental Health Act
The judgment of unconstitutionality of preexisting Mental Health Act
in Japan (2013) (J)in Korea (2016)
iii. State of Human Health and Wellbeing: social welfare (3.3)
Appropriate level of social security (K, J)
Legal obligation of employment of PWMD

(Actual difficulties to facilitate employment of PWMD)
Low employment rate of PWMD
inactive back-to-work from sick leave(Poverty problem)
Social determinants such as poverty, unemployment, violence,
substance abuse, low education, lack of basic amenities, etc. (SA)(Wealthy problem)
Poverty business induced by generous social welfare (J)iv. State of Ecosystem: resource allocation (3.4)(Number of psychiatrists)
An acceptable number of psychiatrists (K)(Education)
Well-educated psychiatrists with global standard of U.S. (K) or U.K(SA)(Financial resources)
Relatively intact control of government, by means of public insurance
system (K, J)
Low cost of treatment
Favorable funding for mental health services (K, J)
Primary care and essential drug-oriented healthcare policy, which isinevitable because of limited resources (SA)(Prevalence)High suicide rates (K, J)
Steeply rising the prevalence of mental disorders (K, J)(Number of psychiatrists and staff)
Excess (J) or insufficient (SA) number of psychiatrists
Insufficient number of mental health nurses and clinical psychologists(K, SA)(Education)
Limited globalization in education of psychiatrists (J)(Facility resources)
Insufficient social rehabilitation services
High number of Mental Hospitals (K, J)
Unacceptable level of some facilities
Sufficient number of outpatient/day treatment facilities not resulting in
de-institutionalization because of excess number of hospitals (J)(Financial resource)Long economic slump in Korea (K); poverty and political corruption (SA)
Although there are sufficient mental health professionals, integrationof mental health service in community-based primary care system has
not been enough(Inappropriate resource allocation)
Unsound (J, K) or limited (SA) financial allocation
Mental health resources centralized in and near big cities and in large
institutions
Squander of medical expense (J)Abbreviations: K, Republic of Korea; J, Japan; SA, Republic of South Africa− 155 −

臨 床 評 価 48 巻

別冊

2021

regime of Imperial system was kept.

3.3 State of Human Health and Wellbeing:social welfare

3.2 State of Community: regulations andpolicies
Within the above-mentioned cultural paradigms
and historical contexts, each of South Korea, Japanand South Africa has established, developed andimproved mental health legislations and mental
health governmental policies.
South Korean Constitutional Court stated 7) that
the Act is insufficient to minimize human right
infringement to deprive freedom of body and does
not provide explicit standard to evaluate what is
the mental disability which needs hospitalization.
Meanwhile, Japanese Court denied the claim of
unconstitutionality of the pre-existing Mental
Health Act.
On the other hand, South African mental healthlegislation is positively evaluated in terms of minimization of such human right infringement 41).
Their legislation defines not only about the consent of related people and diagnosis of psychiatrist
but also how decision-making capacity and risk toharm him/herself or others are defined in the legislations 41). This is the point exactly the Korean
Constitutional Court criticized pre-existing Act.
South African Constitution, established overcoming apartheid, leads the Mental Health legislation with solid human right protection. However,
because of “selectively interpreted, misrepresented” implementation of 2013-2020 mental
health policy, rapid deinstitutionalization of mentally-ill patients caused tragedy of great deal ofdeaths of these people. This was condemned by the
Health Ombud that certain officials and certain
NGOs violated the Constitution and Mental Health
Act and the Mental Health Care Act.

Social welfare, as the foundation of wellbeing of
PWMD, is well-established in Korea and Japan,
meanwhile in South Africa, poverty-related mental
ill-health is regarded as in a vicious cycle, andsocial determinants such as poverty, unemployment, violence, substance abuse, low education,lack of basic amenities etc. has been serious unresolved problems 33). Each of the three countries haslegislative provision for employment of people ofmental disorders, integration of these people into
the society has not been enough.
In contrast, in Japan, its well-established social
security is sometimes criticized that it discourages
the willingness to become economically independent of people in poverty. What is even worse, itcaused unethical “poverty business”, aiming to
exploit from the poverty people, e.g., some mental
clinic provided cheap residence to PWMD to rip
off their welfare payment 42).
3.4 State of Ecosystem: resource allocation
While the laws and policies have been developed, prevalence of involuntary hospitalization isstill now high rate in these countries (Table 1), andpolicy for de-institutionalization has not yet
worked well. In both of South Korea and Japan,
insufficient social services, too many mental hospitals, inadequate allocation of financial andhuman resources, and urban concentration of facilities, along with high suicide rates and steeply rising prevalence of mental disorders, have been
impeding variables 1).
In South Korea, the retrenched government budget due to long economic slump is another threat in
the community 2). Among the total amount of healthresource, only 2.6% has been used for mental− 156 −

Clin Eval 48

health sectors 1). Furthermore, much of financial
resources are spent in mental hospitals, not forcommunity centres. In South Korea, 90% of psychiatric hospital beds are private and in Japan, it is
83% 43). In Japan, squander of medical expensecauses stagnation of de-institutionalization and“comfortable” hospital environment has been reason of justification of long-term hospitalization.
Japan is relatively high-income country and canafford to consume substantial money of publichealthcare insurance for long term hospitalizationand irrational prescription of multiple dosing regimen.
In South Africa, although dramatic democratization in the late 1990th, recent political corruption
has expanded the gap between wealth and poverty.
Their mental health services still have been labour
under the legacy of colonial mental health system,
reliance on mental hospitals (WHO-AIMS). In thecase of Gauteng Province (GMMP), the Health
Ombud’s report 44) stated that “newly-establishedSuppl XXXVII 2021

NGOs were mysteriously and poorly selected,
poorly prepared, “not ready”, their staff was nottrained, not qualified”; “patients were transferred
to faraway places from their homes and communities, bringing additional financial burden and stresson the family”.

4. System-of-Interest for social integration of PWMD
4.1 System-of- Interest under the pre-existing mental health act
The mental health problem space described inFig. 1 can be applied to two specific system-ofinterest (SSoI) under the pre-existing mental healthact in Fig. 2, and the revised Mental Health Act in
Fig. 3.
Seen in Fig. 2, all causal loop diagrams haveeffects of vicious cycles. The details of each links
have been stated in Table 4. This means poor social

Fig. 2 Social integration under the pre-existing mental health act: vicious cycles

The diagram is a system-of-interest diagram that focused on the public perception toward the
Persons with Mental Disorder (PWMD) and the number of inpatient beds. The 4 CLD show somebandwagon effects: social effect (L1-L2), health effect (L1-L3-L4), environmental effect(L1-L5-L6) and co-effects (L1-L5-L7-L4)
Abbreviations: PWMD, Persons with Mental Disorder; CLD, Causal Loop Diagrams; L, Loop
− 157 −

臨 床 評 価 48 巻

別冊

2021

Fig. 3 Social integration under the revised Mental Health Act: virtuous cycles

The diagram is a system-of-interest diagram that focused on the public perception toward the
PWMD and the number of inpatient beds. The 4 CLD show some bandwagon effects like Figure 2.
Abbreviations: PWMD, Persons with Mental Disorder; CLD, Causal Loop Diagrams

integration and long hospitalization is an inevitable consequence under the current system in Japanand South Korea. This bandwagon effect of thesystem makes public prejudice worse. In this condition, it is hard to expect the shifting of the cultural paradigm about mental disorders.

4.2 SSoI under the revised Mental Health Act
Unlike Fig. 2, Fig. 3 illustrates what changes
will be expected in the subsystems, after an enactment of the new, innovative Mental Health Act,
along with the establishments of revolutionary

Table 4 Influence links in the System-of-Interest under the pre-existing mental health act
Link

Actions/ processes/ mechanisms represented in Fig. 2

1

Public prejudice (irrational belief) toward predictability of psychiatry on PWMD to harm him/herself orothers leads to justifiability of pre-existing mental health act in Korea and Japan.

-

2

Coercive measures for dealing with PWMD affect public perception in a negative way. Stigma towards
mental disorders tend to be justified by the official and conventional laws and institution.

-

3

Involuntary commitment-oriented policy is one of the biggest barriers for social rehabilitation.

-

4

Public indifference toward PWMD and insufficient outpatient treatment could cause failure of social
integration which increase the prejudice against PWMD.

+

5The original concept of mental health act induces the health care marketplace to expand the psychiatricbeds. As a result, inpatient beds per 1,000 people are 2.9 and 1.31 in Japan and Korea in 2012, respectively. Economic incentives may add up this trend. The rates of inpatients staying longer than 1 year are
more than 65% in Japan, 37% in Korea, not reported in South Africa in 2014.

+

6

Increased psychiatric beds affect the public perception toward PWMD negatively, like ‘They ought tobe in hospital, and separated from society.’-

7

Institutionalization of PWMD hinders social rehabilitation directly. They lost opportunities to engage
with other people, and lack of social relationship lead to poor social skills subsequently.

-

Abbreviations: PWMD, Persons with Mental Disorders− 158 −

Polarity

Clin Eval 48

Suppl XXXVII 2021

Table 5 Influence links in the System-of-Interest under the revised Mental Health Act
Link

Actions/ processes/ mechanisms represented in Fig. 3

1

A constructive change of the cultural paradigm with healthy skepticism about psychiatric disorders is a
powerful foundation of revolution of the care principle of Mental Health Act.

Polarity+2

Deinstitutionalization oriented Mental Health Act promotes changes from social isolation toward social
inclusion of PWMD of the public.

+

3

Clarification about involuntary hospitalization as unconstitutional and basically human right
infringement induce the re-socialization of PWMD spontaneously. Such proactive arrangement of legal
regulation provokes the social change with knowledgeable public-driven outpatient care and social
inclusion of PWMD.

+

4With the proper intervention for behavioral problems of PWMD along with personalized support toward
employment will facilitate mutual interaction with PWMD and the open attitude of the public about
mental disorders.

+5

According to the revised Mental Health Act, huge capacity for hospitalization is no longer required.
Redistribution of medical resources should be viewed in association with the increased demand for
outpatient care.

-

6

Decrease or even abolishment of big mental hospital like asylum as it is defined to be unjustifiable bylaw is closely linked up with decrease of prejudice and stigmatization that they ought to be in hospitaland separated from society .

-7

Decreased number of mental hospitals and increased capacity of outpatient care promotes social
integration of PWMD, automatically-

Abbreviations: PWMD, Persons with Mental Disorders

policies.
Seen in Fig. 3, all causal loop diagrams haveeffects of positive reinforcements. The details ofeach links are shown in Table 5. This means thechange of social institution such as new innovative
laws or enlightened policies can trigger profoundchanges on all subsystem about mental health.

5. Economic interests of stakeholders
and sensationalism in media
From the above analysis, we hypothesized as
driving force triggers two significant rate-limiting
factors for hindering healthy feedbacks of the system. The first is economic motivation of mental
facilities, which mostly impact on ecosystem (B1in Fig. 4); the second is the issue of journalism
which should mostly impact on cultural paradigm
and public perception (B2 in Fig. 4). These two
causal loops, B1 and B2, may block the virtuous
circle for deinstitutionalization and social integration for PWMD by “lock-in effects”. However, if

we well recognize these two feedback loops andcontrol successfully, two desirable reinforcing
feedback loops will start (R1 and R2 in Fig. 4).
For R1, obvious solution is to switch financial
resource allocation from hospital to communitybased facility. However, the process would takelong time because strong economic incentives ofmental facilities is big obstacle, as typically shownin Japan. Meanwhile, poorly implemented deinstitutionalization plan is typically shown in South
Africa. These two contrasting examples would
clarify critical points to consider.
The secondary factor of the obstacle, the issue ofjournalism, varies in the three countries.
In Korea, the unhealthy commercialism of thepress tends to sensationalize the aberrant behaviour of PWMD. Clinically, violent behaviour orhomicides by PWMD are extremely rare.
Nevertheless, exaggerated and repetitive reports
make people to be scared at mental illnesses.
Imprudent social networking service (SNS) usage
patterns may play roles to increase the prejudices− 159 −

臨 床 評 価 48 巻

別冊

2021

(B2 in Fig. 4). Actually, the Constitutional decision about unjustifiability of involuntary hospitalization legislation have made meaningful changesof the attitude of journalism.
In Japan after the event of slaughter of 19 disabled people, media promote to show the lives ofsuch disabled people and tend to avoid strengthening involuntary hospitalization of a person at riskof harming others. However, some critics argue
that the institutionalization of the disabled itself
indicates the public indifference of human right.
Ostrich policy of Japanese journalism never provide ethical analysis of essential conflict of values
between protection of vulnerable people and fun-damental human right of freedom. We believe thisshould be one of the main causes of inability ofshifting from hospital-based to community based
psychiatric care.
In South Africa, the situation of journalism iscompletely different form both of South Korea andJapan. In South Africa, there is a strong cultural
framework to avoid discrimination, fostered fromtheir modern history to overcome apartheid. We
can find much of media advocacy to achieve
human rights. However, actual limitation of
resource and gap between rich and poor are crucial, unresolved problem. Also, the moral lesson ofGauteng Province (GMMP) revealed that regard-

Fig. 4 SSoI merged with the CLD of two external drivers

This diagram summarizes the ‘lock-in effects’ by two major external drivers, i.e., economic motivations of mental faculties
and yellow journalism about mental disorders. According to the CAT, economic incentives related to the management of mental
health facilities may be included in the ecosystem, and sensationalism in the news media may be included in the community.
However, they would do better to be regarded as external factors for clarification, under the new situation of enactment of therevised mental health act. Only if the two major external drivers are under control, healthy positive feedback will be expected.
(B means negative feedback loop, and R means reinforcing feedback, respectively.)
Abbreviations: SSoI, Specific System of Interests; CLD, Causal Loop Diagrams; CAT, Cultural Adaptation Template− 160 −

Clin Eval 48

less of the ideal Constitution and mental healthlegislation, their misinterpretation and inadequate
resource allocation will inevitably originate
human-made disaster.

6. Conclusion:
For the human rights of PWMD
As described above, it is never easy to achievedeinstitutionalization of PWMD. Drastic decision
making of a nation to shift the limited resourcefrom hospital-based toward community-based carewould prerequisite. Healthy journalism would be a
key factor to overcome deep-routed economic
motivation of private hospitals to keep patients
inside the walls. Journalism is much cultural issue
and various in each culture. However, fundamental
bill of human rights is common in the world.
Therefore, cultural advocate and enlightenment by
journalism based on solid belief and recognition
that justifiability of involuntary hospitalization isinherently dubious would support future directionof reformation. Positive future does not comecheap. By our vigorous system analyses about
ecology of mental health spheres with South
Korea, Japan, and South Africa, mental healthcare
can be reformed constructively and drastically.
Conflict of interests
We declare no conflict of interest in the form of financial support or relationship.
Author Contributions
In this study, HP conceived the conception and designof this research. HP, TS, AD and CK acquired the data.
TS and CK integrate and analysed the data in the whole.
HP, TS and AD drafted the manuscript and figures. All
authors contributed to and have approved the final manuscript.

− 161 −

Suppl XXXVII 2021

References
1) The Economist Intelligence Unit Limited 2016.
Mental health and integration. Provision for supporting people with mental illness: a comparison of
15 Asia Pacific countries.
2) Roh S, Lee SU, Soh M, Ryu V, Kim H, Jang JW, Lim
HY, Jeon M, Park JI, Choi S, Ha K. Mental healthservices and R&D in South Korea. Int J Ment HealthSyst. 2016 Jun 2; 10: 45. doi: 10.1186/s13033-0160077-3. PMID: 27257434; PMCID: PMC4890259.
3) Lee MS, Lim HY, Kim Y, Lee YS. How can a change
in the operating system of the mental health review
board promote the discharge of long-term hospitalized psychiatric patients? A case study of Seoul city.
Int J Ment Health Syst. 2014 Aug 4; 8: 33. doi: 10.
1186/1752-4458-8-33. PMID: 25114716; PMCID:
PMC4128823.
4) Setoya, Y. Overview of the Japanese mental healthsystem. Int J Ment Health. 2012; 41(2): 3-18.
5) Ministry of Health, Labour and Welfare, Japan.
Reference. 2014 Mar 28 [cited 2017 May 1]. Available from: https://www.mhlw.go.jp/file/05-Shingikai12201000-ShakaiengokyokushougaihokenfukushibuKikakuka/0000046405.pdf
6) World Health Organization (WHO). Mental HealthAtlas-2014 country profiles (Republic of Korea,
Japan, South Africa) [cited 2017 May 1]. Available
from: http://www.who.int/mental_health/evidence/atlas/profiles-2014/en/
7) Constitutional Court of Korea. Decision of the unconstitutionality appeal of Mental Health Act Article
24(1) (Case number 2014 Heonga 9), Constitutional
court 2016. 9. 29. 2014 Heonga 9, Law reports 28-2
Sang, 276 [cited 2017 Aug 20]. Korean. Available
from: http://search.ccourt.go.kr/ths/pr/ths_pr0103_
Print.do?cId=010300&seq=0&cname=%ED%8C%
90%EB%A1%80%EC%A7%91&eventNo=2014%
ED%97%8C%EA%B0%809&pubFlag=0&eventN
um=41196&selectFont=normal&showHide=
8) McCurry J. Japan knife attack: stabbing at care centre leaves 19 dead Man armed with knives attacks
facility in Sagamihara, outside Tokyo, before telling臨 床 評 価 48 巻

別冊

2021

police: ‘It is better that disabled people disappear’.
The Guardian. 2016 Jul 26.
9) Dhai A. The Life Esidimeni tragedy: Moral pathology and an ethical crisis. S Afr Med J. 2018; 108(5):382-5. DOI:10.7196/SAMJ.2018.v108i5.13232
10) Dyball R, Newell B. Understanding human ecology:
A systems approach to sustainability. London and
New York: Routledge; 2015.
11) Mental Health Act. Wholly Amended by Act No.
5486, Dec. 31, 1997; Last amended by Act No.
13323, May 18, 2015.
12) Enforcement Decree of the Mental Health Act.
Wholly Amended by Presidential Decree No. 15790,
May 6, 1988; Presidential Decree No. 26683, Nov.
30, 2015.
13) Law Related to Mental Health and Welfare of the
Person with Mental Disorder. Full text as amended(Law No. 94 Dated June 23, 2006).
14) Ministerial Ordinance for Enforcement of the Act on
Mental Health and Welfare for the Mentally Disabled.
Japanese.
15) Mental Health Care Act 17 of 2002, assented to 28
October 2002, Date of commencement: 15 December
2004. (English text signed by the President) as
amended by Institution of Legal Proceedings against
Certain Organs of State Act 40 of 2002, Judicial
Matters Amendment Act 55 0f 2002, Regulations
under this Act: General Regulations (GN R1467 in
GG 27117 od 15 December 2004).
16) United Nations. Universal declaration of humanrights. 1948.
17) United Nations. §1, 3 and 11, Principles for theprotection of persons with mental illness and theimprovement of mental health care. 1991.
18) Office of the High Commissioner for Human Rights,
United Nations. §19, The Convention on the Rights
of Persons with Disabilities. 2006.
19) World Health Organization. Mental health care law:ten basic principles. 1996.
20) The Constitution of the Republic of South Africa. As
adopted on 8 May 1996 and amended on 11 October
1996 by the Constitutional Assembly.
21) National Center of Neurology and Psychiatry.
History of Korean Mental Health and Social Welfare.

Japanese [cited 2017 May 1]. Available from: https://www.ncnp.go.jp/nimh/keikakuold/old/archive/
vision/overseas_kr.html
22) Oh, EH. Paradigm of Korean Mental Health Act:
Prospecting its revision. The 62nd Autumn Meetingof the Japanese Society of Social Welfare. (pp. 179180). the Japanese Society of Social Welfare; 2013;
Tokyo, Japan.
23) Kahng SK, Kim H. A developmental overview ofmental health system in Korea. Soc Work Public
Health. 2010 Mar; 25(2): 158-75. doi: 10.1080/
19371910903070408. PMID: 20391259.
24) Saio T, Sakurazawa H. Odds and sods among thegeese when the gander is away: Reviewing Japanese
psychopolitics. Rinsho Hyoka (Clin Eval). 2014. 41(3):619-26.
25) Health ministry inspects Kawasaki hospital overfake accreditation of doctors. Japan Today. 2015
July 14 [cited 2017 Jul 30]. Available from: https://japantoday.com/category/national/health-ministryinspects-kawasaki-hospital-over-fake-accreditationof-doctors?comment-order=popular26) Hurst D, Roy A. New Zealand man died after beingtied to bed in Japanese hospital. The Guardian. 2017
Jul 13 [cited 2017 Jul 30]. Available from: https://www.
theguardian.com/world/2017/jul/13/new-zealandman-dies-tied-bed-japanese-hospital27) Coovadia H, Jewkes R, Barron P, Sanders D,
McIntyre D. The health and health system of South
Africa: historical roots of current public health challenges. Lancet. 2009 Sep 5; 374(9692): 817-34. doi:
10.1016/S0140-6736(09)60951-X. Epub 2009 Aug
24. PMID: 19709728.
28) Emsley R. Focus on psychiatry in South Africa. Br J
Psychiatry. 2001 Apr; 178: 382-6. doi: 10.1192/bjp.
178.4.382. PMID: 11282826.
29) Makepeace R. The history of psychiatry in South
Africa. Can Psychiatr Assoc J. 1969 Apr; 14(2):221-2. doi: 10.1177/070674376901400216. PMID:
4891135.
30) Ure GB. Mental health care in South Africa 1904 to
2004: legislation influencing ethical patient care
(Doctoral Dissertation). 2009.
31) Timbury G. Report of the Special (Political Abuse of− 162 −

Clin Eval 48

Psychiatry) Committee on South Africa. BJPsych
Bull. 1983; 7: 115.
32) Department of Health. White paper for the transformation of the health system in South Africa (Vol.
382). 1997; Pretoria, South Africa.
33) Department of Health. National Mental Health
Policy Framework and Strategic Plan: 2013-2020.
2014; Pretoria, South Africa.
34) World Health Organization. Human resources andtraining for mental health. Mental health policy andservice guidance package. 2005a.
35) World Health Organization. Mental health policy,
plans and programmes. Mental health policy andservice guidance package. 2005b.
36) Office of the High Commissioner for Human Rights,
United Nations. The Convention on the Rights of
Persons with Disabilities: Training Guide. 2014.
37) United Nations. International covenant on civil andpolitical rights. 1966a.
38) United Nations. International covenant on economic,
social and cultural rights. 1966b.
39) World Health Organization. Advocacy for Mental
Health. Mental Health Policy and Service Guidance
Package. 2003.
40) Fischer J, Dyball R, Fazey I, Gross C, Dovers S,＊

Suppl XXXVII 2021

Ehrlich PR, Brulle RJ, Christensen C, Borden RJ.
Human behavior and sustainability. Front Ecol
Environ. 2012; 10: 153-160.
41) Fistein EC, Holland AJ, Clare IC, Gunn MJ. A comparison of mental health legislation from diverse
Commonwealth jurisdictions. Int J Law Psychiatry.
2009 May-Jun; 32(3): 147-55. doi: 10.1016/j.ijlp.
2009.02.006. Epub 2009 Mar 19. PMID: 19299015;
PMCID: PMC2687511.
42) The Japanese Society for Day Care Treatment. The
Final Report on E-Clinic Issue. 2019 March [cited
2019 Apr 1]. Available from: http://www.daycare.
gr.jp/pdf/eclinicproblem_investigationcommittee_
surveyreport-2019.03.pdf43) Taplin R, Lawman SJ. Mental health care in Japan(Vol. 43). New York: Routledge; 2012.
44) Makgoba MW. The report into the ‘Circumstances
surrounding the deaths of mentally ill patients:
Gauteng Province’: No guns: 94+ silent deaths andstill continuing. 2017 [cited 2017 Nov 1]. Available
from: http://www.politicsweb.co.za/documents/thelife-esidimeni-disaster-the-makgoba-report(Submitted December 15, 2020)(Accepted January 30, 2021)＊− 163 −＊