In this Article
By Michael Iwama
This paper attempts to reconcile my understanding of why a client-centred practice has not been readily adopted in Japan. I am a Canadian citizen born in Japan of Japanese heritage, but raised (and thoroughly socialized) in Canada. I see myself as identifying with Canadian, as well as with occupational therapy cultures. In each designation, I share a distinct set of values, beliefs and social norms.
When I first arrived in Japan to teach occupational therapy, I proceeded to observe and interpret everything around me in this new environment with my Canadian pattern of values and beliefs. Naturally, I interpreted many of the new foreign ways I couldn't make sense of negatively. The propensity for group consensus in the most trivial matters, the seeming lack of straight, honest communication, dramatic changes in people's behaviours according to situation, caused me fits of frustration. It only was when I began to ask myself 'why', and reflected on my own acquired culture, that I could begin to understand and appreciate a Japanese person's unique world and self view. This awareness, in turn, highlighted how culture-bound Canadian occupational therapy and its client-centred approach can be.
A Matter of Culture
Case Study: Mr. Tanaka
Mr. Tanaka was administered the Canadian Occupational Performance Measure (COPM) (Law, Baptiste, Carswell, McColl, Polatajko, and Pollock, 1996) which had recently been translated into Japanese. When asked to express his problems with his self-care, productivity and leisure, he seemed confused and lost for words. He looked to another patient sitting nearby for help to little avail and then back to the card set in front of him. At one point he uttered to his occupational therapist, with a look of sincerity, "Please, I'll leave it to you."
When pressed to answer, he responded with "Please ask my wife and daughter when they come to visit this afternoon." At another point, he apologetically asked, "Could you explain to me what 'leisure' means again?"
Similarly, his occupational therapist later revealed to me that she too was perplexed by the COPM. She had gone to the COPM training workshop and learned how to administer it but felt awkward with the protocol and the aim of the measure. Like Mr. Tanaka, the occupational therapist felt that she had failed somewhat in the process and that "If (she) had tried harder the COPM would have worked better."
It became apparent that the problem was more about culture than about Mr. Tanaka's or his occupational therapist's unsatisfactory performance. Not only is the COPM constructed on the social norms of western societies; it reflects the pattern of values and beliefs of Canada and of Canadian occupational therapists. In other words, Mr. Tanaka's and his occupational therapist's perplexity with the COPM were expressions of a process out of cultural context and of dubious meaning to the participants.
When Mr. Tanaka finished his therapy and was leaving the treatment area, a simple expression from his therapist returned a smile to his face. She said, "Let us try our best again tomorrow." The us and our re-affirmed that Mr. Tanaka was not alone with his quest to improve. It was equally every group member's aim and responsibility to make it happen. Likewise, success would equally belong to everyone and failure would result in each member wishing that they had tried harder.
Client-centredness: Out of social context in Japan
Wa might help to explain any reluctance to use the COPM in Japan or to fully embrace a client-centred approach to care. Wa can mean circle or harmony and reflect the prominence and pre-occupation with one's group(s) over one's self. Within the Wa, one can affirm one's place and role and derive a sense of identity. The meaning of one's life is experienced in doing one's part. Knowing your part and performing it to the best of your ability is a source of joy and fulfillment for many Japanese people. Being put out of the Wa invariably results in deep personal crisis and serves as a powerful mechanism for individuals to sacrifice personal ambition for the sake of being accepted by the group. Japanese collectivism as embodied in Wa often presides over self and individualism. Thus, client-centredness reflects a cultural pattern very much out of social context in Japan.
Persistence of culture in the client
Japanese occupational therapists find themselves struggling to reconcile the Western-world, culturally-entrenched ideas about client-centred practice into their own, profoundly different culture. If the profession of occupational therapy aspires to implement a client-centred practice internationally, the profession needs to consider the various contexts and cultures within which practice occurs in greater depth. In Japan, the guiding principles of client-centred practice must incorporate traditional values and beliefs, and also, reconcile with existing social norms in order to be successful. Ultimately, a client-centred approach, which incorporates Japanese Wa, may be necessary for the sake of rendering effective occupational therapy to Japanese society.
Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollock, N. (1998). Canadian occupational performance measure (3rd ed.). Ottawa, Ontario:CAOT Publications ACE.