November / December 1999
Table of Contents
In this Article
Client-centredness: Out of social context in Japan
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
Culture can mean many different things to different people. For many,
it is about what makes others different from us. Those differences are
often reduced to observable features of people like skin colour, language,
food and customs, to name a few. The common tendency, unfortunately, is
to generalize and reduce individuals to the labels and stereotypical meanings
that have been ascribed to them by the dominant in-group. Culture, in
this article, is defined alternatively to be a shared system of meanings
that "involve ideas, concepts and knowledge, and include the beliefs,
values and norms that shape standards and rules of behaviour as people
go about their everyday lives" (Dyck, 1998, p.68). In this interpretation,
Canadian society, biomedicine, and occupational therapy can represent
distinct cultural groups, each holding their own distinct patterns of
beliefs, values and social norms. Client-centredness is one manifestation
of Canadian occupational therapy culture.
Case Study: Mr. Tanaka
Mr. Tanaka is a manager in a small printing company who was admitted to
the hospital with lower back pain and referred to occupational therapy.
No different than the pattern of behaviours of the other patients on his
ward, Mr. Tanaka changed from his usual gregarious self to, what would
look to the Westerner as, a passive, obedient disposition upon arrival
to occupational therapy. He had transformed into a model patient. He answered
all questions put to him succinctly and did exactly as he was asked by
the occupational therapy staff. That also meant not asking questions and
doing the therapeutic activities to the best of his ability without complaint
or question. When the occupational therapist came to greet him, he bowed
as deeply as he could and maintained his passivity.
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?"
The therapist replied, "I am not exactly sure but I think it is your
hobbies and what you do when you are not at your workplace." At the
end of the session, Mr. Tanaka apologized while bowing incessantly that
he was sorry to have disappointed everyone with his inability to do the
COPM. He promised to try harder the next time.
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
Nakane (1970), a Japanese social anthropologist, was first to describe
the hierarchical structure of Japanese human relations. Her view emphasized
the strong group orientation of the Japanese held together by the persistence
of vertical, as opposed to horizontal, egalitarian loyalties. It's difficult
to imagine, through the Western mind-set, that most Japanese individuals
experience greater difficulty in equal relationships than in hierarchical
relationships. The hierarchical structure of relationships contributes
toward order, harmony and to a certain predictability of the Japanese
collective. This collective harmony is often referred to in Japanese as
Wa.
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
Client-centred practice grew out of and reflects the core values, beliefs
and social norms of both occupational therapy and of mainstream Canadian
society. Ideally, client-centred practice will persist, at least in the
West, because the majority of us believe in its rightness, value it greatly
and have instituted it as standard in our ideas about people. However,
we need to consider the cultural nature of our clients who have not been
socialized in the West, and who may hold values, beliefs and social norms
about health which differ from our own. Paying attention to pervasive
cultural beliefs, values and norms must also be factored into any client-centred
practice.
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.
References
Dyck, I. (1998). Multicultural society. In D. Jones, S. Blair, T. Hartery
and R. Jones (Eds.), Sociology and occupational therapy; An integrated
approach. (pp. 67-80). London: Harcourt Brace and Co.
Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollock, N. (1998). Canadian occupational performance measure (3rd ed.). Ottawa, Ontario:CAOT Publications ACE.
Nakane, C. (1970). Japanese Society. Harmondsworth: Pelican.
Contact
Michael Iwama M.Sc., OT(C), is a third generation Japanese Canadian
who was born in Japan and raised in Canada. He studied Kinesiology (B.Sc.,
UVIC) before going on to finish his B.Sc. and M.Sc. in Occupational Therapy
at the University of British Columbia. Now he is back in Japan as Associate
Professor in the Department of Occupational Therapy, School of Health
Sciences at Kibi International University, and completing a Ph.D. in Sociology.
He can be contacted by e-mail: mkiwama@kiui.ac.jp
November / December 1999 Table of Contents
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