I have been obsessed with this book since I started it a week ago. Nakamura gives us such an intriguing glimpse into Bethel, a community of severely mentally ill people in the remote north of Japan (Ainu country), associated with Japan's Christian church, a driven psychiatrist and a charismatic central group of 'patients'. Bethel includes a set of group homes, some independent living facilities, a business, and treatment at the local hospital. With more than a hundred members, it dominates the town it is located within and has a significant waiting list.
Nakamura contextualises Bethel for non-Japanese readers. She explains the history of mental health treatments in Japan (institutionalisation is lengthy and still common, psychiatry requires no more than a medical degree to practice, epilepsy is weirdly included as a mental illness (as is addiction), and the country has a social welfare system). These sections can make the introduction heavier going than the book rapidly becomes, as Nakamura's ethnographic approach rapidly takes a back seat to the engrossing stories of the residents, the doctors, and the project itself. This is amplified by the addition of two films, viewable online once you have purchased the book, which bring to life the people she is writing about.
Bethel is fabulously interesting. Founded around the central belief that people with schizophrenia should aspire not to be cured, but to live a rich life, the facility is designed around sociality. Residents are minimally medicated, work together to stay safe during delusions (there is, hilariously, an annual prize for the best socially managed hallucination and delusion), and conduct their own diagnosis/research projects into themselves. The latter involves them identifying "sub-types" that focus on how their life is impacted (e.g. schizophrenia of the running-out-of-money and blowing-up sub-types), as well as developing strategies to deal with this. These strategies usually involve working with their delusions and with their community. One moving plan for a young woman whose paranoia made it difficult to function included asking her community to act as a jury for her, acquitting her of the crimes she was worried she might have committed. Principles for the community include " Trust in the power of the group", "Weakness binds us together", "Bethel’s colors [diversity] make sales go up!" and "Don't try to fix your illness by yourself".
Nakamura is clear that she is not qualified or focused to assess the effectiveness of this treatment. But for anyone with familiarity with serious mental health (clearly including Nakamura), it is hard not to fall in love with these concepts. Whereas cure-focused treatments tend to disempower sufferers, focusing on what they lack and on managing a myriad of medication side effects, Bethel's patients exert agency and have rich lives in the here and now. Some of the teachings employed to get here can be jarring: Bethel's principles also include "Go from a “life of ascent” to a “life of descent.”", for example, making explicit the core belief that happiness comes from eschewing ideas of progress. The workshop encourages "goofing off", talking, and "don't try too hard!" but to do so relies on sheltered workshop rules. Towards the end of the book, Nakamura covers many of the challenges encroaching on the system, including those posed by depression and personality disorder sufferers, for whom the intense focus on social connection is less miraculous.
In the end, though, Nakamura succeeds in showing us that even as this community will inevitably change, it has inspired psychiatry across Japan to change, and it has inspired sufferers and their loved ones to demand, experiment with and work towards new futures. And this sense of agency, of perhaps, being enough, is something pretty amazing and hopeful for all our futures.