SCMP Monday, July 16, 2001
The knife-wielding schizophrenic who stabbed eight children to death in an Osaka school last month did more than just take the lives of his young victims.
Mamoru Takuma, 37, did serious damage to the image of the mentally ill in Japan, further reinforcing the fear and dread that characterises the community's perceptions of such individuals.
It has taken a tragedy on the scale of the Ikeda Elementary School stabbings, which also saw 13 pupils and two teachers injured, to force the Government to finally pay much-needed attention to the neglected mental health-care system.
The Japanese public reacted to television images of petrified young children fleeing their classrooms into a playground full of ambulances and police cars with disbelief. This kind of thing happens only in America, many thought.
It has also caused concern in Hong Kong, where people are asking: could it happen here? Perhaps the most disturbing question being asked in Japan is whether the mass killing could have been prevented.
Takuma had a long history of mental illness and suicidal tendencies. He became addicted to the tranquilisers he was given, and was arrested for putting psychotropic drugs into the tea of teachers at the school where he worked. Takuma had been put into a hospital with a lack of specialists to deal with him, and was released without subsequent monitoring. There have also been allegations in the Japanese media that he battered and threatened to kill his ex-wife.
How was it that a man with such a history was free to walk into a school and stab children to death?
The Japanese penal code prohibits punishment of people who are unable to understand that their criminal acts are wrong. There are no facilities specifically designed for the criminally insane and doctors have no special training to handle them. Those committed to psychiatric hospitals can be released at any time without court approval, with no system to decide whether the patient is ready to re-enter society.
More than 80 per cent of the 726 mentally ill people suspected of murder between 1995 and 1999 were never indicted, it has been reported.
Takuma's bloody rampage has helped instigate a debate on mental-health care in Japan on whether to screen psychiatric patients for violent tendencies, allow them to be more easily punished under the law or to install a review system to determine whether and when they can be released from mental hospitals.
As far as Hong Kong is concerned, the mechanisms for dealing with mentally ill people with previous convictions are superior to those in Japan, according to social workers, psychiatrists and lawmakers. They say the SAR has an adequate monitoring and rehabilitation system.
Part of the reason for this is that Hong Kong has already had a tragedy which equals the horror of the Osaka stabbings. Forty children were slashed by a schizophrenic at a Shamshuipo kindergarten in 1982. It was this tragedy which acted as a wake-up call for the Hong Kong Government and led to urgent reform of mental-health care.
In the summer of that year, Lee Chi-hang, who suffered from delusions, stabbed his mother and sister to death at their flat and raced down the stairs. With a knife in each hand, he broke into the nearby Anne Anne Kindergarten where he slashed 40 children, killing three before he was finally shot and wounded by police.
Lee, now 47, is still undergoing treatment for his mental illness at Siu Lam Psychiatric Centre.
Legislator Michael Mak Kwok-fung, a psychiatric nurse who represents the health sector, said the 1982 incident prompted several improvements in the monitoring and clinical management of patients with violent histories.
"In terms of the law, the conditional discharge [from hospital] was introduced into the Mental Health Ordinance, which provided that patients with a propensity for violence would be closely monitored and subject to recapture upon their release," he said.
In Hong Kong, mentally ill persons convicted of violent crimes are generally sentenced indefinitely to detention in special institutions such as the maximum-security Siu Lam Psychiatric Centre in Tuen Mun.
Their cases are automatically reviewed once a year by the Mental Health Review Tribunal - an independent body of doctors, judges, psychiatrists, clinical psychologists, social workers and laypeople - which determines whether and when they can be released. Upon their release, they are sent to psychiatric hospitals, such as Castle Peak, where they are further treated and rehabilitated. When the psychiatric professionals at the hospital think the individuals are ready to enter the community, they are generally referred to "halfway houses" upon conditional discharge.
Alice Fu Lau Shuk-yee, social work supervisor at the Mental Health Association of Hong Kong, which runs seven halfway houses, said by the time these patients reached them, they were generally quite stable.
"Here, we provide them with psycho-social rehabilitation," she said. "Many of them have strong regrets about their past, but they have poor impulse control, so we train them in anger management and build workshops to help in their transition into the community."
Patients are classified into ordinary, target and sub-target groups, the latter encompassing the small minority of mentally ill people with a history of or propensity to violence. Sub-target patients are monitored extra closely and are placed with senior medical officers and more experienced workers.
"After 1982, the Hospital Authority and Government really talked about the issues of community psychiatry and that prompted the creation of these halfway houses," Ms Fu said.
"A lot of the patients have stayed in hospital for so many years that they have to pass many hurdles before they can go back into the community - one patient had spent 20 years in the hospital and did not even know what the MTR was."
It is usually recommended that patients spend two years in a halfway house, but the period depends on each individual's progress. After leaving the halfway house, the patients are discharged and the case is followed up with weekly or fortnightly visits by social workers and psychiatric nurses.
The tricky part, though, is preventing violence before any crime has been committed. Dr Ip Yan-ming, spokesman for the College of Psychiatrists, who has been in private practice for 22 years, said: "No matter what we do, these sorts of accidents can still occur as long as the community is not educated in mental health and does not know how to deal with mental illness."
While psychiatrists watch for patients who may potentially harm themselves or others, there is no foolproof method of screening those patients.
Dr Gabriel Yu Ka-kui, a senior medical officer at the Queen Mary Hospital psychiatric centre, said: "Large-scale studies have been conducted into associated factors of psychiatric illness and crime, but it is still extremely difficult to generalise and infer it.
"In usual psychiatric examinations, we will look for a history of aggression and if we see any symptoms such as delusions of persecution, we will keep a close eye on these patients, follow them and actively trace them if they fail to turn up for an appointment."
But if a patient refuses to receive psychiatric treatment, they cannot be forced into it unless there is hard evidence that they could be a threat to themselves or the public.
"It is not right to institutionalise every schizophrenic because a lot of these people can think very logically," Ms Fu said. "We are trying to move towards community psychiatric care. Institutionalisation would be going backwards."
Psychiatric patients were no more violent than ordinary people. But when they committed violent acts they tended to attract more attention because their methods were unusual and thus more newsworthy, Dr Ip said. "The best prevention is early intervention. But the stigma attached to being mentally ill is a big problem and the only way we can prevent mental illness from getting out of hand is to let them receive treatment without bias."
Dr Ip said some of the worst misunderstanding came from well-educated professionals. They often refused to seek help and thought depression meant they had "failed themselves somehow".
"Even doctors are reluctant to refer patients to a psychiatrist because the patient will react by saying 'you think I'm insane'," he said.
The mentally ill have rarely felt welcome in Hong Kong. While people with physical disabilities or such ailments as cancer and leukaemia may find sympathy, those with psychological disorders tend to evoke fear above all else.
Plans to build mental-health care centres are often met with scathing protests from neighbours. One example was the large-scale opposition in the early 1990s to the opening of a psychiatric rehabilitation centre in Laguna City.
"About one-tenth of the world's population has a psychiatric or neurological illness, but because of the myths, disgrace and avoidance associated with mental illness, many people with diseased minds will not receive treatment, making the problem worse," Dr Ip said. "Add to that the stress and pressure of living in a place like Hong Kong, and one day, without treatment, these individuals will fight back."
According to the Equal Opportunities Commission, as many as 20 per cent or more than a million people in Hong Kong suffer from some form of mental illness, from job-related stress disorders to schizophrenia, but only about 92,000 seek medical attention.
A recent survey by the Hospital Authority also revealed that a quarter of the Hong Kong workforce suffers from high levels of stress at work.
Sociologists in Japan have attributed the rise in violent crimes there largely to a cultural taboo against anger, which prevents people from developing the sophisticated faculties to distinguish between emotion and action. This increasingly leads to rage-induced violence.
"In a city like Hong Kong, we are very susceptible to these pitfalls," Dr Ip said. "We need to be alert to early signs and come forward to tackle them by physical, social and psychological means."
Mr Mak, a psychiatric nurse for nearly 25 years, said one of the biggest obstacles was the attitude of relatives who did not report instances of violence, because they did not want to commit a loved one to a mental hospital. This resulted in family members becoming the most likely victims of any violence. "The main loophole in the system is when we are kept in the dark about such people because of protectionism of relatives or the patients themselves," he said.
Mr Mak called for an increase in outreach help for psychiatric patients, and particularly in the number of community psychiatric teams. Better co-operation between doctors and psychiatrists was also essential, he said, to enable early identification of signs of depression in ordinary people.
"If people are aware of the possibility of their condition developing into a state of mental illness, they will be more likely to come forward before they end up hurting people who are close to them, like their own offspring."
Ravina Shamdasani is a staff writer for the Post's Editorial Pages.