Book Review
Relationships Matter: Roth on H. Yumi Kim, <em>Madness in the Family: Women, Care, and Illness in Japan </em>

Relationships Matter: Roth on H. Yumi Kim, Madness in the Family: Women, Care, and Illness in Japan

Tanya L. Roth

Before professional medical care became widely available, mental illness was often viewed as a personal malady with social impacts. Mental illness did not spread to others like contagious diseases could, yet it still affected those around the mentally ill individual. Families were often the first to experience how mental illness shaped someone’s behavior and interactions with others. As a result, these relationships historically played an important role in treating mental illness, as historian H. Yumi Kim demonstrates in her new book, Madness in the Family: Women, Care, and Illness in Japan. She argues that mental illness in Japan in the late nineteenth and early twentieth centuries must be understood in the social context of communities, villages, and, in particular, families. Kim illustrates that family members – and particularly women – were the ones most often responsible for caring for and treating mentally ill individuals.

Cover for Madness in the Family, featuring a cropped photograph of a Japanese woman's eyes and forehead.
Courtesy Oxford University Press.

In Madness in the Family, Kim expertly exposes the importance of kinship and relationships in defining and treating mental illness in Japan. It’s a book not just about women’s experiences of mental illness, but also their roles as caretakers and guardians. The relationship between individuals and the state matters here, as do the ways in which the Japanese government was trying to exert change. At a larger level, this book is also about Japan’s relationship with the rest of the world at a time when the Japanese were trying to prove themselves to the West. Madness in the Family concentrates on the Meiji, Taishō, and early Showā eras from the Meiji Restoration of 1868 up to World War II. At times, Kim offers historical context before 1868 to give further details about specific practices.[1]

The Meiji Restoration of 1868 marked a significant shift in Japanese history. For centuries, the samurai had controlled Japan’s government, with the emperor primarily a figurehead. In 1868, the samurai willingly stepped aside and restored the emperor’s power. Japan had opened to the West just fifteen years earlier as a result of threatened force from the United States, which sought trade with the island nation. This new relationship with the Western world had massive, lingering repercussions for the Japanese.

Madness in the Family grapples with several fascinating themes, including the myriad ways that Western inclusion and European imperialism affected the Japanese. It’s a case study of what changes and what stays the same in the midst of large moments of change as a country’s or society’s identity shifts. The Meiji Restoration, and the decades that followed, led to a massive change in Japan’s government and how the country engaged on the larger global stage. We often think of these as big issues with little impact on people’s day-to-day lives, but Kim deftly shows how Japan’s shifting identity and relationships with the rest of the world affected everyday experiences like living with mental illness and treating it.

The new relationship between Japan and the West meant that Japanese medical practitioners began to seek training from German and other European experts. Kim highlights the extensive influence that European experts had on the professionalization of psychiatry and medicine in Japan. Western influence remained important in Japan into the early twentieth century.

In late-nineteenth-century Japan, the language of madness was changing, blending traditional, folk ideas of madness with westernized ideas supported by a growing professionalized medical field. Before Western medicine brought a new vocabulary to Japan, Kim explains, “fox attachment” and “fox spirits” were the more common ways to explain madness or other social disorders. People used such descriptions to try to understand behavior changes that defied physical explanations. The introduction of Western medicine provided a new language for understanding such changed behavior.

A black and white line drawing of a fox hanging on the back of a woman in traditional Japanese dress.
A depiction of a fox spirit possessing a person. (Courtesy Wikimedia)

The government and medical professionals tried to reframe fox attachment and the role of fox spirits, claiming that they had better methods of addressing these ailments. New professionals tried to shift care of the mentally ill away from families and into hospitals and modern treatment centers. It was a process of trying to move people away from folk medicine and folk ideas towards a more common, professionalized, Western response to illness. This, Kim argues, was largely unsuccessful. Most people continued to see religious specialists and folk practices as the best solutions for treating madness. Westernized treatments were also expensive. While such treatments might be an option for some, particularly in urban areas, the rural poor could not afford these new treatments.

Holding onto traditional ideas like fox attachment also meant that people continued to rely on older forms of treatment, such as home confinement. For centuries, home confinement had been used to treat mentally ill individuals and others seen as a risk to their families and communities. It consisted of partitioning off parts of a house, usually part of a larger room, and isolating a mentally ill person in that area to prevent them from harming others. By the turn of the twentieth century, Japanese officials and medical practitioners saw confinement as an outdated practice. The government created new laws to regulate and limit home confinement, but the practice continued.

Some families continued to practice home confinement because other treatments were too expensive. Others continued to use home confinement for many reasons, perhaps to keep loved family members within their care. Kim explains that home confinement shows just how significant family care was for treating the mentally ill, while carefully highlighting that when officials spoke of “family” care they almost always meant care provided by women. Ultimately, Kim shows, the government could create new regulations around home confinement, but they could not prevent people from continuing to use traditional methods of treating mental illness.

Kinship and family remain constant themes throughout Madness in the Family, but the last two chapters center Japanese women’s experiences even more directly. Kim makes an important case early in the book for the role of women as caregivers, then focuses the second half of the book more directly on women’s positions within Japanese society and the impact that the professionalization of mental illness had on them from a legal standpoint.

While Japanese psychiatrists translated “fox attachment” into mental illness, by the early twentieth century, Japanese medical experts redefined “hysteria” as a women’s disease, drawing on an older idea of women’s ailments known as the “path of blood.”[2] Men were no longer diagnosed with hysteria; instead, neurasthenia became identified with men. For women, hysteria was a catch-all diagnosis, and not necessarily one that they embraced. However, print media popularized the idea of hysteria as a woman’s disease, quite often through advertisements for patent medicines that claimed to help treat women. In a time when the government defined women’s roles as “good wife, wise mother,” women’s ailments such as hysteria directly contradicted this ideal. Patent medicine products drew on this official image of Japanese womanhood as they tried to sell their products as solutions to help women achieve that ideal.

In Madness in the Family, Kim traces a shift in understanding mental illness in Japan, moving vocabulary away from “fox attachment” and toward “mental illness,” to defining some mental illnesses in the patient’s gender identity. This transition had important consequences for women in particular. Even as women remained the most important caregivers for mentally ill family members confined at home, the state began to pay new attention to the possible relationships between women’s bodies and mental illness. In the early twentieth century, a new type of criminal defense strategy developed, focusing on women who committed crimes while on their periods. Lawyers argued that a woman on her period was not fully in her right mind, because menstruation (and pregnancy) made it more likely for women to commit crimes of passion.[3]

Weaving examples of women’s crimes and menstruation defenses together, Kim shows the ways in which women both accepted and denied the idea that menstruation made them mad. While the criminal justice system used women’s bodies to explain their crimes, women also explained their crimes in terms of family relationships. One defendant, accused of setting fire to her employer’s home, argued that stress from family concerns drove her to desperation and caused her to commit arson. Her brother had been hospitalized recently; her mother was anxious from the ordeal; and the defendant just wanted to make all that stress go away.

From 1868 to the early 1930s, government and professional medical responses to defining and treating mental illness changed immensely in Japan. Yet, these changes had a limited influence on individuals’ experiences of treating mental illness at home and living with people experiencing mental illness. Although the Japanese state created institutions and public health systems that mirrored those of Western countries, it could not fully eliminate long-held ways of thinking, including ideas the state itself had created around women’s roles in society. The history and social context of mental illness, Kim shows, remained a more powerful force for navigating such experiences.


  1. The Meiji period ended in 1912; the Taishō era lasted until 1926, and the Showā era continued until 1989, well after the timeframe Kim examines. These periods are named for the emperors who ruled in those periods, although in the United States most people tend to know of Emperor Showā as Emperor Hirohito.
  2. H. Yumi Kim, Madness in the Family: Women, Care, and Illness in Japan (Oxford University Press, 2022), 90.
  3. Kim, Madness in the Family, 123.

Featured image caption: A cropped photograph of a Japanese woman’s eyes and forehead. (Courtesy Oxford University Press)

Tanya is the author of Her Cold War: Women in the US Military, 1945-1980. She teaches high school history at an independent school in St. Louis, Missouri.