Self‐criticism and self‐reassurance as mediators between mental health attitudes and symptoms: Attitudes toward mental health problems in Japanese workers

Abstract

Japanese workers suffer high rates of mental health symptoms, recognised recently by the Japanese government, which has enacted workplace well‐being initiatives. One reason for poor mental health concerns negative attitudes about mental health problems such as shame, which may be mediated by self‐reassurance and self‐criticism. This study aimed to evaluate shame‐based attitudes toward mental health problems and explore the relationship between mental health attitudes, self‐criticism, self‐reassurance, and mental health symptoms. Japanese workers (n = 131) completed three measures: attitudes toward mental health problems, mental health symptoms, and self‐criticism/reassurance. A high proportion of workers reported negative attitudes about mental health problems. There were strong relationships between mental health attitudes, mental health symptoms, self‐criticism, and self‐reassurance. Path analyses revealed that the total and indirect effects (through self‐criticism and self‐reassurance) of mental health attitudes on mental health were larger than the direct effect alone. Hated‐self and family reflected shame were identified as predictors for mental health symptoms. The findings suggest the importance of self‐criticism and self‐reassurance in mental health and mental health attitudes. Implications for help‐seeking behaviours also are discussed. Interventions aimed at reducing self‐criticism and enhancing self‐reassurance are recommended to improve mental health attitudes and increase help‐seeking in Japanese workers.

Full text

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ACCEPTED MANUSCRIPT
Self-Criticism and Self-Reassurance as Mediators Between Mental Health Attitudes and
Symptoms: Attitudes Towards Mental Health Problems in Japanese Workers
Citation
Kotera, Y., Gilbert, P., Asano, K., Ishimura, I. & Sheffield, D. (2018). Self-criticism and self-
reassurance as mediators between mental health attitudes and symptoms: Attitudes towards
mental health problems in Japanese workers. Asian Journal of Social Psychology. doi:
10.1111/ajsp.12355

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Abstract
Japanese workers suffer high rates of mental health symptoms, recognised recently by the
Japanese government, which has enacted workplace well-being initiatives. One reason for
poor mental health concerns negative attitudes about mental health problems such as shame,
which may be mediated by self-reassurance and self-criticism. This study aimed to evaluate
shame-based attitudes towards mental health problems, and explore the relationship between
mental health attitudes, self-criticism, self-reassurance and mental health symptoms. Japanese
workers (n=131) completed three measures; attitudes towards mental health problems, mental
health symptoms, and self-criticism/reassurance. A high proportion of workers reported
negative attitudes about mental health problems. There were strong relationships between
mental health attitudes, mental health symptoms, self-criticism, and self-reassurance. Path
analyses revealed that the total and indirect effects (through self-criticism and self-
reassurance) of mental health attitudes on mental health were larger than the direct effect
alone. Hated-self and family-reflected shame were identified as predictors for mental health
symptoms. The findings suggest the importance of self-criticism and self-reassurance in
mental health and mental health attitudes. Implications for help-seeking behaviours are also
discussed. Interventions aimed at reducing self-criticism and enhancing self-reassurance are
recommended to improve mental health attitudes and increase help-seeking in Japanese
workers.
Keywords: Japanese workers, mental health attitudes, occupational mental health,
self-criticism, self-reassurance, shame

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Introduction
Japanese workers have suffered from mental health symptoms for years with the
number of diagnosed depressed patients steadily increasing: 441,000 (350 cases per 100,000
people) in 1999, 711,000 (560 cases per 100,000 people) in 2002, 924,000 (730 cases per
100,000 people) in 2005, and 1,041,000 (820 cases per 100,000 people) in 2008 (Ministry of
Health, Labour and Welfare [MHLW], 2015). Japan has one of the highest suicide rates
among developed countries (Organisation for Economic Co-operation and Development,
2015) and 60% of workers experience intense anxiety and distress (MHLW, 2013). Although
the Japanese government in recent years has enacted laws to reduce overtime working to
support workers’ well-being (Hamermesh, Kawaguchi & Lee, 2017), mental health attitudes
among Japanese workers are poor: for example, a review identified that Japanese people
think that mental illness is caused by, among other factors, weakness of personality and
institutionalism (Ando, Yamaguchi, Aoki, & Thornicroft, 2013; Tanaka, Ogawa, Inadomi,
Kikuchi & Ohta, 2003). From a financial perspective, if Japan was able to eradicate suicide
and depression, the country would gain an estimated 2.7 trillion Japanese yen per year (27
billion US dollar) (Kaneko & Sato, 2010). Given this, it is important to explore the possible
reasons why Japanese people have negative attitudes towards mental health problems. One
reason could be a lack of recognition of mental health problems, but previous studies have
also linked it to shame and the fear of being identified as belonging to a social group with
mental health problems (Kawakami, 2006). A survey of Japanese adults (n=1725) reported
that a high proportion of them (43%) would feel shame for seeking help on their mental
distress (Kawakami, 2006). However, specific components of their negative attitudes and
shame about mental health problems have not been thoroughly examined in Japanese
workers; there is a need to evaluate shame about mental health problems and negative mental
health attitudes in this population.

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Shame and Mental Health Symptoms
Shame does not just deter people from receiving help but also directly relates to
mental health symptoms (Corrigan, 2004). Shame in general is an affect that influences
people's well-being and mental health (Gilbert, 1998; Kim, Thibodeau, & Jorgensen, 2011;
Tangney & Dearing, 2002). Shame is associated with depression (Alexander, Brewin,
Vearnals, Wolff, & Leff, 1999; Cheung, Gilbert, & Irons, 2004; Matos & Pinto-Gouveia,
2010), anxiety (Tangney, Wagner, & Gramzow, 1992), paranoia (Matos, Pinto-Gouveia, &
Gilbert, 2013), post-traumatic stress disorder (Harman & Lee, 2010), and eating disorders
(Skarderud, 2007). Furthermore, in psychotherapy settings, shame in psychotherapists or
clients can cause therapeutic rupture (Gilbert & Leahy, 2007), i.e., deteriorations in the
quality of the therapeutic relationship leading to client dissatisfaction. Among Japanese
unemployed individuals, the shame of being unemployed was associated with mental health
problems including depression and anxiety (Takahashi, Morita, & Ishidu, 2015).
Unsurprisingly, shame and shame-based negative attitudes towards mental health problems
were also predictors of mental health symptoms among UK students (Kotera, Green &
Sheffield, 2018c). Moreover, negative self-evaluation about having mental health problems
could cause the ‘why try’ effect, causing poor clinical outcomes (Corrigan, Bink, Schmidt,
Jones & Rüsch, 2016). However, to date, no study has explored the relationships between
shame and negative attitudes towards mental health problems (i.e., mental health attitudes)
and mental health symptoms among Japanese workers.
Shame and Japanese Workforce
Shame - an individual's negative emotion of inadequacy caused by failing to meet
some standard (Tangney, 1990) - has been divided into external and internal shame (Gilbert
1998). External shame is related to the feeling of being looked down on by others, living
negatively in the mind of others and the consequent risk of rejection and disconnection.

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Internal shame is linked to our own self-judgments of being an undesired self (Gilbert 1998).
External, reputation-based shame is strongly embedded in Japanese culture, which has been
described as a shame culture (Benedict, 1946), where social appearances are strongly
emphasised (Inoue, 2007). While internal shame can be linked to self-esteem in the West, the
avoidance of social sanctions, which relates to external shame, is a driving force of people's
behaviours in the East (Muller, 2001). Even people with high self-esteem may avoid certain
behaviours because of the fear of shame (Gilbert, 1998). People may act according to how
they think they will be judged by others, rather than principles (Benedict, 1946). For example,
during the Second World War, to die in combat was seen as a virtue among Japanese soldiers
and surviving was associated with shame about returning home alive (Hikita, 2004).
Similarly, a popular, classic book describing the way of a samurai, ‘Bushido: The Soul of
Japan’ (Nitobe, 1900), emphasises shame in Japanese culture.
Given the importance of shame in Japanese culture, one of the reasons for Japanese
people’s negative attitudes towards mental health problems, in spite of their high rates of
mental health symptoms (Ando, Yamaguchi, Aoki, & Thornicroft, 2013; Tanaka, Ogawa,
Inadomi, Kikuchi & Ohta, 2003; Maekawa, Ramos-Cejudo & Kanai, 2012), is that it is
stigmatised and a potential source of shame (Kawakami, 2006). Moreover, Asian students
living in the UK also report high levels of shame about mental health problems (e.g., Asian
female UK students; Gilbert et al., 2007). Despite this strong relation between Japanese
culture and shame about mental health problems, few studies have focused on the role of
shame in the mental health of Japanese people (Kasori, 2012; Nagafusa, 2002; Okada, 2003;
Okada & Sasaki, 2004). For example, Kasori (2012) found that proneness to shame in
academic settings (e.g., making a presentation) was significantly higher in a depressed group
of Japanese students (n=56) than in a non-depressed group of Japanese students (n=47).
However, these studies did not examine a specific type of shame, i.e., shame about mental
health symptoms, which has been found critical to mental health (Kotera, Green & Sheffield,

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2018c; Kotera, Conway & Van Gordon, 2018b): to date, no study has reported relationships
between shame about mental health symptoms and mental health in Japanese workers.
Kawakami (2006) identified shame about mental health symptoms among Japanese adults,
however it did not focus on workers.
Self-Criticism and Self-Reassurance
Shame, self-criticism and difficulties with being self-supportive and reassuring (i.e.,
self-reassurance) are significantly related to each other and to mental health symptoms
(Gilbert et al., 2010). Shame and self-criticism can stimulate the threat system, while low
self-reassurance inhibits well-being: both are linked to mental health symptoms (Gilbert,
2007a, 2009). Gilbert, Clarke, Hempel, Miles, and Irons (2004) measured two forms of self-
criticism. One is related to self as feeling inadequate and inferior, while the other is related to
self-disgust and self-hatred. The functions of self-criticism include a desire for self-correction
and to avoid making mistakes (i.e., inadequate-self), in contrast to a desire to hurt or for
punishment (i.e., hated-self). Inadequate-self and hated-self were negatively related to self-
reassurance. Shame and mental health symptoms have both been related to self-criticism and
self-reassurance (Gilbert et al., 2010). Those four constructs were strongly related to each
other, and self-criticism was a significant predictor of mental health symptoms in a non-
psychotic clinical population (n=73) who had moderate to severe mental health difficulties
(Gilbert et al., 2010). Kotera, Green, and Sheffield (2018c) recently investigated these
relationships among 87 UK social work students and found that shame about mental health
symptoms and mental health were positively related to inadequate-self and hated-self, and
negatively related to reassured-self. Thus, how people treat themselves mentally, i.e. being
self-critical or self-reassuring, is important to their mental health. Accordingly, the impacts of
self-criticism and self-reassurance on the relationship between mental health attitudes and
mental health symptoms should be explored.

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The three emotion regulatory systems (threat, drive, and soothing systems), the focus
of compassion focused therapy (CFT, Gilbert, 2009), underpins self-criticism and self-
reassurance. In the soothing system, our parasympathetic nervous system, which modulates
rest, acquiescence and digestion, is activated; we feel safe and content, which contributes to
better mental health (Gilbert, 2009). In contrast, high degrees of self-criticism and shame can
activate our threat system, increasing feelings of anger, disgust, and anxiety. It is theorised
that activating the threat system, involving the fight-or-flight response of our sympathetic
nervous system, inhibits the soothing, parasympathetically-driven system and makes it harder
for individuals to accept love and safety, even though self-criticism aims to protect us from
losing social acceptance and love (Gilbert, 2009). This can lead to mental health symptoms
(Gilbert, 2007a, 2009). The drive system runs by excitement and vitality, and seeks
incentives and resources (Gilbert, 2009). Continued activation of this system can also be
problematic, as not achieving or acquiring what was desired can cause us to question our
efficacy, increase self-criticism and cause depression (Gilbert, 2009). A good example is
addiction. When an addict does not gain their desired object or experience, they feel a lack of
control, leading to self-criticism derived from rage and fear of disappointment (Gilbert,
2009). Similarly, shame can hinder our ability to accept our imperfections, i.e., self-
reassurance (Duarte et al., 2017), which mediates the relationship between shame and mental
health symptoms (Marta-Simões, Ferreira & Mendes, 2017), and feelings of contentment
through the soothing system (Gilbert, 2009). In conclusion, self-reassurance is benign as it
relates to our soothing system, whereas self-criticism can be malignant as it activates our
threat and drive systems, which are related to mental health (see Figure 1). Because the
central theme in this study was the relationship between mental health attitudes and mental
health symptoms, mental health attitudes were positioned as a predictor, and mental health
symptoms were positioned as an outcome, and self-criticism and self-reassurance were
hypothesised mediators.

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[Insert Figure 1]
Aims
This study sought to evaluate mental health attitudes among Japanese workers. We
hypothesised that they would have poor attitudes about mental health; specifically, more than
half of them would have over the midpoint scores for negative attitudes towards mental
health problems and shame about having mental health problems (H1). We also explored the
relationship between mental health attitudes, mental health symptoms, self-criticism, and
self-reassurance: mental health attitudes would directly and indirectly predict mental health
symptoms - self-criticism and self-reassurance would serve as indirect pathways from mental
health attitudes to mental health symptoms (H2).
Method
Participants
A total of 143 Japanese workers agreed to participate of which 131 (73 male, 58
female) completed three self-report measures, satisfying the required sample size of 115
based on statistical power calculations (Faul, Erdfelder, Buchner, & Lang, 2009). Participants
were recruited through opportunity sampling via personal contacts and snowball sampling,
using an online consent form and online survey. No incentives were given for participation.
The age range was 22–73 years (M=40.31, SD=11.17); 51% of them worked in major urban
prefectures (Tokyo, Kanagawa, and Osaka) that have more than eight million people; and
21%, 16%, and 15% worked in the service, manufacturing, and education industry,
respectively; 12%, 11%, and 10% were team leaders in a section, presidents and section
chiefs, respectively; and 36% worked at a company with more than 1,000 employees.
Measures

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[Insert Table 1]
Table 1 summarised the details of the measures in this study including their
subscales and measured constructs.
Attitudes Towards Mental Health Problems comprises 35 items evaluating negative
attitudes towards mental health problems in general and three kinds of shame for having a
mental health problem; external, internal and reflected shame (Gilbert et al., 2007). The total
score indexes the level of mental health attitudes. The negative attitudes towards mental
health problems in general are assessed by two subscales: community attitudes and family
attitudes (four items each) assess one’s perception of how their community and family see
mental health problems in general (e.g., ‘My community sees mental health problems as
something to keep secret’ for community attitudes; ‘My family see mental health problems as
personal weakness’ for family attitudes). External shame is assessed by two subscales:
community external shame and family external shame (five items each) assess one’s
perception of how their community and family would see them, if they had a mental health
problem (e.g., ‘I think my community would look down on me’ for community external
shame; ‘I think my family would see me as inferior’ for family external shame). Internal
shame (five items) considers the degree of shame one experiences if they have a mental
health problem (e.g., ‘I would see myself as inferior [if I suffered from mental health
problems]’). Reflected shame is assessed by two subscales: family-reflected shame (seven
items) considers how one’s family would be seen if one had a mental health problem (e.g., ‘I
would worry about the effect on my family’), and self-reflected shame (five items) considers
fears of shame on oneself associated with a close relative having a mental health problem
(e.g., ‘I would worry that my own reputation and honour might be harmed’). All of the
subscales had good internal consistencies (α=.85-.97; Gilbert et al., 2007).
Depression Anxiety and Stress Scale (DASS21) is a short-form version of the
DASS42 (Lovibond & Lovibond, 1995) with 21 items, measuring levels of depression (‘I felt

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that I had nothing to look forward to’), anxiety (‘I felt I was close to panic’) and stress (‘I
found it difficult to relax’). Participants are asked to score how much each statement applied
to them over the past week, on a four-point scale (from 0 being ‘Did not apply to me at all’ to
3 being ‘Applied to me very much, or most of the time’). The DASS21 subscales have good
reliability (α ≥ .87; Antony et al., 1998). The Japanese version of DASS was available (The
University of New South Wales, n.d.). For the purpose of this study, the total score was used
to indicate the level of their mental health symptoms (Lovibond & Lovibond, 1995).
Forms of Self-Criticising/Attacking & Self-Reassuring Scale identifies how people
think and feel about themselves when things go wrong for them (Gilbert, Clarke, Hempel,
Miles, & Irons, 2004), comprising 22 items with three components; two forms of self-
criticalness (inadequate-self and hated-self), and one form of self-reassurance (reassured-
self). Inadequate-self relates to a sense of personal inadequacy (‘I am easily disappointed
with myself’), hated-self to a desire to hurt or persecute the self (‘I have become so angry
with myself that I want to hurt or injury myself’), and reassured-self to a sense of self-support
or compassion for the self (‘I am able to remind myself of positive things about myself’).
Each item is marked on a five-point Likert scale (from 0 being ‘Not at all like me’ to 4 being
‘Extremely like me’). Cronbach alphas were .90 for inadequate-self, .86 for hated-self,
and .86 for reassured-self (Gilbert et al., 2004).
The Attitudes Towards Mental Health Problems and Forms of Self-
Criticising/Attacking & Self-Reassuring Scale were translated into Japanese by the first, third
and fourth authors, who were all Japanese-English bilinguals and had completed the
introductory training of Compassion-Focused Therapy (which was where those two scales
were derived). Then, back-translation was completed by a licenced psychotherapist who was
fluent in Japanese and English, and a meeting was conducted among the four to ensure the
original meaning was captured in the Japanese version. Ethics approval was obtained from
the University of Derby Psychology Research Ethics Committee (Ref: 88-14-YK).

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Results
Analysis was conducted using IBM SPSS version 24.0. The data were screened for
normality of the distributions and for outliers. No outliers were identified. Skewness values
ranged from –.07 to 2.14 and Kurtosis values from –.94 to 5.37. All the subscales and scales
yielded a high Cronbach alpha, indicating high internal consistency (α≥.78; see Table 1).
More than half of the Japanese workers scored over the midpoint in community attitudes,
community external shame, internal shame, and family-reflected shame subscales. H1 was
supported.
As none of the subscales and scales were normally distributed as assessed by Shapiro-
Wilk's test (p<.05), they were square-root-transformed to satisfy the assumption of normality.
Pearson’s correlations were used to examine relationship between mental health attitude,
mental health symptoms, self-criticism, and self-reassurance (Table 2).
[Insert Table 2]
Significant correlations were identified between most of the subscales for mental health
attitudes, self-criticism and self-reassurance, and mental health symptoms.
Self-Criticism and Self-Reassurance as Indirect Pathways
Secondly, path analysis was conducted (H2), using model 4 in the Process macro
version 3 (parallel mediation model; Hayes, 2017, to examine whether self-criticism and self-
reassurance mediated the relationship between mental health symptoms (outcome variable)
and mental health attitudes (predictor variable). Self-criticism was calculated by combining
the scores in inadequate-self and hated-self. Mental health attitudes were calculated by

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totalling the subscale scores of the Attitudes Towards Mental Health Problems scale (Gilbert
et al., 2007).
[Insert Figure 2]
There was a significant indirect effect of mental health attitudes on mental health symptoms
through self-criticism and self-reassurance, b=.23 (self-criticism=.09; self-reassurance=.14),
BCa CI [.14, .32], which explained 21% of the variance in mental health symptoms, and
accounted for 68% of the total effect, indicating a large effect. The direct effect of mental
health attitudes on mental health symptoms, controlling for self-criticism and self-
reassurance, was also significant, b=.10, t(127)=1.99, p=.049, implying that mental health
attitudes directly predicted the variance in mental health symptoms and that mediation was
partial. The total effect of mental health attitudes on mental health symptoms, including self-
criticism and self-reassurance, was significant, b=.34, t(129)=7.34, p<.001. Controlling for
self-criticism and self-reassurance, 29% of the variance in mental health symptoms was
explained by mental health attitudes. H2 was supported.
Predictors of Mental Health Symptoms
Lastly, standard multiple regression analysis was conducted to explore the relative
contribution of the subscales in the Attitudes Towards Mental Health Problems and the
Forms of Self-Criticising/Attacking & Self-Reassuring Scale to mental health symptoms
(Table 3). Gender and age were entered first to statistically adjust for their effects (step one),
and the subscales for these two scales were entered (step two). Because of the many predictor
variables, the adjusted coefficient of determination (Adjusted R2) was reported.
Multicollinearity was not a concern (all the VIF values ≤ 10).

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[Insert Table 3]
The subscales for the Attitudes Towards Mental Health Problems and the Forms of Self-
Criticising/Attacking & Self-Reassuring Scale predicted 47% of the variance in mental health
symptoms, indicating a medium effect size (Cohen, 1988), after adjustment for gender and
age, with family-reflected shame and hated-self as predictors: both positively predicted
mental health symptoms.
Discussion
The aims of this study were to evaluate attitudes towards mental health problems
among Japanese workers and to explore the relationship between mental health attitudes,
mental health symptoms, self-criticism, and self-reassurance. The results showed that a high
proportion of Japanese workers had high shame about mental health problems, and their
mental health attitudes, mental health symptoms, self-criticism, and self-reassurance were
significantly correlated with each other. Mental health attitudes directly predicted the
variance in mental health symptoms and self-criticism and self-reassurance were partial
mediators of this relationship. Moreover, mental health attitudes, self-criticism, and self-
reassurance predicted 47% of variance in mental health symptoms; hated-self and family-
reflected shame were significant predictors for mental health symptoms.
The high proportion of shame about mental health problems in Japanese workers was
aligned with the emphasis of shame in Japanese culture. In particular, their community
external shame and internal shame were high: more than 75% of them scored over the
midpoint of the scale (Table 1), and the mean scores in those two subscales were higher than
UK worker and student samples (Kotera, Adhikari & Van Gordon, 2018a; Kotera et al.,
2018b; Kotera et al., 2018c). This may suggest that Japanese workers were particularly
concerned about how their colleagues would perceive them if they have a mental health

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problem (i.e., community external shame), and how they see themselves (i.e., internal
shame). Japanese workers’ high community external shame may be related to their perceived
loss of face or the perception that mental health problems might damage positive social
impressions (Lin & Yamaguchi, 2011). Japanese workers are sensitive to losing their
reputation at work (i.e., their work community), and thus may feel a great degree of shame
for having mental health problems. This may be related to the strong masculinity of Japanese
culture (Hofstede, Hofstede & Minkov, 2010), where objective success (e.g., climbing up the
organisational or socioeconomic ladder) is respected more than the quality of life (e.g., doing
a job that one loves). Japan’s masculinity score is the highest among 76 researched countries
(Hofstede et al., 2010). Indeed, similar results were found in the UK, another country with a
masculine culture (11th of 76 countries; Hofstede et al., 2010). The fear of negative
perceptions towards mental health problems in a workplace was also reported among UK
workers (Kotera et al., 2018a; Waugh, Lethem, Sherring & Henderson, 2017). Future
research should explore how these cultural dimensions and factors are related to mental
health attitudes in people from different cultures and countries. The high internal shame
reported by Japanese workers may be explained by their construal of self (Markus &
Kitayama, 1991): Japanese people tend to form their identity from how they believe others
see them. If they have a mental health problem, Japanese workers may likely believe that
their colleagues will perceive them as weak (community external shame), which leads them
to think they are weak (internal shame). This helps to understand the high level of relational
concerns in Japanese culture highlighted in a recent study by Ishii, Mojaverian, Masuno and
Kim (2017). They found that relational concerns, such as shame, were the primary decision-
making factor for help-seeking among Japanese Americans, who preferred implicit support
(e.g., receiving emotional comfort without disclosing their problems), whilst self-esteem was
the primary decision-making factor among European Americans, who preferred explicit
support (e.g., concrete advice). Japanese people’s external formation of their identity (as

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opposed to Western people’s internal formation of their identity; Markus & Kitayama, 1991)
may be captured by the high levels of community external shame and internal shame reported
here.
Furthermore, internal shame was more strongly correlated with the community
subscales (community attitudes and community external shame) than with the family
subscales (family attitudes and family external shame) (Table 2). This may be related to the
notion of uchi/soto (in-/out-group) in Japanese culture: people’s behaviours and attitudes
change distinctively when they are inside the group and outside of it (Burt, Bachnik, &
Quinn, 1995). Again, relating to the external construal of self (Markus & Kitayama, 1991), it
is possible that Japanese workers consider their community as soto, and family as uchi.
Therefore, what soto (community, i.e., workplace) is perceived to think matters more to their
internal shame than what uchi (family) is perceived to think (Burt, Bachnik, & Quinn, 1995).
Mental health symptoms were linked to all the shame subscales of the Attitudes
Towards Mental Health Problems (Table 2). This supports findings from other studies in the
UK and Portugal that relate mental health symptoms to shame (Cheung et al., 2004; Matos &
Pinto-Gouveia, 2010). All the subscales of Forms of Self-Criticising/Attacking & Self-
Reassuring Scale and mental health symptoms were correlated with each other (Table 2).
This suggests that Japanese workers with mental health symptoms may want to disparage
themselves and focus on their inadequacy; accordingly, they may find it hard to reassure
themselves. These relationships were similar to those in other cultures (e.g., Gilbert et al.,
2007).
Our path analyses demonstrated that while the direct effect of mental health attitudes
on mental health symptoms, controlling for self-criticism and self-reassurance, was
significant, the indirect effect was larger than the direct effect. Consistent with previous
findings (Kotera et al., 2018b), mental health attitudes were predictors for mental health
symptoms in Japanese workers, implying that the aforementioned educational training about

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mental health to reduce shame and negative attitudes towards mental health problems may be
useful for their mental health. The larger indirect effect (than the direct effect) suggests that
though negative mental health attitudes and shame predicted the variance in mental health
symptoms, self-criticism and self-reassurance were what predicted the greater variance in
mental health symptoms. These findings help refine our suggested solutions for mental health
symptoms: interventions should target reducing self-criticism and enhancing self-reassurance
(i.e., compassion training and collaborative reframing), instead of solely focusing on reducing
shame and negative mental health attitudes in Japanese workers.
Finally, hated-self and family-reflected shame were predictors for mental health
symptoms (Table 3). This suggests that reducing this type of self-criticism and family-
reflected shame may reduce mental health symptoms among Japanese workers. Hated-self is
the desire to mentally hurt themselves in times of difficulty. Compassion mind training would
be useful to reduce hated-self; by practicing compassion for themselves, the soothing system
will be activated (see Figure 1), and this type of self-criticism should be reduced. Similarly,
collaborative reframing, attempting to perceive their and their colleagues’ challenging
situation and internal qualities positively in their work team (Kotera & Van Gordon, 2018),
may also be particularly effective in the collective culture of Japanese workers.
Family-reflected shame is about a degree of worry one has about one’s family if they
were looked down on because of one’s mental health problems (Gilbert et al., 2007). In order
to reduce this type of shame, for example, educational training about the heritability of
depression, which is about 35% (Matsumoto, Kunimoto, & Ozaki, 2013), or aetiology of
mental health problems considering a wide range of potential causes (not only familial factors
but also other environmental or psychological factors) may be useful for workers. This type
of training would educate Japanese workers that their family members’ mental health
problems are not always passed onto other family members and that there are numerous
external factors that could cause mental health problems. Alternatively, helping people cope

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with shame by practicing compassion may be useful (Gilbert, 2009). Such alternative
approaches to the mental health of Japanese workers would be valuable to explore in the
future.
These results suggest the need for a closer analysis of self-criticism related to mental
health symptoms. Exploring the motivations and processes (i.e. why and how) underpinning
Japanese workers criticism of themselves (including shame-related criticism, as elucidated in
this study), particularly when they suffer from mental health symptoms, would be useful. A
cross-cultural study reported that motivation for happiness was linked to higher well-being in
collective cultures, whereas it was linked to lower well-being in individualistic cultures (Forb
et al., 2015). Moreover, Japanese people tend to accept criticism of themselves more than
positive feedback, while Western people do the reverse (Kurman & Sriram, 2002). This
difference was linked with Japanese virtue of modesty (Kurman & Sriram, 2002), which has
not been explored in relation to self-criticism among Japanese workers to date. Future
research should examine the effects of those interventions on self-criticism and self-
reassurance, and its impact on mental health of Japanese workforce.
There are several limitations to this study. First, Japanese workers are not used to
disclosing their mental issues, due to greater concerns about confidentiality than non-Asian
populations (Gilbert et al., 2007), and so may have under reported here. Developing a shorter
version of the Attitudes Towards Mental Health Problems scale would be helpful for data
collection and may mean that more participants complete it. Further, cross-cultural or cross-
industrial comparisons of the Attitudes Towards Mental Health Problems scores would be
helpful for capturing the characteristics of mental health attitudes in each culture and
industry. This study failed to do this because only available data at the time of the study were
UK students and hospitality workers, who would not make meaningful comparison with our
sample. Additionally, relating to a limitation of path analysis (Gelfand, Mensinger &
Tenhave, 2009), there may be a third unmeasured variable in our theoretical model, for

18
example self-compassion or social support, which could reduce mental health symptoms and
self-criticism (Harandi, Taghinasab & Nayeri, 2017; Kotera et al., 2018b; Kotera et al.,
2018c). Lastly, although the Attitudes Towards Mental Health Problems and Forms of Self-
Criticising/Attacking & Self-Reassuring Scale were translated into Japanese by the bilingual
researchers, validation of these scales into Japanese is needed.
In summary, a high proportion of Japanese workers reported shame and negative
attitudes about mental health problems. In line with previous Western studies, significant
correlations were found between mental health attitudes, mental health symptoms, self-
criticism, and self-reassurance in a sample of Japanese workers. Self-criticism and self-
reassurance served as indirect paths linking mental health attitudes and mental health
symptoms. Moreover, hated-self and family-reflected shame were identified as predictors of
mental health symptoms. Accordingly, interventions that target reduction of self-criticism and
enhancement of self-reassurance were recommended for Japanese workers’ challenging
mental health.

19
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28
Table 1: The sub/scales used, their measured constructs, and descriptive statistics (131
Japanese workers)
Measured Constructs
Scales
Subscales
(Range)
M ± SD
α
% over
midpoint
Negative
Attitudes
Towards Mental
Health Problems
Mental
Health
Attitudes
Attitudes Towards
Mental Health Problems
Community
Attitudes (0-12)
7.45±2.59
.78
59.54
Family
Attitudes (0-12)
5.84±2.26
.85
32.82
Shame about
Mental Health
Problems
Community
External Shame
(0-15)
10.62±4.30
.95
76.34
Family External
Shame (0-15)
6.85±2.96
.96
27.48
Internal Shame
(0-15)
11.14±4.29
.93
77.10
Family-
Reflected
Shame (0-21)
12.60±4.25
.86
64.89
Self-Reflected
Shame (0-15)
9.69±2.82
.91
31.30
Mental Health Symptoms
(0-42)
Depression Anxiety and
Stress Scale (DASS21)
Depression
21.00±6.21
.93
Anxiety
Stress
Self-Criticism
Forms of Self-
Criticising/Attacking &
Self-Reassuring Scale
Inadequate-Self
(0-36)
22.20±7.42
.86
Hated-Self (0-
20)
8.84±3.94
.85
Self-Reassurance
Reassured-Self
(0-32)
25.54±7.07
.88

29
Table 2. Correlations between mental health attitudes, mental health symptoms, self-
criticism, and self-reassurance in 131 Japanese workers
1
2
3
4
5
6
7
8
9
10
11
12
13
1 Gender
-
2 Age
-.06
-
3 Community
Attitudes
-.07
-.02
-
4 Family Attitudes
.02
-.04
.23**
-
5 Community
External Shame
-.002
.06
.73**
.24**
-
6 Family External
Shame
-.003
-.14
.17
.62**
.32**
-
7 Internal Shame
.01
-.04
.43**
.28**
.49**
.27**
-
8 Family-Reflected
Shame
.08
.01
.30**
.43**
.43**
.48**
.63**
-
9 Self-Reflected
Shame
.02
-.01
.24**
.07
.33**
.32**
.23**
.38**
-
10 Mental Health
Symptoms
-.08
-.27**
.39**
.25**
.40**
.31**
.39**
.44**
.33**
-
11 Inadequate-Self
-.14
-.28**
.39**
.35**
.43**
.40**
.59**
.48**
.40**
.62**
-
12 Hated-Self
-.12
-.26**
.33**
.23**
.38**
.37**
.47**
.41**
.38**
.70**
.79**
-
13 Reassured-Self
.09
.29**
-.21*
-.10
-.24**
-.29**
-.27**
-.28**
-.18*
-.51**
-.42**
-.60**
-
Gender (M=1, F=2); **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level
(2-tailed).

30
Table
3
. Multiple regression: Mental health symptoms for mental health attitudes, self-
criticism and self-reassurance in 131 Japanese workers
Mental Health Symptoms
B
SEB
β
Step 1
Gender
-.13
.11
-.10
Age
-.02
.01
-.28**
Adjusted R2
.07
Step 2
Gender
-.03
.08
-.03
Age
-.01
.004
-.11
Community
Attitudes
.17
.13
.13
Family Attitudes
.08
.12
.06
Community
External Shame
.02
.10
.02
Family External
Shame
-.12
.11
-.09
Internal Shame
-.11
.09
-.11
Family-
Reflected Shame
.22
.10
.21*
Self-Reflected
Shame
.05
.10
.04
Inadequate-Self
.05
.09
.07
Hated-Self
.48
.11
.47**
Reassured-Self
-.11
.07
-.12
Δ Adjusted R2
.47
Gender (M=1, F=2); B=unstandardised regression coefficient; SEB=standard error of the
coefficient; β=standardised coefficient; *p<.05; **p<.01.

31
Figure 1. Theoretical model based on the three emotion regulatory systems
Mental Health Symptoms
Mental Health
Attitudes (Shame)
+
+
+
-
-
Soothing System
(Self-
Reassurance)
Threat System
Drive System
(Self-Criticism)

32
Figure 2. Parallel mediation model: Mental health attitudes as a predictor of mental health symptoms, mediated
by self-criticism and self-reassurance. The confidence interval for the indirect effect is a BCa bootstrapped CI
based on 5000 samples.
*p<.05; **p<.01; ***p<.001. Direct effects (Total effects)
Mental Health
Attitudes
Mental Health
Symptoms
-.58***
.10* (.34***)
Self-Reassurance
Self-Criticism
2.51***
-.25***
.03***