"I'd rather die": Patients' will and decision-making practice in Japanese community psychiatry

Recent mental health reforms have embraced patient autonomy and shared decision-making, where care unfolds through collaboration between clinicians and patients. However, how decision-making can improve in marginalized psychiatric clinics remains unclear. This paper examines how social psychiatrists at a Japanese community clinic engage with patients' will-especially when it appears resistant, ambivalent, or self-destructive. At Sakura Clinic in Kanagawa, the challenge lies in navigating "strong will" (tsuyoi ishi)-instances where patients reject treatment, defy medical logic, or say, simply, "I'd rather die." Here, decision-making stretches across time, shaped by evolving attunement between patients, clinicians, and their environments. When patients make risky choices, psychiatrists face an urgent ethical question: is this will an existential stance to be respected, or the mark of structural violence to be refused?