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Psychotherapy Integration in Japan

Shigeru Iwakabe
Ochanomizu University

Psychotherapy in Japan is a relatively new area of practice growing rapidly in the last 10 years, especially in the area of education as the problems associated with school-aged children such as bullying and truancy became one of the major social challenges. The majority of Japanese psychotherapists practice approaches developed in North America and Europe, and Jungian theory has been inuential to Japanese psychotherapists. Psychotherapy integration in Japan often take a form of cultural integration that takes two routes: adjusting and modifying technical procedures in the western psychotherapy to suit Japanese client population and developing theoretical concepts that are more in agreement with Japanese culture and its underlying worldview. Psychotherapists in Japan emphasize the importance of a non-talking cure, or silent processes and often employ nonverbal tasks such as drawing and sandbox. They have also developed innovative theoretical constructs that emphasize the importance of healthy dependence between mother and child.
Keywords: cultural integration, parallel therapy, nonverbal tasks

(1) What is the current status of psychotherapy in general in your country? How common or uncommon is it for people to go into psychotherapy? What is the relative standing of psychotherapy and pharmacotherapy? How has the practice of psychotherapy been inuenced by economic factors such as managed care or insurance companies, government nanced health service, etc.? Have there been changes in any of these in recent years or are there trends that are worth informing us of? Psychotherapy is a relatively new area of practice in Japan, although some indigenous forms of psychotherapy have been practiced since the beginning of the last century, and major theories of psychotherapy such as psychoanalysis and client-centered therapy were introduced with little
Shigeru Iwakabe, Ochanomizu University, Tokyo, Japan. Correspondence concerning this article should be addressed to Shigeru Iwakabe, Ochanomizu University, Otsuka 2-1-1, Bunkyoku, Tokyo, Japan, 112-8610. E-mail: iwakabe.shigeru@ocha.ac.jp 103
Journal of Psychotherapy Integration 2008, Vol. 18, No. 1, 103125 Copyright 2008 by the American Psychological Association 1053-0479/08/$12.00 DOI: 10.1037/1053-0479.18.1.103

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delay from their inception in western countries. It is still generally uncommon for Japanese people to seek out psychological services. Social stigma and shame still accompany the pursuit of help for psychological problems and disorders in Japan. Traditionally, there has been a tendency in Japan to perceive symptoms of mental disorders as signs of weakness in ones will or as a lack of self-discipline. Therefore, family members may have little patience for the troubled one: they may blame and criticize him or her for succumbing to psychological problems. Those who seek help are often concerned about others nding out that they have a psychological problem. Information about mental problems needs to be kept within the family in order to protect the individuals career choices, likelihood of promotion, and even the marriage prospects of other family members. As a result, the assistance of mental health professionals is often sought only after the problem has become quite grave. Some clients seek services at facilities that are far from their homes. Others request that all contact with the counseling service be maintained through their personal mobile phone to conceal the fact that they receive therapy from family members. Many Japanese people initially contact medical doctors for psychosomatic complaints such as lowered concentration, chronic fatigue, sleep disturbances, and suppressed appetite even when their problems are psychological in nature. After medical problems are ruled out, patients are sent to shinryo naika or a clinic of psychosomatic medicine. A diagnosis of jiritsu shinkei shitchosho (imbalance in the functioning of the autonomic nerve) is often conferred to patients even when they are suffering psychological disorders such as mood disorders, anxiety disorders, and even personality disorders. There are at least two major advantages in using this ambiguous diagnostic category, unrelated to the more common diagnostic systems such as Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSMIV) and International Classication of Diseases, 10th Revision (ICD-10). First, the fact that these patients suffer from psychological disorders is cleverly concealed to prevent patients from becoming the target of potential social stigma. Second, since such a diagnosis infers that these patients actually suffer from medical conditions, it is justiable not to provide them with lengthy and infeasible psychotherapeutic treatment. The current medical insurance system does not give adequate weight to psychotherapy compared to that of more medically oriented procedures (Ono & Berger, 1995). The fee for psychotherapy conducted with a psychiatrist is approximately 32 U.S. dollars at a hospital and 35 U.S. dollars at a small outpatient clinic, regardless of the length of the session. Psychotherapy provided by certied clinical psychologists is subsidized by national medical insurance plans only when it is provided in medical settings under the direction of psychiatrists. Ultimately, patients diagnosed with having

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autonomic nerve imbalances are usually prescribed antianxiety and antidepressant medications. They are then advised to rest, rather than discussing and solving their problems in a psychotherapy setting, which would be economically less feasible for both patients and psychiatrists. Furthermore, many psychiatrists still rely solely on pharmacological treatment and do not consider psychotherapy as a treatment of choice. According to the survey conducted by Nishizono (1988), the overwhelming majority of psychiatrists considered that 15 minutes of contact is sufcient for most of their patients and that only 5% to 20% of their patients required a full hour of psychotherapy during their meeting. The survey also showed that the majority of psychiatrists saw as many as 50 patients a day. Psychiatrists often defend their position by saying that many patients do not feel comfortable in opening up and exploring their personal life. Instead, they prefer to have an authority gure giving them concrete directives derived from medical knowledge and they are satised with having minimal contact with their psychiatrists. However, an increasing number of patients are requesting counseling and psychotherapy as a part of their treatment. Unfortunately, many hospitals do not have sufcient resources to provide counseling services and their patients are placed on long waiting lists. Many of the clients we see at our university clinic often complain that their psychiatrists never spared enough time for them to talk about what was on their minds. Exclusion from the current health insurance system also affects the practice of psychotherapy. Without the possibility of subsidization, Japanese psychologists do not consider independent practice a viable career option. In the last 10 years, the eld of psychotherapy and counseling in Japan has been undergoing a process of dramatic development. With the economic recession, the social climate is quickly deteriorating. There is an increased awareness of this social deterioration and with it a rapidly growing demand for psychological services to respond to the crisis. For example, the number of clinics of psychosomatic medicine, which are private psychiatric clinics that patients are referred to when it is suspected that their physical complaints have psychological causes, increased from 662 to 1,573 in the three-year period between 1996 and 1999 (Jamic Journal, 2002). During the last decade, there was a sharp increase in the number of violent crimes committed by teenagers, and problems associated with school-aged children (particularly of school refusal syndrome) became a major challenge faced by Japanese educators (Kameguchi & Shigematsu-Murphy, 2001). The most dramatic developments in the eld of psychotherapy are to be seen particularly in the areas of child and adolescent psychotherapy and counseling conducted in schools and other educational settings. In 1995, the Ministry of Education placed one school counselor in each

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public junior high school, where problems associated with school refusal syndrome and bullying are most severe. This is the rst national level counseling and psychotherapy service in Japan. In 2000, 2,250 junior high schools hosted one certied clinical psychologist. This means that 1 out of 4 clinical psychologists work in school settings. Over 90% of so-called school counselors are certied clinical psychologists who perform a variety of functions, from individual psychotherapy to family consultations. Japanese psychologists tend to use the term counseling over psychotherapy regardless of the nature of their work and their patient populations. Differences in the conceptual and historical development between the two elds have not been clear in Japan: many Japanese psychologists are educated mainly with individual psychotherapy techniques based on principles of psychodynamic therapies and work in educational settings, carrying out a wide range of roles that would elsewhere be played by a social worker, a school psychologist, a school counselor, and an educational consultant (Shimoyama, 2000). Nonetheless, as the term counseling gains wide public recognition equivalent to the daily usage of the term therapy in English, psychologists also adopt this term more frequently and widely. It appears that psychologists refer to their service as counseling because the term psychotherapy has stronger connotations of treatment than the term counseling. However, medical doctors are the only profession nationally and legally qualied and licensed by the Ministry of Health and Welfare to diagnose and treat patients. Clinical psychologists are board certied by the Japan Society of Certied Clinical Psychologists to provide counseling and assessment services; therefore, Japanese clinical psychologists tend to avoid the connotation of treatment in the term psychotherapy, even when they apply principles of psychodynamic therapies in dealing with patients intrapsychic problems and symptoms due to psychological disorders. Psychiatrists, on the other hand, almost exclusively use the term psychotherapy when they are the provider of such a service. They even tend to apply a different translation of the term, psychotherapy emphasizing a more medical and psychoanalytic tone to their work. Lastly, the professional association of clinical psychologists, who are the main providers of psychotherapeutic services as well as their educational and training system, is also in the process of rapid expansion and development. The Association of Japanese Clinical Psychology, which was founded in 1982, consisted of 1,936 members in 1989. The membership has increased rapidly in last 10 years. by June of 2001, it had become the largest academic society of psychology in Japan, with 10,869 members. Training programs for clinical psychologists have mainly been developed in the last 10 years. In 1996, the number of accredited Masters programs in clinical psychology was 14. In 2007, 158 schools were accredited, and the number is still growing rapidly. In sum, psychotherapy is still a new eld in Japan, and it has seen its

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most dramatic development in the past 10 years. However, psychotherapy is yet to become the treatment of choice due to a medical insurance system that requires that psychiatrists take a more efcient, biological approach and keep face-to-face contact with each patient to a minimum. Social attitudes toward those with mental problems and toward help seeking are also obstacles to the expansion of psychotherapy in Japan. As a result, Japanese psychologists have moved toward educational and school settings as their main area of practice, working with schoolchildren, their family members, and teachers as their main client populations. (2) What are the most inuential theories and orientations guiding psychotherapeutic work in your country? What are your speculations about how the particular culture, traditions, and values of your society have inuenced the particular approaches to therapy that predominate in your country? Although indigenous psychotherapies widely known outside of Japan such as Morita therapy and Naikan therapy have existed for over half a century, the overwhelming majority of Japanese psychotherapists follow models of psychotherapy developed in western countries. Psychoanalytic therapies and humanistic psychotherapies such as client-centered therapy, each of which has a relatively long history, are widely practiced throughout Japan, followed by cognitive behavioral therapies and family therapies which have more recently captured the attention of psychotherapists as interest in short-term therapies increases. These theoretical schools form a respective academic association organizing annual meetings and have published a peer-reviewed journal since the beginning of the 1980s. Japanese psychotherapists are eager to incorporate new developments and trends from western countries. For example, after the Kobe-Awaji earthquake in 1995, which hit Japans second most populated area causing nearly 5,500 deaths, 35,000 injuries, and leaving 180,000 buildings badly damaged or destroyed, Japanese psychologists became acutely aware of the need to receive specialized training in the treatment of posttraumatic stress disorder (PTSD) as well as crisis intervention. Experts of eye movement desensitization reprocessing (EMDR) were invited to provide a series of training workshops in Japan. By 2001, over 330 psychologists and psychiatrists received training certicates. A recent upsurge of interest in narrative therapies and social constructionism is also of note. In the past ten years, quite a few professional workshops on narrative therapies were held. The publication of books and articles on narrative therapies continues to increase, though the current popularity of narrative therapy is not associated with the specic clinical needs of psychotherapy practice in Japan. What is particularly notable about the inuence of various theories of psychotherapy is the popularity of Jungian psychology. The dominance of Jungian psychology stems from the pioneer work of a single Japanese psychologist, Hayao Kawai, who, after trained at the Karl Gustav Jung

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Institute in Switzerland, introduced and popularized psychotherapy and built the foundation of clinical psychology in Japan. His contribution to the development of psychotherapy in Japan is immense. He was an extraordinarily prolic writer who has put out over 70 books of his own and edited over 100 volumes in the past 40 years. Although he has written numerous professional books directed at practitioners and therapists-in-training on the theory and application of psychotherapy based on Jungian principles, much of his work is directed toward a general audience and focuses on an understanding of Japanese culture through Jungian theory rather than Jungian psychotherapy itself. Using Jungian archetypes he analyzes everything from popular Japanese ancient folktales and myths to social and family problems currently prevalent in Japanese society (e.g., Kawai, 1996). In the past, when Japanese culture and people were examined from a perspective of western psychology, there was a tendency to depict Japanese people as deviations from western norms or as immature, inferior versions of western people. Kawai made links between Japanese culture and psychology without such misleading characterizations. By doing so, he naturalized western psychology into Japanese culture. His books are read and appreciated by a wide audience. His contribution to the understanding Japanese culture through Jungian theory has been highly appraised by psychologists as well as by other academics: he has received literary awards and was appointed to be the Director General of the International Research Center for Japanese Culture in 1995 and of the Agency for Cultural Affairs in 2001. He also served as a committee member of the Central Council for Education and of Administrative Reform, both of which are part of the Government of Japan. His contributions are not limited to publications on Jungian psychology and Japanese culture but also include an active involvement in the training and education of clinical psychologists in Japan. He showed no reluctance in traveling across the nation and giving workshops and participating as a commentator in case conferences for local clinical psychologists and students. In these clinical case conferences, he was highly imaginative, convincing, and inspirational, making reference to ancient Japanese myths, artworks, and the biographies of public gures. He was also a very personable man who was eager to socialize, interact, and mingle with young students and local psychologists. Japanese psychologists look up to Kawai not only as the leader of Japanese psychology but also as an educator. In other words, Kawai was a father-like gure who not only created the foundation and identity of Japanese psychologists but also created a strong emotional connection with a large number of Japanese clinical psychologists through these personal interactions. Therefore, the relationship that Japanese psychotherapists have to Jungian psychology is not simply a matter of theoretical allegiance. It

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represents an emotional connection to someone seen as a great educator and informs their identity as Japanese psychologists. Indeed, Japanese psychologists are more often exposed to and knowledgeable of Kawais interpretation of Jung than Jungs actual theories themselves. Their tie to Jung is mediated by Kawais presence as a writer and as a cultural gure. Psychologists who are not Jungian themselves subscribe to many of Kawais ideas about Japanese culture and its inuence on the psychological life of Japanese people. The dominance of Jungian psychology in Japan is also associated with the history leading to the development of the current professional association of clinical psychologists. The Japanese Association of Clinical Psychology was rst established in 1964 and their rst national meeting held in 1965 with 978 attendants. At the annual board meeting held in 1969, in which the future direction of the association was debated, board members were divided into two opposing groups. One group advocated the reorientation of the association as a sociopolitical group to protest the inhuman treatment of mental patients in psychiatric hospitals and their objectication and debasement through subjecting them to demeaning psychological testing. The other group emphasized the rapid establishment of a national level licensing board as a primary goal. Unable to resolve this fundamental difference, the association eventually disintegrated. When it was reformed in 1973 by those members who had advocated political activism, the majority of members left the association. This incident put an end to the rst attempt to move toward the establishment of a licensing system and the national organization of clinical psychologists. Finally in 1982 a new association (the Association of Japanese Clinical Psychology) was formed with 1277 members. Hayao Kawai was elected as the rst president of the association. The confusion created by the collision of the two opposing groups within the rst association of clinical psychology and the resulting turmoil among clinical psychologists still lingered. The theoretical orientations central to the association were Jungian psychology as well as other depth psychologies, such as object-relations theories. They focus on a symbolic understanding of the clients inner world while maintaining little connection with the empirical methods developed in academic psychology. The journal of the association mainly features single case reports on the process of psychotherapy with little psychometric data on the outcomes of treatment. Systematic studies using experimental designs and quantitative methods are rare. Shimoyama (2001) points out that a connection with the rest of academic psychology and the society was unconsciously avoided to suppress fears of resurrecting the complex problems associated with the licensing issues. Jungian psychology and the choice of case reports as a main method of investigation helped to avoid

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potential conicts until the association of Japanese clinical psychologists attained autonomous functioning. (3) What is the current status of psychotherapy integration in your country? How inuential are integrative approaches? Among therapists who do work integratively, what kinds or approaches to integration have been most important? How have both these developments (the relative importance or unimportance of integration and the kinds of integrations pursued) been inuenced by the particular culture of your society or the nature of how the profession of psychotherapy is organized in your country? Psychotherapy integration is a relatively new theoretical concept to many Japanese psychotherapists. There have not been many publications introducing models of psychotherapy integration published in Japan and they are all recent (e.g., Hiraki, 1996; Murase, 2003). There is only one postgraduate training institute that offers courses and workshops based on integrative thinking founded by Noriko Hiraki, one of the founders of Japanese family psychology. Most recently, major works of integrative therapists such as Paul Wachtel and Les Greenberg have been translated into Japanese and several introductory reviews have been published. With Noriko Hiraki, Hiroko Nakagama, and Takeyoshi Nozue, who have been very active in promoting the integration of family, couple, and individual therapies in Japan, and Tetsuo Fukushima, who has written a series of articles on integration from a Jungian perspective, I organized a group to discuss issues associated with psychotherapy integration. Since 2005, we have held four meetings and over 100 practitioners and graduate students participated in the most recent meeting. Interest in psychotherapy integration is rising especially in psychologists and students in the younger generation. Although there have not been many theoretical works to guide their integration, most Japanese therapists practice some form of eclectic therapy heuristically combining concepts and techniques of psychodynamic, Jungian, clientcentered, cognitive behavioral, and family therapies. In particular, attempts to incorporate a systemic perspective in their work are common (e.g., Hiraki & Nozue, 2000; Kameguchi & Shigematsu-Murphy, 2001). This is due to the fact that many therapists work in school and educational settings where in dealing with schoolchildren, the therapist needs to plan interventions systematically at levels of intrapsychic conicts, interpersonal behaviors at school, the teacherstudent relationship, and the parent child relationship. Furthermore, in introducing western psychotherapies to Japan, where the cultural and social climates were thought to be vastly different, aspects of a theory of psychotherapy or techniques were modied to better serve Japanese patient population. Psychotherapy integration in Japan, therefore, appears in a form of cultural integration, which usually takes two

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distinct routes. One is a modication or incorporation of technical procedures and treatment structures that are more suitable and effective in the clinical reality in Japan. The other is to develop theoretical concepts that are more in agreement with Japanese culture and its underlying eastern philosophies. I call these attempts cultural integration because modications and adjustments are made primarily to assimilate psychotherapy into Japanese culture.

MODIFICATIONS OF THERAPEUTIC TECHNIQUES AND TREATMENT STRUCTURES There are numerous attempts to modify therapeutic techniques. Here, I would like to focus on the two areas that are most widely discussed and practiced: (1) incorporation of nonverbal tasks and (2) mother-child parallel therapy.

Nonverbal Tasks Many Japanese therapists incorporate in the part of their work nonverbal expressive tasks using media such as the sandbox, painting and drawing, and clay sculpture. In particular, the incorporation of sandbox play is most commonly attempted by Japanese therapists. In sandbox play, which was originally developed by Dora Maria Kalff, patients are encouraged to play freely in a miniature sandbox, placing and arranging miniature people, animals, houses, and objects as various as cars and religious statues. The resulting tableau is thought to provide a window into the inner world of the patient, as well as a path through which the patient can express their feelings. The popularity of this technique may be demonstrated by the large membership of the Japanese Association of Sandbox Therapy: there were 1,400 members in 1999, and membership is still growing. The overwhelming majority of members incorporate the sandbox in their work as one technique rather than as the sole method of practice. The procedure is used not only for children but also for teenagers and even adult patients. The popularity of sandbox techniques is reective of the clinical reality of working with Japanese patients, many of whom are often not comfortable discussing personal problems or verbally expressing their feelings in a face-to-face encounter. Culturally based beliefs about language and verbal communication also underlie and contribute to the integration of such techniques in therapeutic practice. Until fairly recently, little value was given in Japanese culture to talking about everything or pilling one guts. Traditionally, it was considered more virtuous to keep ones thoughts and

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feelings to oneself. Accordingly, some of the most inuential Japanese therapists do not believe that language as a medium of self-expression captures and communicates how one really feels any better than do other methods of expression such as painting, music, and sandbox. Furthermore, it is theorized that these indirect expressions allow a more intuitive understanding and sharing through the sensibilities. Inner feelings may be more vividly and directly communicated by images evoked through these media. Conspicuously present throughout these media are symbolic themes and patterns that are thought to more concisely communicate the complex and polysemous nature of ones feelings and situations, even though the meaning of what is expressed may not be explained or even understood. In sum, the use of nonverbal therapeutic tasks as exemplied by sandbox play points to underlying cultural beliefs about the value of verbal interactions (Miki & Kuroki, 1998).

Parallel Therapy In the treatment of children, adolescents, and young adults, therapists often invite the patients mother to have counseling sessions. These sessions are not occasional information-gathering sessions to monitor patient behaviors outside the sessions or to report the progress of therapy back to the mother, but are weekly psychotherapy sessions with a separate treatment contract and structure from that of the child. These sessions are referred to as parallel therapy, or mother-child parallel therapy where the two distinct therapies start concurrently (Omata, 1999). In many university counseling centers and other training facilities, it is often the case that the counselor trainee sees the child, while his or her supervisor works with the mother in a different room concurrently to facilitate communication between the two therapists. In other cases, the same psychotherapist may work with both the mother and her child. When the patient is unwilling to come to therapy or when the mother does not feel she has the authority to order her child to seek professional help because she is afraid that her child will act violently toward her or the child will be upset by her overinvolvement, therapy may be carried out alone with the mother without the presence of the identied patient. This type of therapy is particularly common with the mother of a child or a young adult who, after a duration of absenteeism from school or work, has withdrawn to his or her bedroom with almost no interaction with people other than his or her family members (hikikomori). There are several purposes in parallel therapy beyond information gathering about the child developmental background for psychological assessment. First, it serves a psychoeducational purpose by providing the mother with

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appropriate information about parenting, child development, and the nature of her child problems. Second, by maintaining a good therapeutic relationship with the mother, the therapist can assure continued therapy with the child, as it is usually the mother and not the child who decides whether to continue or terminate therapy. Third and most importantly, parallel therapy provides the mother with the opportunity to receive personal therapy of her own. Many of the mothers who accompany their children to psychotherapy have little if any social network and their marital relationships may also be unstable. Some perceive themselves as failures as mothers and as a result experience such distress that it becomes difcult for them to meet the needs of their children. Others direct exaggerated anger externally at schoolteachers or even mental health practitioners for their incompetence and further alienate themselves from potential sources of help. Therefore, Japanese therapists often give equal emphasis to treating the mother with the goals of establishing her psychological adaptation and relative independence from her child, resolving her own personal issues and relieving anxiety, shame, and perhaps the guilt of failing to be a good enough mother. In sum, Japanese therapists tend to assume that when there are certain problems with children, adolescents, and even young adults, it is necessary and desirable to treat the mother as well because the mother child relationship may not be functioning properly. Parallel therapy may be based on the assumption that successful child and adolescent psychotherapy depends on the establishment of a stable relationship between child and mother. This prevalent view stems from theoretical works of Japanese psychoanalysts who emphasize the importance of mother child relationships, which we will turn to next.

DEVELOPING THEORETICAL CONCEPTS Another route of cultural integration is the development of a theoretical concept that facilitates the application of western models of psychotherapy to a Japanese context. I would like to discuss two theories: Kosawas Ajase complex and Dois concept of dependence (or amae). Both of these concepts sprang out of psychoanalysis and emphasize the strong emotional ties between mother and child in Japan. However, Kosawa and Doi approach psychotherapy in almost opposite ways.

Theory of Amae Dois theory of dependence captured a wide international audience interested in Japan and Japanese culture with the translation of the Anat-

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omy of Dependence (1973), which was published in several languages. Dois work sparked many subsequent works on Japanese culture and psychology. During his training analysis at the Menninger Institute in San Francisco, Doi experienced difculties in nding the right word in English to communicate the nuance of his feeling of amae. Although it could be approximated to the concept of dependence, he believed that no word quite captured its nuances in English. Doi found the origin of amae in the mother-infant relationship, and dened amae as the feeling that all normal infants at the breast harbor toward the mother, the desire to be passively loved, the unwillingness to be separated from the warm mother-child circle and cast into a world of objective reality (1973). To form an attachment relationship, the infant needs to perceive the mother as an external object separate from himself or herself and seek her for both physiological and psychological satisfaction; therefore, Doi considered the need for dependency to be as basic and instinctual as libido. Doi himself has pointed out the similarities between his concept of amae and Michael Balints passive object love. Amae as a Japanese word is a deverbal noun form of amaeru, equivalent to such words as coaxing, fawning, wheedling, and so forth. The verb, amaeru, is commonly used to describe the child behavior of sucking up or laying up to their parents to gain their indulgent attention and to be spoiled by them. It is also used to describe a wide range of adult behaviors that appeal to the maternal generosity of the other in order to gain forgiveness, attention, or caring by playfully and sometimes manipulatively presenting oneself as a child or someone who merits indulgence. According to Doi, amae is present even in adult interpersonal relationships, and ones capacity to construct a mutually dependent relationship is central to healthy psychological development in Japan. His linguistic analysis revealed that amae is so pervasive that many of Japanese words describing emotions are variant forms of expression of this dependency need. This contrasts sharply with western models of healthy personality and psychological development, including Freudian psychoanalysis, that give little signicance to the adaptive role of interdependence. Personality development is often portrayed as the development of autonomy and independence while a dependency need, which is discussed in relation to pathological tendencies, is something that needs to be controlled and managed as the person matures. Dois clinical practice also points to the importance of amae in the treatment of Japanese patients. A variety of psychological maladjustments as observed in his clinical experience in Japan were associated with distorted forms of the dependency need and failure to build appropriate interpersonal relationships for satisfying ones dependency need. Doi pointed out that for psychotherapy to be successful with Japanese patients, amae or a dependency need has to be brought into awareness. Furthermore, the patient needs to

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learn to relate to others by building a sense of trust rather than being unconsciously driven by ones dependency need. Dois analysis goes beyond linguistic analysis of the word amae by attempting to explain the whole structure of Japanese society and culture, proposing that amae operates in social structures such as the Emperor system and even in the typical behavior of Japanese people in front of western individuals.

Kosawas Ajase Complex One of the rst attempts to develop a theoretical concept to modify theories of western psychotherapy was carried out by Heisaku Kosawa. Kosawa was one of the rst psychoanalysts to establish independent practice in Tokyo in the 1930s and became the central gure of psychoanalytic activity after World War II. He left Japan to study at the Vienna Psychoanalytic Institute between 1932 and 1933 and received supervision from Richard Sterba and Paul Federn. During his visit to Vienna, Kosawa delivered to Freud a treatise entitled the Ajase complex; two varieties of guilt consciousness, in which critical distinction is made between Japanese or western guilt and eastern guilt using the Buddhist legend of Prince Ajatasattu (ajase in Japanese). Kosawa felt that the Oedipus complex needed to be replaced with the Ajase complex when applying psychoanalysis to Japanese patients. Kosawa derived his theory of the Ajase complex from two Buddhist sources. As I will explain later, the original story line was vastly modied and, as many critics point out, his version of the story is a forceful appropriation (Kitayama, 1993). I would like to present the most recent version by Kosawa that was later modied by his student, Keigo Okonogi, because this version is the most widely known and discussed (Okonogi, 2001). Queen Vaidehi, wife of King Binbashara in ancient India, was childless and feared that unless she bore a child to the throne, the king love would fade as her beauty declined with age. Out of a desperate desire to bear a prince, she consults a prophet, who informs her that a male child will be conceived upon the death of the ascetic three years later. Too anxious to wait out the birth of a prince, Queen Vaidehi murders the ascetic, who, right before he breathes his last, reveals his curse: he will be reincarnated as the son of the king, who will someday murder his own father. In that moment, the queen conceives the prince, Ajatasattu, who was already murdered once by his own mother before his birth. Fearful of the ascetic curse, Queen Vaidehi tries to murder the prince by delivering him from the top of a tall tower. The prince survives with only a broken nger and grows up to be a wholesome boy. As an adolescent he nds out about the secret

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of his birth. Disillusioned with his mother, he attempts to murder her. However, tormented by the intensity of the guilt he feels over the attempted matricide, he is overcome by a skin disease. No one but his mother will approach and nurture him because of the foul odor emanating from his sores. In spite of his mother patient nursing, the prince condition does not improve. The mother seeks the help of the Buddha and confesses her troubles. Through her encounter with the Buddha, she achieves insight into her conicts, and eventually her son recovers from the vile illness. Prince Ajatasattu later became known as a wise king. This Buddhist tale was believed to show a psychological process leading to the restoration of a sense of oneness with the mother. The child is embraced by the mothers forgiveness and devoted nurturing in spite of his intention to kill her. As the child experiences a sense of being one with the mother in ghting the illness, a sense of guilt emanates from the within. Okonogi calls this type of guilt autonomous guilt or spontaneous guilt and contrasts it against the patricidal Oedipal guilt that arises from the fear of punishment and results in the separation of the child from his mother. Whereas the Oedipus complex underscores the sexual nature of the mother child relationship that needs to be severed, this Buddhist tale emphasizes the nongenital nature of the mother child relationship reestablished. Kosawa theorized that neurosis as seen in Japanese patients is a psychological state in which a person has to repress his or her psychological need for dependency on the mother because he cannot believe the mothers bottomless love. Therefore, Kosawa concludes that psychoanalytic treatment in Japan requires undoing the repression of a dependency need for the mother and the restoration of a sense of identity with the mother (Okonogi, 2001). In other words, Kosawa practice of psychoanalysis involved accepting the patients transferential feelings of dependence and responding with limitless maternal affection so that his patients can experience a sense of oneness with the therapist. Later, Okonogi added another interpretation of the Ajase complex: Ajase rage against his mother originated from discovery of her selshness in having used him in order to cling onto her husband, King Binbashara. Okonogi terms this rage of a child at the discovery of his or her origin in the parent sexual relationship misho-on or prenatal resentment, and points out that the Ajase complex illuminates not only childrens ambivalence toward their mothers, but also women ambivalence toward maternity. Both Doi and Kosawa emphasize the mother-child relationship and the role of dependence in the Japanese psyche. However, Doi treatment method departs from that of Kosawa in that he does not consider the establishment of a dependent relationship between the therapist and the

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patient desirable. To the contrary, he advocates that the amae or a dependency need be brought into awareness and replaced by a more conscious process of building a sense of trust. Doi was originally a student of Kosawa. He left Kosawa because he disagreed with the treatment method Kosawa used, which deviated from the standard practice of psychoanalysis (Takeda, 1988). In sum, these attempts consistently emphasize the importance of the mother child relationship in Japan. It appears that these theoretical and clinical developments are attempts to both assimilate western psychotherapy into Japanese culture and also to uncover cultural biases inherent in these theories. Although the purpose of these attempts is to modify theoretical concepts and techniques to t a Japanese client population, it does not necessarily follow that they portrait the psychology of Japanese people accurately. Taketomo, for example, pointed out that Doi arbitrarily selected and discussed only one aspect from the various denitions given by lexical sources, emphasizing a unied Japanese national character, while overlooking the metacommunicational processes associated with a more common usage of the term (1986). Nagayama questions the clinical value of amae because its denition is too ambiguous to guide clinical interventions (2001). In turn, Kosawa Ajase complex has also been criticized for its arbitrariness in mixing two sources of sutra and changing the storyline. Kosawa revised and modied the story of Ajase to the extent that it no longer resembled the original story, which depicted father-son hostility resulting in patricide similar to the story of Oedipus (Kitayama, 1993; Okonogi, 2001). Although these attempts certainly capture some of the cultural characteristics crucial to applying psychotherapy to Japanese patients, it appears that there is a tendency or bias toward building a coherent, historically consistent, unchanging picture of Japanese people as a whole. Dale (1970) points out that Japanese theories of psychology such as these are more the concern of nihonjinron, the appropriation of academic discourse to demonstrate the uniqueness of Japanese culture and people. Japanese psychologists often emphasize the importance of understanding the uniqueness of an individual using detailed case studies. However, when it comes to a cross-cultural comparison between Japanese and western culture, they are quick to make the assumption that all Japanese people possess similar psychological characteristics or exhibit similar psychological processes. Because of this tendency toward the assertion of a unied national character inherent to most attempts at cultural integration, it is important for Japanese therapists to question whether cultural integration is always desirable. Psychotherapy may be appealing to some patients precisely because it is foreign and different from what Japanese people usually do.

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Andrew Grimes, a British psychotherapist practicing in Tokyo, observed that some Japanese prefer to talk about their problems in English to non-Japanese therapists (Grimes, n.d.). Cultural codes of behavior associated with speaking Japanese make it difcult for them to be emotionally expressive and direct. For such clients, expressing oneself in a foreign language can be a liberating experience in which they acquire new ways of looking at their life and handling their problems. In other words, cultural integration may prematurely strip away the novelty of cross-cultural experience inherent in psychotherapy. In sum, cultural integration offers a unique contribution to the project of psychotherapy integration by modifying techniques and theoretical concepts to better serve culturally different populations. Cultural integration is always attempted in some form or another when a western theory of psychotherapy is imported. However, what has been overlooked are the method and process of these integration attempts and the potential pitfalls due to modications. It will be benecial for Japanese therapists to examine how these attempts are carried out and what the potential benets as well as pitfalls of these attempts are. (4) What seem to you the most distinctive things about how psychotherapy is practiced and thought about in your country? What might those of us outside your country be least likely to know or appreciate? One of the most distinctive things about the practice and theory of psychotherapy in Japan is the relatively undermined value of verbal communication and understanding, which runs counter to the common characterization of psychotherapy as the talking cure. Indeed, Japanese therapists seem to value instead a non-talking cure, in which change is hypothesized to occur through silence, nonverbal interactions, and solitary introspection, even when applying western psychotherapies. The incorporation of nonverbal techniques such as drawing and sandbox play that I have briey explained in the answer to the Question Three relies on just such routes to change. For example, Hironaka denes the primary role of the therapist in applying the sandbox technique as just to be or to stay with the client, and to receive and appreciate what is expressed in the sandbox as if it were a piece of art (Hironaka, 1998, p. 112). The client, engaged in sandbox play, does not need to be encouraged to explain verbally what he or she has made or what he or she is doing. Neither are therapists encouraged to communicate their understanding or interpretation verbally. The emphasis on a nontalking cure is also associated with a distinct therapeutic relationship stance quite different from those commonly delineated by western models of psychotherapy. This may be further exemplied by indigenous therapies such as Morita therapy and Naikan therapy in which not verbalizing ones ideas and not talking about problems are an integral part of the therapy (I would like to describe these therapies briey

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to illustrate this point. Please refer to Reynolds (1976) for a more complete discussion of these therapies.) Morita therapy, which was developed as a treatment for neurosis and conditions similar to current denitions of obsessive compulsive disorder, is an inpatient treatment method that usually continues for one month. The process of Morita therapy can be divided into four stages, each running for approximately one week. In the rst stage, patients stay in bed and are prohibited from engaging in activities such as seeing people (including their family members), talking, reading, smoking, or drinking, all of which might divert their attention from their illness. The goal of this stage is for patients to learn to endure and accept their obsessive thoughts as part of their nature without ghting them or engaging in a futile attempt to analyze and achieve a solution to them. The second stage consists of solitary, light manual tasks such as gardening and carpentry work. In the third stage, patients are assigned an increased workload of similar manual tasks in order to further cultivate a desire for and joy in work. In the nal phase, which is preparation for return to society, patients start commuting to their respective places of work or school. Throughout the treatment, interaction between therapist and patient is kept to a minimum. When the patient inquires about the meaning of a task or questions its effectiveness, the therapist task is to tell them not to question, and not to ght anxiety or fear but to bear it and accept the fact that they have such feelings. Patients keep a daily log of their thoughts throughout the day. Therapists, however, only give encouragement and do not comment on the content of the log. In Morita therapy, change is hypothesized as occurring not from understanding the nature of ones problems and mastering them, but from accepting and learning to lead ones life with the problems and symptoms. Therefore, patients do not talk about their thoughts and feelings, but instead learn to live without being caught in the struggle to control them. The focus on manual labor and minimal interaction between therapist and patient makes it impossible for patients to focus directly on solving the problems for which they sought treatment, while at the same time providing them with a surplus of time in which they have to face such problems by themselves. This paradoxical setting defeats patients attempt to solve their problems and opens up a different avenue of change: learning to bear and coexist with their symptoms. A similar relationship stance and course of change are portrayed in Naikan therapy. Naikan therapy, which was developed by Ishin Yoshimoto in 1937, is a structured method of self-reection aimed at understanding and appreciating the fundamental nature of human existence through examining one interpersonal relationships with signicant others (Naikan means introspection or looking inward. The most traditional format for

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Naikan therapy is a 1-week retreat in which one reects upon the events of one entire life for 15 hours each day. Clients are placed in a large room and are each surrounded and divided by folding screens. Clients are prohibited from chatting with other participants, making phone calls, leaving the room, or even following the events of the outside world by watching television or reading the newspaper. Meals are carried to the place where they sit and introspect. Clients sit facing the wall alone in a room and are directed to think about three questions: (1) What have I received from signicant others, such as parents, siblings, teachers, and colleagues; (2) What have I given to them; and (3) What troubles and difculties have I caused them? The introspection promoted in Naikan therapy is meant to illuminate aspects of ones life in which one has been helped, supported, and forgiven by others in spite of the troubles that one has caused them. The profound sense of gratitude and appreciation of others that is said to result often leads to an intense emotional experience in which one realizes how selfcentered and self-absorbed one has been. This feeling is meant to lead to a recognition of the joy and happiness of daily life and a feeling of connectedness with others. The interaction between therapist and patient is limited to the routine transaction of inquiring about the progress of introspection. Naikan therapists visit each patient for only three to ve minutes every two hours. They do not ask after the details of introspection or any feelings evoked by it. Similar to Morita therapists, Naikan therapists use set phrases to provide encouragement and to thank patients for sharing their thoughts. In both Morita and Naikan therapy, therapists do not sit face-to-face with patients, but rather merge somewhat into the therapeutic setting. Neither Morita nor Naikan therapy provides their patients with an opportunity to directly express their feelings to the therapist. Nagayama points out that this relationship stance allows Morita therapists to maintain adequate distance from the patients, to be free from becoming the target of transference feelings, and to empathize with patient feelings that arise from emotional involvement in performing the assigned tasks (2001). The therapeutic relationship is mediated by the therapeutic task: the therapist empathy is expressed toward the patient involvement in the therapeutic task, not toward the patient as he or she suffers from the problems that brought him or her to therapy. Change is said to occur when the patient discovers the functioning aspects of his or her life. In Morita therapy, this is the patient perseverance in continuing to work despite troubling thoughts and feelings, whereas in Naikan therapy, it is the discovery of the previously unrecognized affection and caring of signicant others. Perhaps I need to clarify that neither Morita therapy nor Naikan therapy is a major force in Japan. Both therapies have a relatively long

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history and certainly reect aspects of traditional Japanese culture. However, it does not follow that they are more effective or more suitable to the Japanese population than are western therapies. A great many Japanese people, particularly of the younger generations, will perceive both the tasks and the relationship styles in these indigenous therapies to be oldfashioned and incompatible with their way of life. The strong emphasis on traditional Japanese culture and philosophy in both Morita and Naikan therapies may appear just as foreign to contemporary Japanese people as western therapies that are applied without any modication. However, Japanese therapists appear to assume that the route of change described by these therapies is also accessible and viable even when practicing western therapies. Verbal interactions easily give way to the client silent introspection with the therapist simply being with the patient without attempting to inquire or understand what goes on in his or her mind. Many clinicians write that the most important work is being done when the patient is simply thinking and experiencing in the presence of the therapist. I watched a demonstration tape conducted by one of the primary founders of client-centered therapy in Japan. It is the only demonstration available by a Japanese client-centered therapist. I was puzzled by his style of therapy, which was not even remotely similar to what I learned as client-centered therapy in my training. (I grew up in Japan but received all of my clinical training and academic degrees in psychology in Canada.) As soon as the session started, the therapist closed his eyes. Although he opened his eyes from time to time and directed his gaze in the client general direction, it was not clear whether he was actually looking at the client. He certainly demonstrated Rogerian reection, but very rarely. Mostly he sat with his eyes closed and nodded his head. Even when the client seemed to have achieved some sort of understanding of his feelings, the therapist simply nodded and another bout of silence began. The client looked at the therapist more often, but mostly looked down and kept talking. Verbal communication and understanding seem to play a small part compared to silence, which can tell us that something important is happening, though it does not tell us what important thing is happening. It appeared that the emphasis was on a kind of silent process, and that not facilitating the client experience or verbalizing the client feelings took the place of the whole purpose of therapeutic interaction in client-centered therapy. Japanese indigenous therapies and western psychotherapies such as client-centered therapy are quite different in terms of underlying worldviews, treatment structures, therapeutic process, and so forth. Nonetheless, it is relatively easy for Japanese therapists to envision the avenue of change described by Morita therapy or Naikan therapy while practicing and following western models of psychotherapy. Changes in these therapies res-

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onate well with common cultural ideals of living in a state of reconciliation with life adversities as opposed to pursuing ones ideals of happiness and satisfaction. Some Japanese patients experience changes similar to the ones described in Naikan therapy, even though they receive client-centered therapy and other nondirective therapies with the therapist taking a traditional stance to promote the patient autonomy and independence development. They feel a stronger attachment toward family members (sometimes in spite of continued or escalating abuse and mistreatment) and renewed interest in their work and daily life, yet with little sign of a deepened understanding of or improvement in their living circumstances. The peculiar mixing of two almost contradictory ways of approaching patients is reective of one aspect of modern Japanese society and its culture. Japanese society has maintained some of its traditional culture and thinking, but it is also a capitalist nation with a highly developed economy and the associated value system similar to modern western nations. Both aspects seem to coexist, sometimes with no sense of contradiction or incongruence. (5) As you have come into contact with therapists from other societies than your own (, e.g., at meetings such as this), what kinds of things have struck you about the differences in the assumptions and attitudes that they bring to their work in comparison with your own? What struck me in this roundtable was not irreconcilable differences in the cultural assumptions and attitudes that therapists from different countries bring to psychotherapy and its integration, but how much we dedicate ourselves to and share of the culture of psychotherapy and psychotherapy integration. We all are eager and willing to open a dialogue and to go beyond various boundaries to learn and enrich our knowledge of psychotherapy. Difference is perceived not as a barrier but an opportunity for learning and discovery. Mutual interest and willingness to learn from difference facilitate our communication and help us overcome the barrier of language as well. This process also leads to a self-reective stance in examining and articulating ones own cultural and personal assumptions. At the same time, psychotherapy integration appears to be a common language and a culture of its own. Nonetheless, there are striking differences in attitudes toward the role of scientic research in psychotherapy between therapists in Japan and in the countries of other presenters. In both cases, the health insurance system interacts and strengthens the attitude toward science. In all the presenters home countries, the services of psychologists are covered by health insurance. Psychotherapy is recognized as a valid form of treatment and is incorporated in the treatment of many psychological disorders. Furthermore, the form and nature of their service is to some extent determined by the health insurance system. A social and governmental

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demand for accountability drives psychologists to demonstrate the efcacy and effectiveness of psychotherapy. This creates a close link between psychotherapy and scientic research, and moves psychotherapy toward the establishment of a variety of empirically supported treatments. Psychotherapists in many countries are willingly, and even at times unwillingly, working to establish and negotiate the bridge between science and the practice of psychotherapy. This may be one of the main factors driving common forms of psychotherapy integration that assimilate aspects of cognitive therapies into other systems of psychotherapy, such as psychodynamic therapy and experiential therapy. The tendency is more conspicuous with technical eclecticism that purports to systematically reorganize techniques of psychotherapy based on research evidence rather than on philosophical ideas and beliefs. It appears that the connection with cognitive therapies represents both an actual and a symbolic link to science, academic psychology, and accountability. On the other hand, in Japan where there is little connection with the medical insurance system, the development of psychotherapy appears to have taken a different direction. Psychotherapy has moved toward establishing a connection with anthropology, literature, and art to borrow various forms of expressive methods that allow us to access the natural growth tendency within us without changing its course. Human nature is conceptualized as something that dees natural science and logical reasoning. Those psychologists who established the foundation of clinical psychology in Japan were unwilling to open their work to scientic examination because, as I explained in the answer to Question Two, such a tie may shake the establishment of professional identity of clinical psychologists in Japan. As a result, Japanese psychotherapists are relatively free from the social demand for effectiveness and accountability. However, their practice is turning into an esoteric pursuit that is opaque even to psychotherapists themselves. Although not all Japanese psychotherapists share this view of science, this attitude toward science is still the dominant one in Japan. It is true that psychotherapy has a longstanding ambivalent relationship with scientic research even in North America, where empirical investigation of process and outcome of psychotherapy has been most actively conducted: there are many psychologists who are pessimistic about bridging the gap between the research and the practice of psychotherapy. However, the dominant attitude of Japanese therapists toward science is a perilous one. It isolates Japanese psychotherapists from the developments of the rest of the world, which is not desirable even if such isolation may help encourage the building of uniquely Japanese psychotherapies. In addition, it may also hinder psychotherapy from gaining social recognition. I feel that it is important for Japanese psychotherapists to examine this

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closed attitude toward science and explore potential avenues for incorporating scientic research into psychotherapy in order to make a greater contribution to society.

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Takeda, M. (1988). Nihon fudo to Iryoseido tono Kakawari [The link between the Japanese climate and the medical system]. In M. Nishizono & J. Yamamoto (Eds.), Nihon, Asia, Kita-amerika no seishin-ryoho [Psychotherapy in Japan, Asia, and North America] (pp. 171194). Tokyo: Kobundo. Taketomo, Y. (1986). Amae as metalanguage: A critique of Dois theory of amae. Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry, 14, 525544.