Japanese Models of Psychotherapy
David K. Reynolds
Although modern psychotherapeutic forms are relatively recent contributions to dealing with human suffering in Japan, their roots extend deeply into Japan’s history. A brief examination of the history of Japanese psychotherapeutic practices may contribute to our understanding of the conceptual framework that the therapist and layperson bring to the therapeutic encounter.
Prehistoric evidence indicates that trepanation was practiced during the Neolithic period, perhaps as treatment for mental disturbance. Herbs, poultices, hot baths, cold baths, steam baths, moxibustion (the burning of moxa powder on energy points of the skin), pine needle fumigation, fasting, acupuncture, acupressure, bloodletting, and ingestion of the blood of poisonous snakes were used psychotherapeutically from earliest recorded times. Diet and rest were offered at specialized Buddhist temples.
Shamanism has been practiced in Japan since prehistoric times (Sasaki 1969). By the early twentieth century, common treatments for mental illness included hypnosis, autohypnosis, breathing exercises, prayer, suggestion, bed rest, physical exercises, life-style training, work therapy, travel, massage, and various religious exercises. Psychoanalysis was introduced around 1920 but has never become popular as a mode of treatment.
German-Austrian medicine dominated Japanese psychiatry during the late nineteenth and early twentieth centuries (Bowers 1965). The emphasis on a narrow diagnosis and biological approaches to psychotherapy 111still predominates in the medical universities today, although interest in mentalistic treatment forms has increased since the introduction and influence of American medicine in the early 1950s. Electroconvulsive treatment and insulin shock therapy were quite commonly practiced until the 1970s, when concerns with patients’ rights initiated a reevaluation of their appropriateness. Tranquilizers, antidepressants, and lithium are commonly prescribed; sophistication in psychopharmacology is at least on the level of that in the United States.
Physical facilities for the treatment of the mentally disturbed remained primitive well into the twentieth century. The Law of Confinement and Protection of the Mentally Ill, enacted in 1900, provided for the construction and maintenance of private cells for the mentally ill in their family homes. In 1919 the numbers of persons in mental hospitals and in private dwellings were nearly equal, and as late as 1950, 2,671 people were confined in cells in their homes (Kumasaka and Yoshioka 1968). Since 1950, however, a new law has required hospitalization rather than home confinement. Special instructional facilities for the developmentally disabled have been in operation since 1956. Community psychiatry, residential care facilities, day-care centers, and halfway houses have never found favor in Japan.
In 1975 there were 276,159 beds in over a thousand mental hospitals in Japan, nearly one-quarter of the total hospital beds in that country (see Ikegami 1980 for a full discussion of the growth of inpatient psychiatric facilities in Japan). Today the great majority of psychiatric inpatients are treated in private psychiatric hospitals of less than three hundred beds. Each hospital generally has some connection with a university medical school that is a major source of its referrals for admission.
In order to discover Japanese therapists’ views of the current status of Japanese psychotherapy, I prepared a set of open-ended questions regarding the most influential therapists and the most influential therapies in Japan today and outstanding changes in Japanese psychotherapy during the past five to ten years. Ten interviews with knowledgeable therapists from a number of universities yielded responses that were much the same, if colored somewhat by my informants’ university and professional affiliations.
In response to a broad question regarding influential persons, my 112informants frequently asked whether I was interested in those who wield power in therapeutic circles, conduct research, and contribute theory, or those who actually practice psychotherapy and have written about their practice. For the most part the names given to me were persons who have done both. In terms of therapeutic preference, most of those mentioned have a psychoanalytic background. Of the nine therapists most frequently named, three are Freudians, one is a Jungian, and each of the remaining five specializes in another mode or specialty area of therapy: Nishizono (Kyushu University), Doi (recently retired from the Japanese National Institute of Mental Health), and Okonogi (Keio University) are Freudians; Kawai (Kyoto University) is a Jungian; other names included Kora (Morita therapy), Yoshimoto (Naikan therapy), Nakai (schizophrenia therapy), Kasahara (adolescent therapy), and Kato (cross-cultural therapy).
As for influential therapies, the respondents distinguished between those favored by psychiatrists and those favored by others. Psychoanalytic styles of therapy are in favor among psychiatrists, particularly Japanese versions of Freudian therapy emphasizing psychodynamically oriented counseling. Among psychologists, social workers, and counselors, there is more interest in Jungian psychoanalysis, nondirective Rogerian therapy, autogenic training, behavior therapy, biofeedback, hypnosis, transactional analysis, group therapies, art therapies, Morita therapy, and Naikan. Some psychiatrists also use these modes of therapy in an eclectic way. It is noteworthy that no physician considered psychopharmacology to be a form of psychotherapy, yet dispensing medication is the primary medical response to mental disorder in Japan, as it is in the United States.
An examination of the stock list of the major distributor of medical books in English gives an idea of the topics and therapies of interest to psychiatrists in Japan. Neurology and neuropsychiatry merit a whole section in the catalog. Biological, biochemical, and somatopsychic approaches to psychiatry are next in frequency. Then come general works on psychiatry and volumes devoted to specific disorders, of which schizophrenia, depression, epilepsy, and sleep disorders are particularly noticeable. Books focused on psychopharmacology follow in frequency. Other specific psychotherapeutic approaches are represented by a few books each on hypnosis, psychoanalysis, electroconvulsive therapy, family therapy, and perhaps ten volumes on behavior therapy. Books about child psychiatry, developmental disorders, and addictions (including alcoholism) 113 are about equally represented with less than ten volumes each. There are a few books each on sociopathy, social aspects of mental health, and aging. I suspect that the order of frequency of topics on this list would not appreciably differ from that in most psychiatry departments in the United States. The emphasis is clearly on biological (including neurological) and chemical approaches to the understanding and treatment of mental disorder in contrast to verbal approaches.
Informants also showed remarkable consistency in their evaluations of developments in Japanese psychotherapy during the past five to ten years. Many pointed to the variety of therapies practiced in Japan today, including versions of many Western forms of psychotherapy. Among these methods in current use are psychoanalysis, short-term therapy, crisis intervention approaches, transactional analysis, group therapy, family therapy, couples counseling, gestalt therapy, encounter groups, logotherapy, sensitivity training, and behavior therapy (Doi 1978). Most of these therapies have undergone modification to make them more suitable to Japanese patients and therapists. For example, transactional analysis in Japan finds more positive value in the “parent” aspect of the self than does Western transactional analysis (Ikemi and Sugita 1975). And Japanese encounter groups and sensitivity training programs tend to be “softer” and more supportive in orientation than their Western counterparts. As experience with a variety of therapies has lengthened, so too has a more critical understanding of their application. Fifteen years ago the psychotherapy journals carried introductory articles on these therapies; now they include more specialized reports on the effectiveness and subproblems of these approaches.
Another trend that can be observed is the rapid entry of psychologists and other professionals and nonprofessionals into this field, once completely dominated by psychiatrists. The new therapists tend to be younger and to be attached to public agencies associated with the Ministries of Health and Welfare, Education, and Justice. They work in schools and institutions for the handicapped and in some clinics, usually in nonpermanent positions. However, because psychiatrists alone among psychotherapists can be reimbursed through health insurance, private practice by therapists other than psychiatrists is rare. It may be said that both psychologists and caseworkers in social welfare have broadened the definitions of their capabilities over the past fifteen years from roles as specialists in psychological testing and social welfare, respectively, into the field of individual and group therapy. 114
In general, there has been a surge of interest in the possibilities of verbal psychotherapy for clients and practitioners. Interest in the therapeutic applications of art (drawing, modeling, dance, painting, calligraphy, etc.) is matched by a new look at psychoanalysis, particularly Jungian analysis, and, as these have attracted attention in the West, a serious reconsideration of indigenous Japanese therapies. Unfortunately, the interest is not matched by facilities for supervised training. There are very few adequately trained therapists in Japan, whether physicians or those in other fields, and no licensing is required to practice therapy. Beyond some very minimal level, skills are developed as the therapist accumulates experience on the job. Most of my informants mentioned this problem as a key concern for the future of psychotherapy in Japan.
The Japanese Clinical Psychological Association (Nihon Shinri Rinshō Gakkai) was refounded in 1982 following its breakup in 1969 due to internal political disputes. Twelve hundred persons attended the first meeting in October 1982. With the spread of psychologists into a domain once considered to be the exclusive realm of psychiatry, some sort of power struggle might be expected. No clash has yet occurred, probably because of the strong position of physicians in Japan, but the conflict that is currently occurring in the United States must inevitably be repeated in Japan on some level.
Changing Symptom Patterns
Psychotherapies must adapt to fit the changing form of symptoms and complaints of patients. In Japan over the past forty years, neurotic complaints regarding fear of blushing have decreased and phobias concerning eye contact have increased (Maruyama et al. 1982). A number of therapists remarked on the recent increase in neurotic depression—not a true clinical depression but a sort of neurotic discomfort with depressive affect. What seems to have fostered these changes?
Some therapists believe that as shyness has decreased among young people the fear of blushing has become less of a concern for them. One therapist pointed out that fifteen or twenty years ago it was not uncommon to see high school baseball players tremble when they took part in televised ball games. These days they appear more relaxed. Difficulty relating to others remains, however, and some observers believe that the resultant self-consciousness has found more common expression in eye contact phobia. I suspect that this interpretation ignores an important 115element of self-concealment. The Japanese people are careful about what they reveal to others concerning their thoughts and feelings. Except under special circumstances (for example, when drinking) it is regarded as both thoughtless and potentially troublesome to expose one’s inner concerns and emotions (particularly those that might appear to be unsympathetic or otherwise unacceptable). Pervasive fads such as wearing clothing and carrying purses or briefcases of the same styles and discussing the same newspaper and magazine articles may be seen as acceptable ways of concealing fear of personal deficiency through overt uniformity. Blushing reveals to others one’s inner turmoil, and so some Japanese make extreme efforts to control it. My guess is that the variety of situations that provoke blushing has decreased as urban Japanese have become better at distracting themselves from upsetting stimuli and suppressing the external display of inner upset. In other words, young cosmopolitan Japanese have become more skillful at dissimulation and therefore less likely to fear blushing.
Eye contact may reveal one’s thoughts and intentions, and it may also indicate prying concern with the inner states of one’s companions. The deception of self and others reaches awareness on the level of discomfort surrounding eye contact. Tanishima Iwao, a Morita therapist, told me that though the Japanese traditionally used words to reveal themselves to others, they now use words to conceal themselves from others. Psychological discomfort from eye contact often indicates some level of deception and secrecy.
Turning next to consideration of the increase of neurotic depression, we find therapists who believe that this reaction is a response to realistic concerns in the lives of modern Japanese. According to some therapists, the fear that a single failure in life can affect one’s whole future is perfectly valid under current conditions. It appears, for one, that choices of occupations or careers have become increasingly narrowed. Males in salaried positions specialize in their work to such a degree that at retirement they are unprepared to engage in other pursuits and activities; for example, they cannot cook and have not developed the habit of taking evening walks or talking with other family members. Therapists report a lack of self-sufficiency, a narrow self-image strongly tied to role specialization. Furthermore, there seems to be a basic inability to control or assure success; there is no way of assuring victory in the game of life even though one is playing well and hard. Thus, if the employer doesn’t give a promotion or if the husband squanders money, there seems to be no 116effective recourse. Perhaps the picture painted here is harsher than reality; however, the sense of hopelessness and helplessness that accompanies neurotic depression becomes more understandable when considered in this light. Other depressive symptoms such as sleeplessness and lack of appetite may be associated with worries about repayment of loans, lack of job mobility and advancement, and the like.
Japanese Models of Psychotherapy
A definition is a conceptual tool more or less useful for a particular person or persons in a particular time and setting. In the next few sections we will consider some of the ways that a Japanese therapist and patient together come to define psychotherapy. Consideration of some models of Japanese therapy provide insights to such questions as: How do patients’ conceptions of psychotherapy differ from those of their therapists? How does the training of therapists affect their definitions of therapy? How does a layperson learn to define psychotherapy, come to know what to expect from treatment, and evaluate which life problems require psychotherapeutic help? How does a patient’s definition of psychotherapy change over time during therapy? How do therapists and patients negotiate to define or redefine the process and goals of therapy?
Four models or definitions of psychotherapy that are employed in Japan are presented below. For present purposes, psychotherapy is defined as a system of treatment for mental disturbance in which at least one variant of the system is practiced by physicians in hospitals. This definition excludes the mental health support and information offered through the media, friendships, educators, shamans, and so forth, but these dimensions often appear (usually implicitly) as underlying features of interactions between therapist and patient in Japan. The four models indicate implicit understandings of what psychotherapy constitutes in various settings. I have called them the healing model, the training model, the interaction model, and the salvation model. Each model posits a characteristic definition of the source of suffering, who may be suitable for treatment (and what that person is to be called), how treatment may proceed effectively, what constitutes cure or progress, and who has responsibility for that progress.
The Healing Model
Perhaps the most prevalent model of psychotherapy in modern Japan is the healing model. From this perspective, a patient goes to a therapist 117for relief from mental suffering just as an ill person seeks out a physician for cure of any disease symptom. This model implies some responsibility on the therapist’s part for a correct diagnosis and an accurate prescription of medication, diet, and any other form of treatment deemed necessary. The patient, in return, must follow the therapist’s directions faithfully. If by doing so relief is not forthcoming, the patient can change to another, more suitable therapist. Underlying this medical healing model is a consumer model. The therapist (usually a physician) offers a service. The patient knows what is the desired service and what is a satisfactory performance of the service. And the patient is free to shop around when the service is considered to be inferior. Chemotherapy provided by the general practitioner or psychiatrist fits this model well, as does behavior therapy and most hypnotherapies.
The Training Model
A second model found commonly within the practice of Japanese psychotherapies might broadly be called “training.” From the perspective provided by this model, psychotherapy offers guidance for psychological growth and development. Like a tutor for college entrance examinations or a judo instructor or a teacher of flower arrangement, the psychotherapist provides information about aspects of living and advises the patient/trainee how to surmount lack of skill and ignorance.
The training model is quite different from that of the healing paradigm in that the tasks and goals of the participants are defined along different lines. In contrast with the healing model, in which the therapist is seen as the chiryōsha (medical healer), in the training model the therapist is viewed as a shidōsha (guide). As a guide, the therapist takes more responsibility in defining the patient’s difficulties and progress. Within a healing framework the patient is the expert, basing judgments on current feeling states, because patients alone know best how they are feeling. However, within the training framework is the assumption that the trainee may not be mature enough to recognize the basic problem or the current status of progress. Feeling terrible, for example, may not be considered a misfortune of training but rather a marker in the trainee’s development or an insignificant side effect of some much more important step forward into another area of growth.
The training therapist is responsible for shaping the regimen to fit the individual needs and stage of competency of the patient/trainee, but the trainee has final responsibility for progress. He or she must practice hard, devoting time and effort to self-development, demonstrating to the 118therapist commitment and a willingness to be shaped by the program. Failures in training therapies are never the fault of the therapist. Failures are always seen to be caused by the inadequate or misdirected efforts of the trainee. It follows that moving from teacher to teacher because of lack of progress makes little sense (in contrast with the consumerism of the healing model).
Morita therapy, some styles of Naikan, and Seiza therapy fit this model (Reynolds 1980). In less clear fashion it appears that Freudian therapy and transactional analysis are forced into this model by some Japanese patients. Zen trainees appear to operate with this conceptual model.
The Interaction Model
The interaction model is related to the training model and to the salvation model discussed below. The interaction model draws on the Japanese recognition of the importance of social relationships, and it is given additional support by the importance of the therapist-patient relationship in Western psychotherapeutic theory, which is held in high regard. In Japan, social ties such as those within families, work groups, and among classmates are generally strong and satisfying. It is understandable that a relationship, in this case the relationship between therapist and patient, can be seen to have a supporting, even a healing, quality. In the West, Rogerian and most psychoanalytic therapists stress the value of the therapist-patient relationship. In working with some neurotic and nearly all of the more severely disturbed patients, including psychiatric inpatients, most Japanese psychiatrists, psychologists, and social workers use this supportive mode of therapy.
The methods, goals, and mutual responsibilities of the interaction model of psychotherapy are ill defined. Again, the lack of adequate training in therapeutic techniques among those who practice in Japan must be emphasized. One of my Japanese therapist informants with extensive Western training pejoratively tagged this vague Japanese interaction style “muntera‚” a term that means unskilled chatting. We must be careful here not to evaluate Japanese interaction therapy by some supposed Western standard. Patients do appreciate the attention and concern shown to them during therapeutic interactions. Doi (1973a) has pointed out the strong element of passive dependency (amae) in the Japanese character and the Japanese people’s need for signals from others that they are being lovingly cared for. When therapists using interactional methods try to force self-revelation and openness into the therapeutic 119 relationship (following culturally inappropriate Western guidelines), they commonly encounter resistance from their Japanese patients. Severe problems have been reported in family therapy, T groups (face-to-face therapeutic groups focusing on interpersonal interaction), psychoanalysis, and encounter groups when too much pressure is exerted to reaffirm something other than positive, accepting interpersonal relationships.
The acceptance of Rogerian nondirective therapy by psychologists in Japan can be understood, in part by its lack of pressure in interaction. Japanese patients are very reluctant to express and merge honne and tatemae (the personal/private and the socially acceptable/public aspects of self) even within a sheltered psychotherapeutic setting.
The interaction model implies a patient’s unswerving trust in the therapist as an expert and mature human being. It also implies a long-term sustaining relationship—at least patients tend to infer such elements. Termination of therapy can be very difficult and complex and can bring with it feelings of abandonment. After all, family, classmates, and workmates are archetypes of long-term sustaining relationships. From the perspective of a newly admitted patient, it may appear unproductive to invest in a short-term therapeutic contact, no matter how supportive. In this model the therapist is less the healer or guide and more the dependable, strong, esteemed, and authoritative companion.
The Salvation Model
The final model for consideration here is religious, the model of salvation. Therapies in this mode offer two forms of relief from mental anguish. The first form is immediate. Relief comes when concerned advisors and fellow believers listen to the patient’s tales of suffering and share their own experiences in return; the warmth of community acceptance and a sense of purposeful living envelop the patient. A unique form of long-term relief comes in the belief that suffering endured in the present will be vanquished in the world of life-after-death. Even though the validity of this promised relief cannot be ascertained before death according to any strictly rational standards of verification, the hope can nevertheless make current suffering more meaningful and more bearable. Modern religious interpretations (in Buddhism and Christianity, for example) speak of heaven and hell in this life, thus focusing on changes of attitude and behavior in the here-and-now rather than in some afterlife. Naikan, one form of therapy that fits the salvation model, 120reflects this “terrafication” of religious concepts in its maxim “To act according to one’s own convenience is to be a devil; to act according to the convenience of others is to be the Buddha.” (It is interesting to note that somewhat secularized versions of Naikan are offered by physicians in hospitals in Kagoshima and on Honshu.)
Responsibility for salvation (not cure) within this model clearly lies in the devotee (not patient). Deities do not fail; human beings lack faith, perpetrate harmful acts, and fail to do good. Although efforts may be made by therapists to individualize the devotees’ worship, the goal and means of salvation are absolute, following the scriptures. Ultimately, all must follow the same path to the same end.
Like the training model therapies, salvation therapies accept “normal” members as well as troubled ones. Similarly, both models tend to blur the boundaries between normal and abnormal. We are all ignorant, suffering, and in need of salvation.
I have suggested that Japanese patients perceive psychotherapy according to one or more of the four schemata presented above. Patients tend to select a mode of therapy that fits their perception of what psychotherapy ought to be. For example, a few years ago those who came for Naikan therapy at Gasshōen Temple in Mie prefecture tended to be elderly farm folk, strong believers in Jōdō Shinshū Buddhism, which, in stressing salvation, is congruent with the Gasshōen variant of Naikan. Such clients would have had a great deal of trouble adapting to a Freudian-based therapy. In contrast, those who attend the meetings of the Morita therapy mental health organization, Seikatsu no Hakkenkai, tend to be urban white-collar workers, young adults or of middle age. These meetings incorporate lectures and classroom discussion of assigned readings. The educational format of this style of Morita therapy echoes the past experiences of formal education in this middle-class population. It meets their current need for an intellectually understandable system taught within a formal educational context.
It is not realistic in the case of large, complex societies to assume that because therapist and client share the same basic cultural background they generally bring common notions, including models of therapy, to their encounter. Similarly, when therapist and client come from different cultural backgrounds, their therapy interaction will not necessarily be 121strained or fruitless (Reynolds and Kiefer 1977). Were there no social need for negotiation within the psychotherapy setting there would be no need for therapy itself. When the understanding of therapist and client match perfectly with a model and there is a shared commitment to that model, therapist and client are one. The exchange is something other than psychotherapy.
However, when a Japanese therapist perceives a client to be operating under assumptions of a model contradictory to the therapist’s own views, there is usually some attempt to get the client to redefine assumptions so that both will operate similarly and congruently. My experience as a therapist in Japan and my observations of other therapists there have centered on situations in which therapists using training or salvation models encounter clients with contradictory healing models. The negotiations for reevaluation of the clients’ problem, the process to bring about improvement in the condition, and the criteria of progress are of great interest. What takes place during these negotiations? Although studies are still incomplete, I can offer some preliminary thoughts and observations.
In this area of redefinition, one of the first tasks for the therapist is to establish an image of having an expertise and specific knowledge regarding the client’s case. This image enhances the therapist’s bargaining power in reaching agreement with the client on the model of therapy. The therapist’s expertise can be established by certain titles and educational degrees and by publication of books and pamphlets describing cured patients with problems like those of the negotiating client. Successes in therapy and testimonies may also be paraded during meetings attended by previously treated clients and newcomers, and the therapist may point to self-cure using the preferred method.
In Morita therapy the therapist often asks questions that are, in fact, predictions about the client’s symptoms. For example, the therapist might ask, “And, then, after you became self-conscious about looking into people’s eyes while carrying on a conversation, didn’t you begin to fear that other people recognized that you were self-conscious?” Once the client is convinced that the therapist truly understands his or her problems, an important step has been achieved in model bargaining.
It is rare to hear a therapist ridicule, interrupt, or flatly contradict a client’s choice of therapy model. Rather, the therapist listens politely, then attempts some variety of reeducation. It may be useful to have other, more advanced clients teach the preferred model to newcomers. In inpatient 122 Morita therapy this task is accomplished through meetings and group living, and in the Moritist mental health organization, through group meetings, retreats, and magazine articles about personal experiences. In Naikan therapy extensive use is made of audio tapes of prior clients’ insights. These tapes, which are broadcast over an intercom system in many Naikan facilities, provide models of proper introspection, insight, and the preferred view of therapy to later Naikan clients.
Through the influence of the therapist, fellow clients, and written and audio materials, the client comes to reinterpret ongoing and past experiences as more in accord with the preferred model. At Kora Kōseiin, for example, the client comes to adopt the Moritist perspective that living a full life in spite of suffering is more important than relief from suffering. The healing model that the client may earlier have held is now abandoned. At Gasshōen the client learns how to use suffering as encouragement to purify the heart, a goal more worthy than immediate relief of symptoms. Again, the healing model is abandoned. Both Morita therapy and Naikan teach the client that relief from suffering may occur, but such relief is merely a by-product of the more important task of character development.
Typically, when negotiations fail, the client struggles and struggles but eventually searches for another therapist whose style better fits his or her initial model. To continue in therapy with an incongruent model is to engage in a meaningless and painful exercise. A few clients continue with the original therapist, trusting the character of the therapist but failing to adopt the therapist’s model. By definition, there can be no satisfactory resolution of the client’s difficulties in such situations because the models include divergent definitions of “resolution.”
Thus far we have considered primarily differences among four models of Japanese psychotherapy. There are, however, some fundamental features that are employed in nearly every form of therapy in Japan. These common features provide a clue to the essential ingredients of any successful therapy as well as insight into the essence of neurotic disorder.
One feature common to most forms of therapy is specification. The practice of requiring the patient to be specific, detailed, and precise in descriptions of self and symptoms is a key element to successful therapy. The intake interview of the various therapies requires such specification 123and can be viewed as part of the therapy process, not merely as a precursor to therapy. Morita and Naikan therapists ask for detailed accounts of the symptoms, when they began, specific problems resulting from them, and the like. Psychoanalysis calls for detailed specification of dreams and other material from the productions of the client’s mind. Within the framework of salvation therapies, vague confessions are unsatisfactory; they must be detailed and precise.
The neurotic person characteristically tries to escape from these demands for specification by making abstract, vague, ambiguous, generalized statements. “I’ve always been this way.” “I felt terrible all week.” “Nobody ever liked me.” Such statements are characteristic of the neurotic person’s estrangement from everyday concrete reality. Concreteness and precise specification force the client to think in more realistic terms about self and world.
A second characteristic of neurotics is a sort of self-centeredness, an aspect of neurosis that is noted and dealt with by Japanese therapeutic systems by techniques to dissolve self-focus. The clients focus attention on what is happening to them, to their feelings, tensions, and problems. Morita therapists point out that this self-focus prevents the client from observing reality, what is actually occurring at any given moment. Accordingly, self-centeredness restricts the client’s ability to respond realistically, to merge the self with the immediate situation. Naikan therapists see this inflated self-centeredness as a sort of screen that obscures the clients’ perception of who they really are—takers from others more than givers and sources of trouble and burdens to those around them. When the clients come to an experimental understanding of who they are (through Naikan introspection), feelings of contrition and gratitude will emerge and the self-focus will be redirected toward serving significant others.
It is worth noting that many Japanese (and Western) psychotherapies seek to dissolve this excessive self-focus through initial flooding of the client with an excess of self-focus. Absolute bed rest in Morita therapy, Naikan meditation, Shadan therapy, zazen (sitting Zen meditation), seiza (a form of quiet sitting meditation with emphasis on proper breathing), free association in psychoanalysis, baseline recording and step construction in behavior therapy, systematic desensitization, reflecting techniques in Rogerian therapy—all focus the clients’ attention on themselves as the initial step in eventually pulling their attention away from the neurotic self-focus. 124
A third feature common to all therapies is the requirement that the client do something. The sort of doing varies, of course, from therapy to therapy. In some forms the doing is meditation (focused attention) or work therapy or talking for long periods or taking medication. Even within the context of medication, the therapeutic interaction often centers on when and where and whether or not the client consistently takes the prescribed medication. In other words, no therapy allows the clients simply to be totally passive; some responsible effort on their part is required. Like the dissolution of self-focus, such tactics pull the client back into dealing with everyday reality.
Another feature common to all therapies is the use of the weight of authority. It struck me as I watched a recent Japanese television serial based on the famous tale of the forty-seven samurai that the hated Lord Kira was consistently referred to in honorific terms, even by his avowed enemies. He was Kira-dono and Kira-sama (terms reflecting his high position), but never the Japanese equivalents of “that Kira” or “the dog Kira” or even the ordinary Japanese equivalent of “Mr. Kira.” He automatically deserved use of proper exalted terms of address and reference simply because he was a member of the nobility.
My informants report (and my observations confirm) that there is no such perfect consistency in following this custom today (if, in fact, there was in the past). Nevertheless, compared with Americans, modern Japanese speakers do tend to use verbal markers of high status based on social position (and not on some personal relationship or mood of the speaker) when addressing or referring to persons of social status markedly higher than their own. Americans appear generally to use nonstatus referents to social superiors when not in their presence. Similarly, Americans seem more likely to shift estimations of the debts they owe parents on the basis of fluctuations in their personal feelings about their parents at the moment. It is not uncommon during my research in gerontology to see elderly Americans desperately try to avoid arguments and maintain smooth relations with their offspring in order to assure themselves of continued affection and economic support. Such circumstances are not unknown in Japan, but I encounter them less frequently there.
One principle underlying these patterns of behavior is that social status carries more weight than temporary feelings (kimochi) in Japan than in the United States. Authority has enjoyed particular privilege in Japan, as is to be expected from a tate shakai, a society with strong vertical organization. 125
In the light of this traditional respect for authority it is useful to note recent trends of rebelliousness toward institutionalized positions of authority and the orientation of indigenous psychotherapies toward issues of authority. Newspapers and television news broadcasts are filled with reports on intrafamily violence (children attacking parents), intraschool violence (students attacking teachers), lawbreaking (drug traffic, homicide, burglary, embezzlement), legal action against corporations and public figures, and demonstrations against the military and against the country itself. It is not difficult to think that these news items reflect an explosive challenge to authority within the family, schools, laws, business, government, the military, and even toward the hallowed national identity.
Challenges to authority may be understood (if not always condoned) in terms of individual and personal feelings and assessments of immediate situations. Authority in and of itself is no longer sufficient to ensure deference. In the past, challenges to authority in Japan were usually couched in self-sacrificial behavior such as suicide on the doorstep of a politician. Modern challenges may involve some risk but often hold the possibility of immediate reward as well. This modern-day defiance is regarded by some as a reaction to uncritical acceptance of the demands of authority and a move toward healthy disrespect and critical doubting of social power—along American cultural lines. However it is viewed, it is clear that authority in Japan faces assault on many fronts. What have Japanese Buddhist-based therapies such as Morita therapy and Naikan to say about authority, and what can they offer the modern client pulled about by shifting tides of authority and challenge in modern Japan?
It can be argued that a major element of all Japanese psychotherapies involves a restructuring of attitudes toward authority figures and a subsequent refocus of the client’s thoughts toward therapeutic issues. The model and representative of authority within the psychotherapy setting is, of course, the therapist. What therapy offers the client in orientation toward authority will be reflected in the relationship between therapist and client. In Morita therapy the therapist remains a strong leader with overt directive influence tempered by paternalistic concern, much like the traditional pattern. In this setting, however, the authority figure is seen to have suffered, too. The therapists are very likely to relate their own experiences of neurotic misery before their encounters with Morita’s method. This facilitates patient identification with this authority figure. Identification makes more palatable therapists’ authority to regulate 126their patients’ lives. It also prompts patients to endure the strict regimen by offering hope that they can overcome suffering, just as their therapists did. The refocusing element of therapy involves the shift toward having patients see their own responsibility in governing their lives moment by moment. Without relying on authority to direct them, they must learn to discover what needs to be done in this moment and in the next. Authority is taken for granted, but personal initiative is stressed.
In Naikan, both within the setting itself and in guided reflection on the past, the client is presented with images of authority figures who are kind and supportive regardless of the client’s faults. Therapists will suggest particular meditation themes during each visit, thus directing their clients course of therapy, but the therapists will also bow to clients and serve them food, listen patiently to their confessions, and offer encouragement or even shed a tear with them. Again, the authority of the therapist remains unchallenged, taken for granted. Unlike Morita therapy, where the therapist’s authority is buttressed with the sense that straightforward directing is required in that setting in those moments, Naikan encourages clients to view the therapist’s authority as a kind of service, as what the client needs. Both elements, authoritarian guidance and personal initiative, are present in both therapies, but the emphasis seems different. In Naikan, refocusing of attention directs the clients to evaluate what they did in their relationships with others (particularly authority figures). They are encouraged to ask themselves what they contributed to their superiors, what troubles they caused authority figures. Again, the acceptance of the “natural” system of authority is balanced by a recognition of personal responsibility and meaningfulness of action.
Neither Morita therapy nor Naikan supports feelings of impotence in the client. Both refocus the clients’ attention toward the ways in which the clients themselves influence the world, all the while accepting the influence of authority over them. Because all human beings must come to terms with reality of powerful figures in their lives from infancy through adulthood, these Japanese methods (and the resulting attitudes toward authority) are worth consideration as resolutions of these panhuman issues.
A final shared feature of therapies worth mentioning here is the initial acceptance of clients as they are. For the therapist to do otherwise would be to risk causing the client to leave the therapy setting, or, possibly, to sabotage the therapy process. Although not always explicitly verbalized each therapist has in mind a model of what humans are, what neurosis is, 127what cure is, and why clients are as they are (London 1964). As we have seen, this model may not be identical to the models that clients bring to therapy. Yet therapy must start somewhere, and it starts with acceptance, not rejection, of the clients themselves. Though a particular client’s model of therapy may be rejected ultimately, the psychotherapist sets an example by accepting the client as a person. Such an example may eventually help the clients to accept themselves.
In this overview of Japanese approaches to mental health I have emphasized the socially legitimized variations. As in the United States, in addition to formal therapeutic systems there are numerous informal and religious methods of dealing with mental health problems. Even within recognized psychotherapeutic institutions and clinics there are fads and regional variations. What I have presented appears, necessarily, more systematic than is the case in actual practice.
Two of the therapeutic systems described above, Morita and Naikan therapy, have been introduced to the West with some initial success. It remains to be seen whether Japanese therapies will have a major impact on treatment methods in the West.
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