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    Psychiatric Care of the Foreign Community in Japan

    Douglas Berger; Albert Einstein College of Medicine, Bronx, New York

    Gendai No Espuri (Lesprit Daujourdhui), 412: 76-86; 2001. (Although the original manuscript here is in English, the published version was in Japanese and is slightly different).


    I would like to take this opportunity to introduce the topic of caring for the psychiatric needs of the foreign community in Japan at a clinic that I established called the American Psychotherapy Center (Now called the Meguro Counseling Center). I will give a discussion of the kinds of patients I see and some of the basic approaches to their treatment. Finally I will provide a few actual case examples.

    My personal training included 4 years of university and then 4 more years of medical school at New York Medical College. After medical school I had 4 more years of psychiatric residency at New York Medical School and then 1 year fellowship in Consultation-Laison Psychiatry (psychiatry for patients with concomitant medical illnesses). My connection with Japan started in medical school in 1985 where I was an exchange student at Tokai University in Kanagawa studying neurology and psychiatry, and then again in Residency in 1988 I returned to Tokai to do research in schizophrenia for 6 months. In 1992 I returned permanetly to Japan to do research on eating disorders and dissociative disorders at Tokyo University where I recieved a P.hD in Medical Science. Since then I have been consulting with pharmaceutical companies on drug development and have founded the American Psychotherapy Center where I have been seeing patients in psychotherapy and counseling, both Japanese (in Japanese) and Westerners in Tokyo.

    I would also like to introduce Dr. Fred Shane of the International Clinic in Roppongi. Dr. Shane is a graduate of an American medical school and he has practiced as a General Practitioner in both the Kobe and Tokyo areas for over 50 years. Dr. Shane estimates that one-fourth to one-third of the patients he sees have psychiatric needs as their central focus of care. Referrals from professional counselors as well as clinic walk-ins compose the patients that he has to evaluate in the short period allotted to a busy medical practitioner who did not originally train in psychiatry. One of Dr. Shane's first medical patients in the 1950's in Japan was an uncle of Dr. Berger. Dr. Shane and Dr. Berger realized this fact over 40 years later in the late 1990's after Dr. Berger mentioned to Dr. Shane one of his uncles lived in the Kobe area in the 50's.

    Types of Patients Seen at the American Psychotherapy Center

    I think we should start with why most Westerners, and even many Japanese seek therapy with a Western therapist. First, for the Westerners is of course the language and cultural aspects. Even for Japanese therapists who speak good English or even if they have lived in the West and have Western psychiatric qualifications, there may still be basic differences in thinking patterns and in interpersonal relationships that make most Westerners prefer to have therapy from another Westerner. For Japanese, there is the feeling that psychotherapy is more advanced in the West, but there is also the sense that it is easier to share personal feelings with someone "outside" the Japanese social system.

    The tpyes of foreign patients seen at the American Psychotherapy Center reflect the strange mix of occupations that attracts foreigners to work in Japan. These include everything from hostesses and strippers, English teachers, TV and radio talents, to the presidents of the Japan subsidiaries of multinational corporations. The last few years have seen an influx of expatriates in the computer and financial market industries.

    Most of the patients have relatively mild conditions like depression and mild manic depression, panic disorder, anxiety disorder, obsessive compulisve disorder and personality disorder that causes interpersonal difficluties. Almost all of the problems have been present since before the person came to Japan and has little to do with the stresses of living in Japan (even though there are stresses to live here like not being allowed to move into an apartment because of being foreign, not given responsibility in a Japanese corporation, etc.). Persons with more serious illnesses like psychotic illnesses, serious suicidality, etc. are not able to continue to work in Japan and usually return to their country of origin. Once in a while there are well-functioning persons with schizophrenia who will come for help; as well as long-term residents of Japan who have supportive Japanese spouses and/or do not really have any place of support to return to in their countries who may also have a schizophrenia or other psychotic illness.

    Most of the Japanese patients at the American Psychotherapy Center are young women in their 20's and 30's. Some have commented that, "I would not feel comfortable discussing my feelings with a Japanese man because they are not good at those kinds of discussions". I think some of this relates to the relationship these women have with their fathers who may have been too strict, unavailable, or unempathic and these are often issues to discuss in therapy. Another reason, however, is that because Japanese psychiatric practice has focused mostly on serious psychotic illness and medications, psychotherapy has not flourished as well. This may relate in part to the cultural tendency to be more open about one's feelings in Western culture where feelings and personal difficluties are not usually expressed in Asian societies.

    Psychotherapy and Medication Link

    Now I would like to move onto the psychotherapy and medication link. Many patients need medication in addition to counseling. These are usually patients with severe mania, depression, panic/anxiety, obsessions and compulsions, and other symptoms. It is possible for a non-Japanese to get the Japanese Medical License as Dr. Shane has, however, there are currently a number of criteria. You need of course to have graduated a foreign medical school, and you need to have either a spouse visa or a permanent resident visa in Japan. Then you have to pass level 1 of the Japanese Language Proficiency test and then you have to pass the Japanese National Medical Board Exam. Although I received a Ph.D. from a Japanese University, I do not have a Japanese medical license. When I recommend medication for a patient I give my recommendations to Dr. Shane or another Japanese physician who then does the actual medical care. Having a few doctors watching the patient's medication and symptoms is also a nice safety net to make sure there are few side-effects and that the medication is being taken properly.

    Psychodynamic Psychotherapy

    Now I'd like to go over some of the ways I personally like to think about psychotherapy. The basic premise is that persons have had a number of main issues from their childhood; ie. not feeling loved, not feeling validated, feeling controlled, power struggles with family etc. As they get older they try to master these feelings both within themselves as well as in their relationships with others; these desires to master these issues or protect themselves give rise to behaviors (psychological defenses) that can often make their problems worse.

    For example, I have been treating a man who had felt very controlled by his father and older brothers. In elementary school he was like the leader but then he became bullied in high school as had small stature and the bigger guys did not like his haughty attitude. As an adult he is quite cynical and has passive-aggressive behaviors (aggravates people by not doing things or doing them in ways others do not like: for example he often does not have the session fees). But he still wants very much to be liked by others. His behaviors are an attempt to master his childhood experiences and protect him from the uncomfortable feelings of inferiority but they actually push people away from him. That people will not respect him then becomes a self-fulfilling prophecy for him and leads to interpersonal conflict and dissatisfaction in life which is why he came for therapy.

    This type of psycotherapy is called Psychodynamic psychotherapy. Psychodynamic psychotherapy is often taken to refer to therapy that is based on the "Ego-Psychological" model of psychological functioning described by Freud and others, but also includes the "Self-Psychological" model proposed by Heinz Kohut, and the "Object Relational" model developed by Melanie Klien, Otto Kernberg, and others. Object relations is described well at this site http://www.object-relations.com/define.html and will not be discussed here.

    The Ego-Psychological model is based on the idea that people have 1.) an unconscious, 2.) a "transference" of relationship style with significant others from childhood to other relationships in adulthood (the relationship with the therapist is the paradigm for the patient's transference), and 3.) "defenses" that attempt to prevent the emergence of uncomfortable emotions.

    The unconscious holds ideas and feelings that are often conflictual, and usually attempts to satisfy both needs in some compromise. This results in both maladaptive (symptoms and personality pathology), and adaptive (one's general style of pleasure, productivity and healthy relationships) traits at the same time. Talking to patients over time forms a relationship where clues are offered about unconscious habitual patterns of thinking and feeling. Dreams are also a very useful way of gaining an understanding about one's unconscious. The aim is to find a small number of pervasive issues that run through the course of the patient's pathology that can be traced back through his or her personal history. Therapy attempts to help the patient work through their conflicts in a more optimal way by analyzing the patient's transference and defenses. This process can sometimes be difficult because of unconscious resistance the patient has to giving up the defensive style that they have used for so long.

    Psychological conflict often arises from the need for both love and independence from one's parents. For example, if one's parents are intrusive, expressing the need for love to them can be difficult. A teenager with "over-neat" parents who keeps their room messy is expressing both the need to be independent (not doing it their parent's way), and the need for love and care (mom has to come in and clean up) at the same time. They may have symptoms including anger and irritability or anxiety and depression when others don't continue to provide affection in the face of their oppositionalism (both a defense against directly expressing their conflictual anger and love to their parent, and their unconscious "transference" style-maladaptive in this case).

    When defenses fail, psychological symptoms (i.e., anxiety, depression) may emerge, and relationships with others may not go well when defenses are maladaptive. For example, when boasting as a defense against unconscious feelings of inadequacy fails, depressed feelings can appear and relationships can sour because it is not an adaptive way to relate.

    The Self-Psychological model is somewhat less structured, but basically consists of the need for children to be "mirrored", or supported and praised, by their parents as they strive to achieve. Empathic failures are thought to distort and inhibit the development of an adequate sense of self (both conscious and unconscious), that then leads to symptoms and impairs one's relationship style with others. Again, defenses attempt to compensate for these failures of self-development. Empathy is the main therapeutic tool in the Self-Psychological model that is used to help the patient resolve their feelings of inadequacy. Analysis of the patient's transference and defensive style is used in therapy in order to understand the origin of the empathic failures, and to improve any maladaptive relationship styles that are thought to be based on the underlying feelings of inadequacy.

    Further reading on psychodynamics can be found in: The Psychodynamic Formulation: Its Purpose, Structure, and Clinical Application. By Samuel Perry, M.D., Arnold M. Cooper, M.D., and Robert Michels, M.D., American Journal of Psychiatry, 1987;144:5:543-550.

    Cognitive Therapy

    Another type of therapy that is helpful is called Cognitive therapy. Cognitive therapy deals with changing one's dysfunctional cognitions (thoughts), emotions, and behavior. Identifying and correcting one's negative or distorted automatic thoughts is the key. These autonomatic thoughts occur rapidly while an individual is in the midst of a particular situation. The more the situation stresses the person's emotionally sensitive issues, the more they are likely to react with a distorted thought that will then affect their emotional state adversely. A brief list of these automatic thoughts includes: all-or-none thinking, magnification, personalization, selectively extracting the negative out of a situation, catastrophizing, minimizing, "should" statements, and labeling (self and/or others). Underlying (unconscious) cognitive schemas (e.g., "no one loves me") are thought to be at the crux of the propensity for development of cognitive distortions.

    Patients with problems such as depression and anxiety, or interpersonal difficulties, have many negative and maladaptive automatic thoughts which can lead to behaviors (e.g., helplessness, withdrawal, aggression, or avoidance) that make the problem worse, resulting in more disturbed mood and leading to more dysfunctional thoughts, in other words a vicious cycle. Cognitive therapy attempts to help patients recognize and change these cognitive errors through discussion with the therapist, outlining and listing the situations and distortions in writing, and homework practice. Behavioral change may be necessary to modify long-standing maladaptive patterns of behavior that reinforce the distortions.

    Cognitive therapy may be very useful as an adjunct to help patients see how their thoughts make thier mood bad or worse. It doesn't say anything about the causes of the distortions or the underlying schemas, however, or how they pan-out in interactions with others. Psychodynamic psychotherapy is usually required for a deeper understanding of oneself as it deals more with the unconscious concomitants of one's emotional life and how these impinge on relationships.

    Some studies have shown that antidepressant medication can reverse the cognitive distortions of patients with serious depression. It may be that distortions are more likely the result of biological factors (i.e., one's neurochemicals controlling mood are disturbed) in severe depression, while distortions resulting from one's personality style may be more of a cause of disturbed mood in more milder conditions. So even though the jury is still out on the exact causes of one's distortions, it makes clinical sense to give patients an idea of how their distortions may be contributing to their emotional trouble.

    Combining a few forms of psychotherapy is usually the most helpful. Medication may be needed in combination with psychotherapy for more severe symptoms, or if the patient has not responded to a number of psychotherapies, depending on the problem. Though many people have understandable reluctance to go the medication-route, the principles of: 1.) "If you don't try it you'll never know if it works", and 2.) "If you don't like the medication you can stop it", can prevent that select group of people who really need the extra biological jump-start from wallowing for years in unnecessary emotional distress. If one's brain chemicals (neurotransmitters) are really disordered to the point that psychotherapy alone does not help, these chemicals will probably not normalize just because the person wants to "do it on their own" any more than a diabetic can will themselves to produce insulin. People may conclude that the problem results from a situation in their lives rather than a disorder in mood-regulating neurotransmitters because their life-situations are easier to see, and because the prospect of having a brain-chemical disorder feels like another emotional burden to bear. While this is understandable, and while this author is a strong proponent of the value of psychotherapy, this can end up to be a "cognitive distortion" that impairs their getting important help.

    Suggested Readings

    Beck, J: Cognitive Therapy: Basics and Beyond. New York: Guilford, 1995.

    Burns, D.D: Feeling Good. New York: Avon Books, 1980.

    Fava M., Davidson K., Alpert JE., Nierenberg AA., Worthington J., O'Sullivan R. Rosenbaum JF: Hostility changes following antidepressant treatment: relationship to stress and negative thinking.Journal of Psychiatric Research. 30(6):459-67, 1996 Nov-Dec.

    Case Examples

    1. Never feeling loved enough

    As I discussed above, one's behavior based on unconsious needs can often lead to negative outcomes. Many of my patients have put themselves in very dangerous situations. One of my young women patients did not have much contact or love from her father as she was growing up. She became very attached to her boyfreinds and was so sensitive to rejection that she would cut her wrists if they tried to break up with her. To overcome this fear she began to prostitute herself, going on paid dates with men that included psysical relationship. This way she always felt in control of the men rather than they controlling her intense neediness. The money in these relationships represented her control and so she was very attached to having men give her money along with their attention.

    Finally she met a man who brought her to a hotel room. He stole 50,000 yen from her wallet while she was in the shower, and then when she confronted him, he forced her to have sex with him and threatened to kill her. He also made her drink his urine. Finally after a number of hours and he was really tired he said she could leave the hotel room where she barely escaped with her life. Another time she narrowly escaped getting trapped in a van with a man where a video of them having sex would have been taken to be sold then on the black market. This is an extreme example of how one's behaviors representing unconsious issues can result in a maladaptive outcome. The goal of therapy was to have her become able to tolerate the risk of loosing love from men and to see the problems she was getting into by using her defense of trying to control men.

    2. Not separating from children

    Although I have had to deal with persons trying to cut their wirsts, taking pills, getting trapped in hotel rooms with a rapist etc., nothing had shocked me more than this case. The patient was a 20 year-old half-Japanese half-American woman. She had 2 prior episodes of schizophrenia (hearing voices, having delusions people wanted to kill her etc.) where she received medication while an in-patient in the United States. She had come once a week for 5-weeks regularly and I was increasing her medication dose. Her mother was bilingual, articulate, international, and had a very elegant demeanor about her. The mother kept close contact with me telling me how her daughter was doing in-between sessions. She had only come 5 times and one day the police called me to tell me the mother strangled the daughter to death and then jumped in front of a train herself and suicided. The mother left a suicide note stating she was sorry to everyone for doing this.

    It would of course have been very difficult for any therapist to see that this would occur, but because I was so focused on the daughter's problem, I had failed to see how the mother herself had gotten so involved in her daughter's illness that she had not seen themselves as two different people. Later I had heard how over-attached the mother had been to her children since they were born. She could not wait until the medication worked or even bring her daughter back to a psychiatric hospital. The lesson here was for me to notice exactly how the whole family was functioning not just how sick only the patient was. This shows how serious caring for these persons can be and that the complexity of human behavior and psychiatric illness cannot be underestimated.

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