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ZEN AND THE ART OF PSYCHOTHERAPY: BRIEF SESSION COGNITIVE THERAPY IN JAPAN
(1) Keio University School of Medicine,
Department of Neuropsychiatry,
35 Shinanomachi,
Shinjuku-ku, Tokyo 160
Japan.
(2)Albert Einstein College of Medicine, Bronx New York. Tokyo Institute of Psychiatry, Tokyo Japan
ABSTRACT
Due to economic pressures and the development of pharmacotherapy, it is becoming more and more difficult to spend fourty-five or fifty minutes per session. In order to modify the mental schemas and personality structures that predispose to psychiatric symptomatology to a degree that will prevent relapse and improve well-being, psychotherapeutic approaches are indispensable in our experience. In Japan, many patients benefit from a brief session cognitive approach of approximately fifteen minutes per session with medication. The main purpose of this approach is to help patients to modify their distorted cognitions in order to foster a sense of control internally as well as externally, and to improve their communication with important figures. Several techniques of such brief-session psychotherapy are discussed in this paper: 1)Respecting the patient's abilities and individuality to help the patient to make most use of them. 2)Modifing cognitive distortions by focusing on the so-called "hard-core" schema of "I'm unlovable" and "I'm helpless". 3)Follow the patient's activity both inside and outside the treatment. 4)Discuss long-term goals, and promote acceptance of their limitations. Application of the above technique with Japanese patients using the concepts of Zen Buddism and the Japanese Tea ceremony as a background base, and their relation with modern western cognitive and dynamic therapy theory, is also discussed.
INTRODUCTION
Psychotherapy appears to have become less important recently due to the advent of more effctive psychotropic medication with fewer side effects and increasing evidence of neurophysiological and genetic factors in mental disorders. Especially in the United States, this trend has been facilitated by economic pressures causing psychiatrists to cut the time spent with each patient.
These facts, however, do not mean that psychotherapy is actually unnecessary. If the DSM-III-R (1987) Axis I state disorders become more treatable with pharmachotherapy, then the Axis II personality disorders or traits will become the main target for psychotherapeutic approaches which can be effective in a limited time frame.
One model for this kind of approach is found in Japan where interview time has been restricted due to the public insurance system. Japanese psychiatrists who can spend only ten to fifteen minutes per session have tried to develop techniques to understand and help patients in brief sessions. This paper will describe the techniques which one of the authors (Ono) has developed in this regard.
The basic principle of these techniques are based mainly on Beck's cognitive theory (1976) and dynamic psychotherapy. Beck (personal communication) stresses the importance of two schema, "I am unlovable" and "I am helpless", in the pathology of personality disorder patients and calls them "hard-core schema". The authors think that these two schema are important to understand and treat not only in personality disorders but also in other psychiatric disorders.
Beck's "hard-core schema" concept overlaps considerably with the "triple C concept" (cognition/control/communication) which the authors have used in creating psychologic change and in the amelioration of symptoms. With the help of the clinician, patients try to change their distorted cognitions into more rational and adaptive ones which helps them regain a sense of control internally as well as externally. This change can improve their communication with important figures which then strengthens social suppots. Regaining a sense of control leads to modification of the "helpless schema", and improvement of communication leads to modification of the "unlovable schema".
The idea of helping oneself with helplessness through self-empowerment has a long history in Japan in Zen where one's potential strength lies only within oneself, and only by one's efforts can one increase it (Benedict, 1946). As a fencer must learn to stand easily on a pilliar, a patient must learn to stand on their own emotionally. In Zen, one might associate oneself with a teacher, but the teacher cannot teach in the Occidental sense as only what is internally learned is of any importance.
Statements from the therapist might be akin to the Zen "Koan", or problems given which have no rational solution. For example, "to concieve the clapping of one hand", or "To feel the yearning for one's mother before one's own conception". The koans are felt to be bricks which help one knock on the door to enlightenment about human nature. For Japanese this door is the door of haji (shame), and once one finds a way out of their shame one is free to experience life without bonds. This can be seen as one abandoning on'e "observing self" that for many Japanese patients keeps them bound in obsessions on duty, responsibility and how they are percieved by others. Further discussion of Zen will be presented below.
MEDICAL INSURANCE SYSTEM IN JAPAN
Almost all medical fees in Japan are covered by the public health insurance system with patients having a ten to thirty percent co-payment. If the fee becomes high (over appoximately nine hundred dollers in total), or if the patient is indigent, the fee is subsidized. Psychiatric patients are also supported by a special law which provides subsidies for psychiatric treatment if a patient applies. Although everyone has to pay for this heath system, the payment is affordable for everyone because it is based on a sliding scale depending on income.
In this health insurance system, however, the importance of psychological approaches such as psychotherapy tend to be neglected compared to that of more medically oriented procedures. For example, the fee for psychotheapy by a psychiatrist is 2800 yen (27 dollars) at a hospital and 3300 yen (31 dollars) at a small outpatient clinic regardless the length of the interview. This situation makes it necessary for Japanese psychiatrists to see as many patients as possible during their clinical hours. This tendency is also related to the the fact that 8000 psychiatrists are working for one hundred and twenty million people in Japan.
According to a 1987 survay by Nishizono (1988) the avarage number of outpatients per day at 252 facilities was about 50 including 1.7 new visits. These patients are seen by only one psychiatrist in most of these settings with an average interview length of less than fifteen minutes. According to a study by Fujita, Koga, Takeuchi, and Takemasa (1993) in which anxiety disorder vignettes were given to psychiatrists, more than 90 percent of the respondents answered that they would spend less than 30 minutes with each patient.
NON SPECIFIC FACTORS
Clinician's Attitude
In order to treat a patient effectively in a brief session, nonspecific factors (Frank, 1979) such as the atomosphere of the treatment setting play an important role. A clinician's empathic attitude and nonverbal communications are important in this regard. This contribute to the development of a "holding environment" (Winnicott, 1965) which is a nonspecific factor thought to affect the outcome of psychotherapy. An especially important nonspecific factor in Japan that is felt to connect the patient and the therapist is "silence" which, in Zen Buddism, is considered to be the essence of human existence (Kino, 1966).
Silence in the therapeutic relationship is colored by the clinician's internal and external attitudes. Internal attitudes consist of the clinician's way of thinking about the patient's psychological experiences. External attitudes consists of clinician's facial expressions, postures, intonation of voice, timing of verval and nonverval expressions, and other various factors. These attitudes contribute to an affect attunement in the therapeutic dyad which is similar to the relationship between a mother and an infant as described by Stern (1985). This therapeutic relationship helps to produce a corrective emotional experience (Alexander, 1966), helps a patient reconfirm their existence, and modifies both the "unlovable" and the "helpless" schema.
Therapist's Internal Attitudes
One of the most important internal attitudes of the therapist can be explained by the concept "Ichigoiche" of the Japanese tea cermony. Ichigo means a "whole life" and Ichie means one meeting. Naosuke Ii (1815-1860), a famous politician who tried to open Japan after two hundred years of isolation, quoted the term, "Ichigoichie", to describe the psychological attitude of the tea ceremoy host (Kino, 1966). The host should think that this is the only opportunity they will ever have to see the guest. With this in mind the host is able to treat the guest with feeling, enabling meaningful psychological interaction. The guest, in turn, also feels the thoughtfullness of the host and is able to leave the room with satisfaction. This kind of experience makes it possible to internalize a good object image, and both the host and the guest are able to "see" each other internally at any time in the future.
This attitude of the host can also be applied to psychotherapy. The clinician should conduct an interview by keeping the Ichigoichie feeling in mind. This means that the clinician should try to help the patient feel that they have gotten something important out of the session. For example, a meaningful experience for the patient could be to just spend time with the clinician if they had not been able to associate with other people for a long time despite a desire to do so. Patient whose problems developed secondary to cognitive distortions would need to begin cogntive restructuring techniques.
Focusing on the patient's needs allows the patient to leave the room with the satisfaction that a tea ceremony guest does even if the length of the session is brief. This kind of experience helps patients to internalize the clinician's good object image as well as a good self image with its accompanying warm affect; this modifies the "unlovable" schema. Furthermore the patient can also internalize the strategies and attitudes the clinician has used in the treatment. These internalizations cultivate the patient's ability to cope with difficulties outside of the sessions, which can then modify the "helpless" schema.
In order to strengthen these experiences the "Zanshin" concept of the tea ceremony is also useful. ZAN means remain and SHIN means mind. Zanshin is the word used to express the psychological attitude at the time when a host sees a guest out. The host should not just start cleaning-up after the meeting. They are expected to stay, quietly reexperiencing the excitement of the meeting which still remains in the room. These psychological attitudes are also important for a clinician. The clinician should silently spend at least several seconds reflecting on the meeting with a patient before beginning the next work. This attitude will be sensed by patients.
Respect the Patient's Ability
The clinician's attitude is basically to acknowledge that the patient has a leading part in the treatment and to respect their position in this regard. This is a basic principle of cognitive therapy. In cognitive therapy patients' distorted cgnitions need to be identified by the patients own cognitions.
In order to make the most of the patient's capability in treatment, a clinician can utilize Socratic questions. The clinician should avoid giving an interpretation regarding the patient's unconscious fantasies. When a patient complains of distress and psychological pain, it should be taken at face value.
Patient-Therapist Match
In order to make the most of nonspecific factors, therapists and patients need to be congenial to each other. Okonogi (1987) suggested that the drop-out rate in the psychotherapy of borderline patients is low when the clinician-patient combination is well matched, and that this is important for referring psychiatrists to keep in mind.
In the Japanese system in which the medical fee is low, patients can easily choose a clinician because they can decide after a few trial visits. The advantage of this is that patient can independently find a clinician they match with. On ther other hand, these patients might end up in a "revolving door syndrome". In order to avoid this problem the clinician should ask about treatment history, especially about prior patient-therapist relationships at the initial session. This information is important in predicting future therapeutic relationships. If necessary, the clinician should recommend the patient to go back to their former clinician.
The experience of behaving independently in the therapy allows patients to practice coping strategies and problem solving by themselves. The patient also feels that they have achieved or aquired something in the session. This enhances the patient's self-efficacy, strengthens their motivation for the treatment, and finally modify the "helpless" schema. Usually patients have been neglected by important others. The experience that their thoughts and feelings are respected induces a corrective emotional experience and modifies the "unlovable" schema.
Preventing Patients' Regression
Respecting the patient's decisions in a collaborative way may prevent further regression. Most patients when first seen are already regressed. If the patient is allowed to regress further, there is the danger of experiencing a "malignant" regression as described by Balint (1968). This can lead to various types of iatrogenic borderline-like behaviors. Preventing regression can strengthen both the "helpless" and "unlovable" schema. Shortening session time can also help to prevent unnecessary regressions.
SPECIFIC FACTORS
Treatment Process
The principles of cognitive therapy can be applied to the usual treatment process. This consists of four stages which can be conceptualized based on the "KiShoTenKetsu" (introduction, development, turn, and conclusion) process. The description of "KiShoTenKetsu" originates from classic Chinese writing style and is also used as a model for the Japanese writing style. Although the actual treatment process usually can not be clearly classified into four stages, this conceptualization is useful for clinicians to estimate where they are in the treatment.
In the first stage, the clinician and patient collaboratively and concretely assess the patient's realistic life problems and their psychological problems. Based on the asessment, psychological and biological treatment approaches are proposed, clarifying the similarities with, and differences from the patient's expectations.
At the second stage, cognitive approaches are applied to focus on, and modify distortions of automatic thoughts, and review the the daily schedule. In order to utilize these cognitive approaches effectively in a brief session the focus is put on the automatic thoughts derived from the "helplessness" and "unlovable" schema. At the third stage, the "hard-core" schema themselves should be identified and modified based on the themes that repeatedly appear in the automatic thoughts. In the fouth stage the patient is helped to prepare to seperate from the clinician, and to start moving in to the real world on their own.
Basic Model for the Treatment
As Beck (1976) has pointed out, clinicians need to have their own basic blueprints for understanding and treating psychopathology. Figure 1 shows the basic model for treatment (Ono, 1993). An individual responds in different ways to internal and external stimuli. These could be interpersonal conflicts, realistic burdens, physical conditions, and internal experiences such as fantasy and memory.
These stimuli induce reactions in thought, mood, behavior, and body. These reactions themselves can then become stimuli. These stimuli and reactions are mediated by cognitions which are determined by the underlying schema. The formation of the schema is influenced by both genetic and environment factors.
Recently, the treatment of personality disorder patients has led cognitive therapists to pay more and more attention to the underlying schema (Beck, Freeman, et al., 1990). As mentioned before, Beck stresses the importance of "hard-core" schemas as "I am unlovable" and "I am helpless" in the treatment of personality disorder patients. It is also useful to utilize the "hard-core" schema to identify and modify distorted cognitions, and to heighten a sense of control and communication in other disorders as well.
Initial Interview
Although the interview time per patient is limitted the clinician should try to spend between 30 and 60 minutes at the initial interview. In this session the clinician and the patient collaboratively try to assess the problems based on the model described above. First, the realistic problems are asessed. Are there any problems in the family and/or work? How much are they supported in these situations? What is his/her fiancial condition? How much have they achieved in the tasks related to their developmental stage in life?
Then, a screening physical exam is done and a mental status is taken. The clinician should assess the patient's assets and strengths as well as the problems. Throughout the therapy the clinician repeatedly conducts this kind of assessment and identifies which areas have improved and which have deteriorated.
During this assessment the clinician tries to find the relationship between the manifest problems and the underlying hard-core schema. Inquiring about the characteristics of the patient's personality as described by the patient is also useful to get to the underlying schema. The descrepancies between the clinician's impressions and the patient's descriptions are important because they may reflect the patient's cognitive distortions. The results of the assessment are discussed with the patient, and this is important in order to promote the patient becoming able to conduct a similar assessment on their own. The amount of information to be given to the patient is determined on the context of the treatment.
Through this assessment, the clinician and the patient can deliniate the concrete problems and decide their hierarchy. This process enables the treatment to focus on more important and treatable issues and shorten the session. The patient and their significant others are encouraged to describe the characteristics of the patient's personality. They use both dimensional and categorial descriptions. These descriptions are useful because they usually reflect the patient's self image and interpersonal relationships.
The other important issue in the initial interview is to discuss the long term goals in the patient's life. If this can be made clear, it strengthens the patient's motivation. This kind of communication also conveys that the main purpose of treatment is to increase psychological well-being as well as to reduce symptoms.
If the clinician and patient can not make long-term goals clear they should at least try to image a certain picture of the patient's future. This picture might then become clearer as both participants achieve the short term goals.
Some patients may feel frustrated from the start of the treatment. If the patient has strong expectation to be cured they will soon realize that the clinician is not powerful enough, and they can become easily disappointed. If that is the case, the clinician can point out that the patient tends to have unrealistic expectations and that this tendency might have caused other interpersonal problems.
Because of cultural factors, however, Japanese patients rarely express these intense negative feelings outwardly and instead tend to keep them supressed. It is therefore important for Japanese clinicians to look for discrepancies between what the patient says and their behavior, attitudes, and facial expressions as information about hidden feelings. The more severe the personality disturbance (ie.--borderline structure), the more obvious these discrepancies will become.
Psychoeducation
After the initial assessment the clinician tries to share the imformation with the patient in an educational way. Patients are usually afraid of the idea that they are suffering from a psychiatric disorder or have psychological problems. Psychoeducation can reduce this kind of unnecessary fear and help patients to face these problems.
Booklets which describes disorders in lay terms is useful. One of us (Ono) recently wrote a book entitled, "Utilizing the Depressive Experience -- Cognitive Therapy for Depression" (1990) which has been well recognized by Japanese patients and patients' relatives as well as specialists. Some patients that have severe depression, however, had compained that it was difficult to read even an easy book. In response to this, Ono wrote a comic book (1993) which describes a middle aged man who suffered and recovered from depression by restructuring his cognitions with the help of his family. Comic books are widely read in Japan and are a good means to provide educational information visually as well as verbally.
Pharmacotherapy
Psychoeducation is also necessary for pharmacotherapy. It has been widely acknowledged that pharmachotherapy and psychotherapy are not contradictory but rather complementary (Manning, Frances, 1990, Hollon, DeRubeis, Evance, 1990). Pharmachotherapy is expected to ameliorate the symptoms initially, which then makes it possible to focus on psychological or personality issues using psychotherapeutic approaches in shorter sessions.
From the authors' experience in Japan, however, more than half of patients have concerns about medication. They fear that medication would cause a disasterous change in their body or that they might become dependent on the medicine. Some of them do not want to take medicine because they do not want to accept the idea that they have difficulties in their mind, or to be controled from outside.
Because cognitive distortions can be identified in patients' reactions, it is useful to discuss concerns related to medication. At the same time the clinician should ask a patient how much and in what way they want to take medication.
