FOUR STAGES IN ONE SESSION

The "KiShoTenKetsu" concept described above can be aplied to the process of one session which will now be described.

1. First Stage: "Ki"(introduction)

In this stage the patient reports what happened since the previous session. The patient also assesses both the positive and adverse effects of medication. The clinician helps the paient to clarify the problems and gains, and identifies one or two issues to focus on in the session. For clarification, it is helpful for the clinician to use common sense. This does not necessarily mean that their common sense is correct. However, the descrepancy between the patient's story and the clinician's common sense sheds light on the patient's underlying problems.

When the clinician discusses a problem they should avoid forcing the patient to accept their viewpoint. The patient's own wording should be used as much as possible. Improvement in sleep and appetite are good indicators of change.

2. Second Stage: "Sho"(development)

At the second "Sho" stage the clinician and the patient collaboratively try to begin to solve problems from a cognitive point of view, especially the modification of "hard-core" related thoughts and images, which will be described in detail in the third stage.

Modifying Cognitive Distortions

In brief session therapy, thoughts are modified into more flexible and adaptive ones just as they are in standard cognitive therapy. For this purpose, Socratic questioning and guided discovery are used The importance of wider, flexible thinking has been acknowledged for a long time in Japan as being important for psychological well-being. A Zen priest Takuan (1573-1648) clearly pointed out this issue. His idea, which had a big influence on the "Bushido" (the samurai spirit), shares many similar points of view with cognitive theory.

In his writing he repeatedly underscored the importance of free movement of the mind. He said that a person cannot see all the leaves if they stand in front of a big tree looking at only one leaf. This is similar to the case in which one becomes trapped in anguish when their mind looses flexibility and becomes unable to move freely. He writes, "It is best not to have your mind stop at one point just based on whatever you may see or hear."

It is not enough just to understand such ideas intellectually. It can be utilized only after one acquires practical techniques. Priest Takuan uderscored this by saying "Even if you see reason, it is useless until you gain command of practical techniques …… Technique and reason are closely connected to each other, like the wheels of a car." The importance of flexible thinking in Zen relates to the heavy burden the Japanese put on themselves through self-survellance. Whereas Westerners identify their observer-selves with their sense of rationality and pride themselves in keeping one's wits in time of crisis, the Japanese feel an incredible relief when they can release the restraints of self-watchfulness. Zen declares that there is a more efficient plane of human consciousness when this burden falls away (Benedict).

The techniques of cognitive therapy identify and modify automatic thoughts and help adaptation to reality. Focusing on automatic thoughts and images derived from the both "helpless", "unlovable" hard-core schema is important in order to help modify cognitions in a brief session. A patient will mention them as they discuss issues related to internal or/and external control, or interpersonal relationships. These shema are expressed as distorted views of self, others, and the relationships to others.

Transference Utilization both Inside and Outside the Treatment

Clinicians should pay attention to transference because it contains a lot of information related to cognitive distortions. As mentioned above the clinician should be problem-oriented as well as reality-oriented. The main focus is on here-and-now issues in order to prevent regression. Even when the patient's past is discussed, it should be compared with the present.

In order to keep sessions short, it is necessary to take up cognitive distortions that occurs outside the session as well. Regressed patients easily transfer their maladaptive relating styles to others in their outside lives and this causes interpersonal problems and cognitive distortions. This makes it possible to briefly identify and resolve the patient's maladaptive behaviors and thoughts by modifying cognitive distortions related the "hard-core" schema that occur not only inside, but also outside the treatment.

Don't Forget the Positive Side

The clinician should not to overlook positive aspects in the patient's life, and these should be supported in the treatment. Therapists are usually good at pinpointing patients' negative aspects. Patients are also specialists at reporting negative aspects more negatively. As a result, the clinician tends to conspire with the patient to find every fault, and this only strengthens the patient's negative cognitions.

The clinician should look for signs that indicate that the patient is able to control their thoughts, feelings, and/or behavior, or that they are able to communicate with others. After listning for a while the clinician should verbally strengthen any cognitive restructuring. Alternatively, the therapist may support the patient nonverbally.

The clinician should empathize with the patient's distress because, if the patient's positive side is mentioned repeatedly, the patient may become frustrated thinking that the clinician does not apprciate their psychological pain. In addition, if the clinician says things like "you are always focusing on the negative side because you feel you are inadequate", the patient may feel criticized. This kind of intervention may only help to enforce the "helpless" and "unlovable" schema. In order to avoid this, the clinician should try to explain at length what they want to convey by quoting concrete examples and by using the patient's words as much as possible. If the patient says that they are not getting better, the clinician may say, "Although you say you are not going better, your voice became louder and you said you started walking faster. This seems like you are getting better."　In order to get objective information, questionnaires as the Beck Depression Inventry, Beck Anxiety Inventry, and others can be given as well.

The clinician can also use general information regarding symptomatology in order to avoid criticizing the patient, ie., " Mood is generally thought to recover slower than other symptoms are. So you may be still feeling distressed internally even if you look like you are getting better." or "Generally people tend to recall only the painful events and to focus on the distress. That is a cognitive distortion as you know. Do you think this is happening to you?"

The clinician may clarify this by quoting some events that everyone can identify with, "You might not be able to see your own changes if you try to find them every day. This is the same experience of parents. They do not notice that their children are growing taller because they see them everyday. Grandparents who see their grandchildren once a year, however, easily notice the growth."

Sometimes it happens that nothing has changed during a certain period. In that case the therapist should not be in hurry or become despaired. The therapist should check themselves and identify any dysfunctional thoughts, ie., " I am powerless", "The patient will be disappointed with me", "my colleagues will be surprized at my inadequacy", etc. The clinician and the patient should reassess the patient's life to look for problems which may have been left out. It is also often necessary for patients to accept reality as it is. They have to acknowledge and psychologically integrate the fact that there are problems which cannot be easily resolved and that life can go on with them.

Dysfunctional Thought Record

In order to assess both realistic and distorted thinking properly it is useful to recommend patients to keep a Dysfunctional Thought Record as described by Beck (1979). The clinician, however, should not force this on the patient as the patient often will not follow this (similar to homework for students) and the therapeutic relationship can become strained.

The main reason to let the patient record thoughts in their own way is that the purpose of the record is not only for the modification of dysfunctional thoughts but also to cultivate problem-solving ability. Having their own format and using it in their own way allows the patient to experience that their individuality is respected. This experience will strengthen the motivation to participate in treatment and enhance patients' self-reliance.

During this procedure the clinician should not focus only on negative aspects as has been previously pointed out. The way Morita-therapists handle a patient's diary is a good example (Fujita, 1986). In Morita therapy, the patient is thought to be unable to get out of distress because they are obsessively fixated on their symptoms or daily problems. Because these symptoms and problems often cannot easily be ameliorated, the patient is encouraged to accept the difficulties as they are, and to do whatever they can little by little. In order to foster this, the clinician intentionally neglects patients' complaints about their difficulties and instead focuses on the areas where they have dealt well with their difficulties.

It is important for the clinician to determine what will be communicated to the patient because it is not therapeutically appropriate to convey everything. Patients may sense that the therapist is benevolent by this and this allows the patient to see that they are accepted and cared for even when it is not directly verbally expressed.

Reorganizing Daily Activities

The life of psychiatric patients is usually disturbed. A large number of patients report that they are withdrawn from social activities. This tendency is usually more prominent in chronic patients. This can function as a factor to maintain or worsen symptoms and a vicious cycle may develop. In order to interrupt this vicious cycle and to reorganize daily activities, the patient is advised to plan a daily schedule. Assessing degree of pleasure and life satisfaction is important in cognitive therapy. The patient should be helped to become able to have a sense of fulfillment in their activities such as job, housework, study, etc.

3.Third Stage: "Ten" (turn)

In the third "Ten" stage the "hard-core" schema is the main focus. Although it is difficult to clearly divide the second and third stages. They can be differentiated based on which parts, the automatic thoughts or the schema, are the main focus. The task here is to modify the "hard-core" schema based on an understanding of the repeating themes in the automatic thoughts. In earlier sessions the second stage is longer and in an later sessions the third stage becomes longer.

Clinical interventions become more acceptable to the patient if the clinician uses the patient's own description of their personality assessing the "hard-core" schema. In the "Ten" stage the patient is helped to realize that it is unrealistic to think that they should be able to do everything or, conversely, that they cannot do anything. Patients need to acknowldge that it is natural for them to be cared for by someone but that they cannot get this from everyone. During this process it is useful to keep the long-term goals in mind.

4.Fourth Stage: "Ketsu"(termination)

In the final "Ketsu" phase the patient's feedback is gotten, homework is assigned, and medication is prescribed if needed. The homework assignment is important in order to shorten the session, to modify cognitive distortions through actual practice, and to understand transferences in daily life.

CASE EXAMPLES

1. Develop Patient's Own Daily Schedule

A fourty-two year old Japanese male college professor was diagnosed as having bipolar disorder, type II. He was severely depressed with sleep disturbance. After several sessions, he developed a daily schedule that graphically recorded his work, leisure, sleep, life events, medication, mood changes, etc. In this way he tried to control his daily life visually. Although the descriptions were detailed (which reflected his obsessionality) the clinician did not confront this because it was not interfering with his activity. The therapist respected the patient's coping style as his way of controling his internal and external life, and together with the patient made a plan for the following week's activities, expecting that his helpless schema would improve. Partly helped by this procedure his depression lifted.

2. Developing a Sense to be Loved

A fifty-eight year-old single Japanese female was seen for obsessive behavior, impulsive shoplifting, and depressed mood with suicidal ideation which had lasted for more than 30 years. Because she was hard of hearing and had no relatives, she talked only to her supervisor at work and a nun at a small convent to which she had belonged for several years. She started writing down events and thoughts during the previous week in tiny handwriting on a small memopad. She always read them aloud as if she was asking for the clinician's approval. Her detailed descriptions reflected her obsessive and dependent style.

At the same time, she tried to teach the clinician by including a quoted passage from a novel or essay in her memos. Although the clinician thought that the patient was trying to deny her dependency on him by this, it was not interpreted. He understood it as the patient's way to control the treatment situation and, at the same time, to communicate with him by giving information. The clinician expected that these efforts would result in the modification of her "helpless" and "unlovable" schemas. This expectation was supported by the fact that the patient functioned well with few symptoms and attended the clinic every other week for a fifteen minute session where she mostly read and the clinician made a few comments.

3. Helping to develop a sense of control

A thirty-two old single Japanese male was diagnosed as having major depression for eleven years. He complained of severe lethergy and loss of interest. In the third session he said, "I have gradually become able to keep a diary about my feelings and thoughts though It has been very difficult for me to even write down a memo. I have also become able to clean my desk. I am now trying to do whatever I can."

The therapist said, "You seem to have regained a sense of control by doing daily trivial things. I think it is a good way to make you feel good." The patient added, "I will suffer a setback if I am confronted by a big wave of difficulty." The therapist clarified that this reaction is his usual attitude to see the future in a negative way, and clarified that he often challenges big difficult tasks when he feels good, and usually fails with following through on them. Then the therapist pointed out that these experiences make him feel like a failure and exacerbate his depression. The patient agreed with this interpretation and started developing a daily schedule.

TOWARD TERMINATION OF TREATMENT

Once the "hard-core" schemas have been modified and the patient becomes more confident, they should be able to have more meaningful interactions with others. At this point the patient is ready to seperate from the clinician without much difficulty. At termination, patients are told that they can come back whenever necessary. In Japan, where a strict appointment system has not been established, the patient can easily return to the therapist any time. This situation fosters the feeling in the patient's mind that they are supported. It is interesting that oriental culture has symbolized human interdependency in the Chinese character "人" (human being) in which two lines can be seen supporting each other.

Some patients may become over-dependent due to this system. Overdependency can be avoided by respecting the patient's individuality and deciding on termination together with the patient, basing the decision on improvement in the patient's daily activities.

CONCLUSION

Recent findings suggest that pharmachotherapy can ameliorate not only symptoms but also problematic behavior. The authors believe, however, that it is difficult to modify underlying shchema only by medication. In order to modify these schemas to the degree to prevent relapse, psychotherapeutic approaches are often required.

It is becoming more and more difficult to be able to spend fourty-five or fifty minutes per session, and furthermore, full-time sessions may not be necessary for all patients. Frances, Clarkin, and Perry (1984) pointed out that the theory and research supporting the 50-minute hour were not very convincing. There are, of course, patients who will require longer-session psychotherapy such as psyhoanalytic psychotherapy or cognitive therapy. Such psychotherapy also plays an important role in training in order to understand psychodynamic and therapeutic processes.

In Japan many patients seem to benefit from a brief session cognitive approach of approximately fifteen minutes per session. Shortening the treatment session not only improves the cost performance but also prevents malignant regression. This is true even for these patients who develop a network approach of multiple specialists and relatives to support him/her.

It is certainly difficult to deal with the entirety of a patient's psychological problems in a brief session. This approach can help a patient to change by providing them with a sense of fulfillment in that they had identified and resolved their problems by themselves and through the experience of sharing communication with another person they were able to grow. These experiences strengthen ones sense of control and cultivate self-confidence which can then modify the "hard-core" schema.

It has to be underscored that these approaches have been develpoed based on clinical experience in Japan. These techniques could, however, be modified for patients with different socio-cultural backgrounds, as Freud (1958) recomended modifying therapeutic style to the individual personality of the treatment.

Japanese are said to be emotionally less expressive, often use nonverbal communications, and tend to accept interdependency over individuation as described in the "Amae" concept by Doi (1973). These factors will color the way Japanese therapists approach psychotherapy with Japanese and are part of the reason why cognitive therapy may be more useful than exprressive therapies in Japan. It is especially interesting that the idea of the Zen priest Takuan and the concept of cognitive therapy share common viewpoints. This may be another reason why cognitive therapy is easily adaptable to Japanese patients.

It is also encouraging that the authors' technique of focusing on the "triple C" developed in Japan can be integrated with Beck's "hard-core" schema concept. This suggests that the "hard-core" shema concept may be a universally basic theoretical framework. It is also possible to shorten the therapy session by utilizing this concept even with patients of a different sociocultural background. While brief session cognitve approach seems promising, these clinical impressions remain to be systematically studied.

REFERENCES

1. American Psychiatric Association Committee on Nomenclature and Statistics (1987) Diagnostic and Statistical Mannual of Mental Disorders (3rd edition). American Psychiatric Association, Washington, D.C.

2. Alexander, F. (1966) Psychoanalytic Pioneers. Basic Books, New York.

3. Balint. M. (1968) The Basic Fault. Tavistock, London.

4. Beck, A. (1976) Cognitive Therapy and the Emotional Disorders. International Universities Press, New York.

5. Beck, A. T., Rush, A. J., Shae, B. F., Emery, G. (1979) Cognitive Therapy of Depression. Guilford Publications, New York.

6. Beck, A.T., Freeman, A. & Associates (1990). Cognitive Therapy of Personality Disorders. Guilford Press, New York

7. Benedict, R. (1946). The Crysanthemum and the Sword. Charles E. Tuttle Co., Inc., Tokyo, Japan

8. Doi, T. (1973) The Anatomy of Dependence. Kodansha International, Tokyo.

9. Freud, S. (1958). Recommendations to Physicians Practicing Psycho-Analysis. In Strachey, J. Ed.: The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII, Papers on Technique. The Hogarth Press and the Insititute of Psycho-Analysis, London.

10. Frances, A., Clarkin, J. F., Perry, S. (1984) Differential Therapeuticsin Psychiatry: The Art and Science of Treatment Selection. Brunner Mazel, New York.

11. Frank, J.D. (1979) The Present State of Outcome Studies. J. Consult. Clin. Psychol. 47, 310-316.

12. Fujita, C. (1986) Morita Therapy, A Psychotherapeutic System for Neurosis. Igaku-Shoin, Tokyo

13. Fujita, K., Koga, Y., Takeuchi, H., Takemasa, K. (1993). Comparison of Treatment of Anxiety Disorders in the UK and Japan. Clinical Psychciatry , 35, 1167-1174 (in Jpanese).

14. Hollon, S.D., DeRubeis, R.J., Evance, M.D. (1990). Combined Cognitive Therapy and Pharmachotherapy in the Treatment of Depression: In Combined Pharmachotherapy and Psychotherapy for Depression (Ed. D.W. Manning & A.J. Frances). American Psychiatric Press, Washington, DC, 1990.

15. Kino, K. (1966) Zen. Nippon Hoso Kyokai, Tokyo (in Japanese).

16. Manning, D.W., Frances, A.J. (1990). Combined Therapy for Depression: Clinical Review of Literature: In Combined Pharmachotherapy and Psychotherapy for Depression (Ed. D.W. Manning & A.J. Frances). American Psychiatric Press, Washington, DC,

17. Nishizono, M. (1988). Psychiatric Treatment and Psychotherapy in Japan: In Psychotherapy in Japan, Asia, and North America (Ed. M. Nishizono & J. Yamamoto). Kobundo, Tokyo (in Japanese).

18. Okonogi, K., Katayama, T., Fukatsu, C., Watanabe, A., Kitayama, O., Nakamura, R. (1987): Psychotherapy of Borderline Case in Three Outpatient Clinics --Prognosis and Outcome--. Japanese Journal of Psychiatric Treatment, 2, 369-387, (in Japanese).

19. Ono, Y. (1990). Utilizing the Depressive Experience -- Cognitive Therapy for Depression. Seiwa Shoten, Tokyo (in Japanese).

20. Ono, M.D. (1993). Psychotherapeutic Implication of the Alexithymia Concept. Japanese Journal of Psychosomatic Medicine, 33, 77-85 (in Japanese).

21. Ono,Y. (1993). Depression -- Discovering the truth about one's mind. Kobundo, Tokyo (in Japanese).

22. Stern, D. (1985) The Interpersonal World of the Infant: A View from Psychoanalysis and Development Psychology. Basic Books, New York.

23. Winnicott, D. W. (1965) The Maturational Process and the Facilitating Environment. The Hogarth Press Ltd., London.