Bulls In The Desert. Computer scan of photo. (Original: Oil on canvas. Circa 1954 by S. Berger).

Therapy Approach


Most of the psychological problems seen in the foreign community in Japan seem to be part of difficulties people had well before they came to Japan. Although there are many stressful situations related to being a foreigner in Japan that can cause a lot of frustration, some people seem to project their own problems onto the Japanese (i.e. label them as the cause of their problems). In order to study the effect of stress of living abroad, Dr. Berger developed the "Expatriate Adaptation Inventory" (EAI) data base designed to evaluate a number of psychological issues related to living in Japan. An initial study using the Expatriate Adaptation Inventory was published in the journal Psychological Reports. Dr. Berger has also worked extensively with mixed-cultural (Japanese-Western) couples and families who sometimes have cultural misunderstandings that impair their relationship.

One's stress, perception of stress, and ability to cope with stress, are important factors that predict one's adaptation to a foreign culture. Interest in the culture and language of Japan, and keeping a balance of Japanese and Western friends of both sexes, is a good way to minimize stress and facilitate coping. When these fail, it is often important to look into that person's pattern of relationships during their formative years, in addition to a possible biological basis for the problem. Psychotherapy is one of the mainstays of helping many persons with psychological suffering. Dr. Berger has also begun an on-line Therapy Journal aimed at providing a candid look at what happens in therapy sessions from the therapist's point of view.

The Mind-Computer Paradigm and Standard Psychotherapeutic Methods

Because you are reading this through your computer, it might be appropriate here to mention that Dr. Berger often uses the metaphor of a computer with his patients. Although a computer has a garbage can to throw away unneeded or disturbing documents, humans have no way to permanently rid themselves of emotional waste. Humans can only rearrange their feelings and memories, though they often try to "forget" painful things. One of Dr. Berger's approaches in is to help patients rearrange these ideas, memories, and their associated feelings in a better way than they have up to now using a Psychodynamic (Ego Psychology, Object Relations, and Self-Psychology), and cognitive-behavioral framework. This is an example of Psychopharmacology-Integrated CBT (Cognitive-Behavioral Therapy), where a medication-illness paradigm is integrated with a psychology-psychotherapy paradigm in order to boost treatment effects from both angles. Dr. Berger also uses group therapy to help people improve their relationships to others. The group provides a framework where one can receive feedback from, and look at their reactions to the other group members. In other words, because the purpose of the group is psychotherapy, each member is a "therapist" of sorts for the others. This makes the group different from the usual social relationship one has and a powerful tool for therapy.

Some other analogies Dr. Berger has noticed between the human mind and computers are: 1.) That there is an "unconscious" behind the screen that is doing things the user can't readily see that sometimes causes glitches; 2.) Programming a computer, or putting in the system software, is like bringing up and educating a child: resultant functioning reflects the initial input; 3.) If your hardware is broken, like in a stroke (actual brain damage), new software (experiences, learning, relationships) will not easily fix the damaged areas. Some differences between humans and computers is that although they do relate to each other (i.e. networks), computers have no feelings, and they don't grow up, play, or romance with each other (not that they have told us about yet).

Viewed simplistically, psychiatric problems can be divided up into "software" disorders and "hardware" disorders. "Software" disorders are mainly those that are evident in one's personality style. How a person handles their issues of control, belittlement, loneliness, self-adequacy etc, and how this affects their identity and social relationships are very commonly seen problems in a psychiatrist's office. Personality is thought to develop from an interaction of one's biological temperament and early life experiences. Psychiatric illnesses like severe Depression, Manic-Depression (Bipolar Disorder), Obsessive-Compulsive Disorder, and schizophrenia, etc, are "hardware" disorders in the sense that the biochemical function of a few nerves may be altered by abnormal neurotransmitter levels or faulty receptors for these transmitters, or other "nuts-and-bolts" kinds of biologic abnormalities resulting in the disorder. In addition, as "software" and "hardware" are not as neatly separated in the brain as in a computer, these dimensions may cross-interact so that having a mix of both types of problems is very common. For example, you may have experienced that when you get a cold you get more irritable, lose motivation, lose interest in seeing other people, etc. In the same way, a biologically caused depression can affect one's personality in similar ways. The only difference is that with a cold it is clear the cold is the cause as you have other physical symptoms, but with depression, the symptoms are more psychological in nature and the symptoms of depression may blur with one's personality. Psychotherapy and treatment for depression may clarify whether the symptoms are due to personality or illness.

While no one knows the exact causes of the "hardware" illnesses, genetic inheritance, viruses, or defects in the growth and development of the nervous system seem to be involved. Also, although these disorders are biological illnesses of the brain similar to neurological diseases like Parkinson's Disease, Multiple Sclerosis, or Alzheimer's Disease, because a psychiatric illness also effects one's sense of "self", they are harder for the person to fully accept. "Software" problems are usually treated with psychotherapy, and the "hardware" problems often (but not always) need some medication therapy in addition to psychotherapy. Dr. Berger can provide you with detailed information on psychiatric medications as appropriate; he also uses psychotherapy and non-medical therapies whenever possible in the treatment of these kinds of psychiatric disorders. Please also refer to this site: Counseling Tokyo: Depression and Anxiety Specialists for more information.

The Core Issue-Defense Paradigm

A central theme in therapy is that everyone has certain core issues like feeling inadequate or unloved that threaten psychological stability. Psychological defenses attempt to mitigate the negative effects of these core issues but sometimes these defenses are maladaptive (i.e. trying too hard to get noticed by others or getting into unhealthy romantic relations) and lead to psychosocial troubles for the individual. This paradigm is closely related to the Ego-Psychological Psychodynamic model described above.

Understanding and reworking these defenses and how they lead to trouble, as well as minimizing the effects of one's core issues is a very powerful tool in therapy. The model is clearly described to the patient, and the therapist and the patient work together to make a clear picture of how these factors fit together for the patient's individual situation. It is often helpful for patients to write their own "case description" in the third person in order to help with an objective understanding of oneself (see the case examples below). This understanding can then help one to develop more adaptive life strategies (defenses), thus leading to fewer troubles, as well as minimizing the negative influences that specific core issues may have over one's daily life.

Core Issues

Core issues are mental schemas that one has about oneself and the world. They are often unconscious, coming to the surface only under specific psychosocial stress. Some examples of core issues are that of feeling: unloved, unwanted, unvalidated, inadequate, threatened, controlled, belittled, that one always to blame or is at fault (guilt), etc. While everyone has more or less of all of these issues to negotiate as a child, the intensity of these issues that remains as an adult differs from person to person, probably determined by a mixture of early life experiences and relationships as well as family genetics. Core issues that remain unresolved serve as major drivers in one's personality structure as an adult.

Defenses and Psychosocial Troubles

Core issues threaten one's sense of psychological stability and one needs to have defense mechanisms against them. For descriptive purposes, defenses can be divided into adaptive (mature) defenses that lead to contentment and smooth psychosocial functioning, or maladaptive (immature) defenses that lead to psychosocial troubles. Adaptive defenses include things like logic, making jokes, praising and helping others, as well as sublimating one's feelings into work and play (ie. a person who has aggressive impulses and who becomes a boxing announcer is using a relatively adaptive defense against his aggression). Defenses are largely unconscious; one is not usually aware they are using a psychological defense in everyday behavior, although insight into one's defenses can be obtained in psychotherapy. Resistance is also an important feature of defenses as one does not want to easily give up the way they have become used to dealing with the world.

The more maladaptive the defenses one uses, the more likely one will have troubles in life that result from them. Maladaptive defenses include things like bragging, devaluing oneself and others, projecting one's feelings about oneself into others (i.e. misogynists and bigots project their own internal devaluation onto others), exploiting others, externalizing one's aggression (like getting into fights easily etc.), avoidance, over-control of others or of one's own environment and activities, passive-aggression, frantic attempts to avoid break-up of a relationship, constantly trying to punish oneself or to make up for one's guilt, and many others. You can see that the maladaptive defenses are more child-like, more unrefined, and can easily lead to trouble. When one's first-line defenses fail, one tends to resort to more and more maladaptive defenses, leading to more trouble, and sometimes to a catastrophic reaction (e.g. a suicide attempt to get a lover back after all other attempts have failed).

Troubles can be divided into active or acute troubles that greatly bother the individual, and inactive or chronic troubles that the individual may or may not be aware of (see the case descriptions below for examples). The troubles are usually the complaints clients bring to the sessions, they do not often come to talk about their defenses or core issues.

The basic mechanism then is:

Early life experiences and family genetics leading to a particular set of Core Issues that threaten psychological stability. The Core Issues are protected by Defenses: Adaptive (leads to smooth psychosocial functioning) or Maladaptive (leads to psychosocial Troubles). Troubles can be divided into active or acute troubles, and inactive or chronic troubles.

Core-Issue Defense Paradigm Flow Graph

(click the image to view an expanded version)

Defenses Can Sabotage The Therapy

Please click here to read this important section on how defenses can be used in psychotherapy to help one understand and work-through maladaptive behavioral styles.

Case Examples

It is often helpful to give some concrete examples in order illustrate how the Core Issue-Defense Paradigm works. All the cases below are modified versions of real persons in order to protect confidentiality. You might find it easy to conceptualize how one's core issues, defenses, and the results of these defenses interact if you jot them down in a diagram fashion as you read the descriptions. Although some diagnoses are also mentioned in the cases below regarding personality style, Dr. Berger believes it is more helpful to understand the mechanisms of one's particular style rather than simply the definition of a diagnosis which often does not adequately describe the complexities of each individual.

The cases below describe some commonly seen problems in Dr. Berger's practice:

Case 1: Let's start off with relatively straight forward case of a 35 year-old Western man who works as a stock broker in Tokyo. His dad was very strict and critical. He likes sports cars, lots of money, likes to date many woman at once (has never been in a serious relationship), only goes out with beautiful women, idealizes connections he has to people of power, criticizes others who don't have the things he has, and tends to boast about his various abilities. He gets enraged when he is not being noticed or is slighted. He has never had any prior psychiatric treatment.

He comes into the session with a chief complaint that his three girlfriends have found out about each other and they are all angry at him and want to break-up with him. He wants advice from me on what he can do to keep them all in the relationship and states that he is feeling very "unstable". What are his troubles, defenses, and core issues? First, his troubles can be divided into active troubles: the problems with the three girls, and inactive troubles: he has never been able to get into a serious relationship with a woman as he is so focused on being admired by many at once, and people don't want to be his friend because his boasting pushes people away. His major maladaptive defenses include grandiosity (boasting and needing to be connected with great things like sports cars and only beautiful women), need to be admired (and consequently exploiting the women for this end), projection and devaluation (projects his own self devaluation into others), and over-idealization of others in order to "borrow" their greatness to help prop-up his own self esteem. He gets enraged when his grandiosity needs are not met which is his last ditch attempt (a regression to an even more immature defense when the first-line defenses fail) to protect himself from having a more uncomfortable core issue feeling state arise. His core issues seem to include feeling unvalidated and belittled but we don't have enough information yet. His feeling "unstable" is a signal of the core issues bubbling up through the failed defenses.

How will I treat him? Just giving him advice on how to keep the girls (which I don't really have the ability to do anyway) only reinforces his maladaptive defenses; and his asking for help with this indicates a resistance he has to change the defensive structure he has used for years. This resistance is an important feature of defenses as one does not want to give them up easily. He is also not really aware that this defense is maladaptive and this is because the defenses are often unconscious, another important feature of defenses. Once we can get him to see the whole picture of his core issues and how his use of maladaptive defenses results in subsequent troubles, only then can he begin to engage in seeing how he needs to rework his defensive structure and deal with some painful feelings he may have about himself on a more unconscious level, and that tend to bubble up when his defenses fail. We will do this by discussing the major themes in his life from the past (especially how his critical dad may have made him feel belittled), his present relationships, his relationship style with the therapist, and information from his dreams. He will need a lot of praise and support from me to get through the initial phase of hurt from the three girls who have basically left him. Group therapy might also be a useful way for him to get a view of himself from the other group members who can gently encourage him to see the way he comes across. Most psychiatrists would describe this man as having a Narcissistic Personality.

Case 2: An American man in his 30's came to see me for depression. He was a software engineer who had lost his job and was quite depressed with sleep disturbance and loss of appetite and suicidal feelings. He had also lost interest in his girlfriend and wanted to break up with her, as had happened to him with every previous girlfriend when the relationship got closer. Most of his girlfriends had a non-assertive style and were dependent on him for affection. He seemed very caring and kind to others and he emphasized his desire to cooperate with his therapy to improve himself. He couldn't believe that he had lost his job because he felt he was a good "team player" at work.

His depression responded well to antidepressant medication. Over the course of therapy, however, he would sometimes not show-up for sessions or come late, and he would be very apologetic for this, but yet note how much he needed help. He would also anger his bosses at work by not showing up or coming in late or not doing what he was told, and he eventually he lost more jobs and had a long period of unemployment without searching for a new job as actively as he could. He was finally able to engage in a committed relationship with a woman who was very strong-minded and harshly criticized his passivity. His mother was an alcoholic and would often belittle and control him when he was a child. His dad also had treatment for depression.

Understanding this man is not as easy as in Case 1. His active troubles are his inability to keep his employment and his trouble maintaining his intimate relationships with women. His inactive troubles are not having as many friends as he could have, and not living up to his actual talents. His depression was a secondary result of all the troubles, or one could say a domino-effect trouble, although there may have been some genetic predisposition inherited from his dad. His main maladaptive defenses are an alternation of obedience and defiance because he views most relationships as a struggle for control as he did with his mother (his core issues are feeling controlled and belittled). His defiance manifests as a passive-aggression, i.e. aggravating others by acts of omission (not showing up for things, not looking for a job etc.) rather than aggressive acts of commission. He was able to make a commitment with his new girlfriend because she served as a barometer for him to fine-tune his obedience and defiance cycle: giving him reason to be defiant but yet admonishing him to cooperate. He lost interest in his previous girlfriends because they were more passively committed to him. His pride, as a defense to his sensitivity to being belittled, also gives him trouble because he becomes passive-aggressive when he feels he is not being valued at work etc.

After the acute treatment phase with antidepressant medication and supportive meetings, the psychotherapy of this man will require having him clearly see his defensive cycle and how it impairs his life. He will need to see that he does not have to view relationships as a potential struggle, and the therapist can help him with this by tolerating his challenges. As in the first case, group therapy can serve as leverage for him to break-through the barrier of resistance and denial of his pattern of defenses. Most psychiatrists would describe this man as having a Major Depression and an Obsessive Personality style because of his issues with struggles.

Case 3: A Japanese woman office lady in her early 40's wanted help in understanding her new American boyfriend. He was over 12 years younger than her, and had been sent to Japan from his company's home office. They worked at the same company and his desk was only a few rows away from hers. She said he said things like, "you don't owe me anything" and "I'm an independent guy" and she wanted me to explain to her what they meant because she felt serious about him. She complained that although he would send her some emails through the course of the day, he often left the office without a "goodbye email". They had dates where she would quietly follow his lead, even though she had other opinions (i.e. he insisted they take a long car ride to a resort area when she knew the train was much faster). On their most recent date he suddenly said he was going to the gym. She described the current boyfriend as easily irritable, sometimes changing his plans with her suddenly. As a child her dad was always working and he would often go out with his colleagues on his days off. Her mother was more focused on her older brother's scholastic endeavors. She divorced over 10 years ago because she felt her first husband was cold and distant. Her last boyfriend of 7-years duration was an affair with a married man. She also reported occasional panic attacks of sudden high anxiety and hyperventilation that worsened when she felt a boyfriend was separating from her.

Can you determine her troubles, defenses, and core issues without reading further? Her active trouble is that she is head-long in a relationship with a man who objectively does not seem to have the same feelings for her, and her inactive trouble is that she cannot get in a healthy relationship because she has a pattern of agreeing to go out with men who are either not able to relate on an intimate basis themselves (her ex-husband), or are not logistically able or willing to get serious with her (her last boyfriend was married and her current boyfriend is clearly not interested in real intimacy). She is willing to engage with the current boyfriend in spite of the hurdles of his being a generation younger and their working in the same office with the inherent problems of mixing her private and professional business. Her major maladaptive defense is that of dependent clinging even in the face of no real intimacy on the part of her partner. When this defense fails, she may have high anxiety or panic attacks that reflect the depth of the core issue(s) she needs to defend against. Her core issues are probably related to feeling unloved or unwanted, possibly originating from her relationship with her parents.

Treating her will not be as easy as case 1 or case 2 because she is more focused on quenching her needs for a partner (i.e. resistance to changing her maladaptive defenses) rather than looking at herself and trying to devise a different interpersonal strategy. Even after carefully explaining the mechanism of her troubles and defenses to her she still asked me, "So his saying he is 'independent' means he is not really interested in me right?" She only came to one session with this agenda and did not reschedule an appointment. She will probably contact me again only if she has a failed attempt in intimacy; at least I gave her the beginnings of a psychological tool box that she can use to help herself. Most psychiatrists would describe this woman as having a Dependent Personality. She also seems to suffer from Panic Disorder that may improve with counseling and could possibly require medication if the panic attacks became disabling.

Case 4: This case is an example of a complex interaction among a number of core issues. A 37 year old Irish man requests therapy because he is anxious about the prospect of getting married to his girlfriend who has begun to give him an ultimatum on marriage plans. He had been married before for a few years to a woman he liked very much, but was anxious throughout the marriage, and felt great relief when his wife found another man and broke up with him. He usually avoids searching for women and does not actively seek affairs, but will engage with attractive women who approach him. He had previously dated and had a sexual affair with a married women who was very attractive but began to call it off when she wanted to break with her husband to get serious with him. He had also recently gone on some dates with another very attractive single woman he met through work, and although she seemed ready to start a sexual affair, he did not let himself go through with this.

His mother was very controlling and needy of his attention and especially so after his parents divorced when he was a child. He reacted to this by avoiding her and began to feel antipathy towards her. His dad was a drinker and somewhat unavailable emotionally. He is a very likeable man and very much wants to bring his relationship with his girlfriend to intimate fruition. He describes his girlfriend as being quite "lovable" but not a "trophy" woman like the women in his affairs. He is generally anxious, tends to binge-drink on alcohol and is a heavy smoker.

His core issues are a combination of fear of being controlled, which he likely got from his relationship with his mother, and a desire for validation fueled by feeling inadequate both from his mother's controlling style and from his father's inability to provide positive feedback. He has tried to suppress the great affection needs he had from his mother because she was so difficult. This interplay explains why he wants the intimacy that was lacking in his own family but shies away when relationships get close because of his fears of being controlled. It also explains why he is willing to engage in affairs with women who have a built-in barrier to intimacy like married women where he can satisfy his validation (and sexuality) needs and yet be protected from intimacy and the fear of being controlled. He is more likely to engage with "trophy" women in these affairs in order to satisfy his sense of inadequacy. He has essentially made a "compromise" with all these needs he has by having a girlfriend but trying to keep her at a safe distance and having affairs with the trophy women while adjusting his distance to them just enough to satisfy his validation needs. He rarely seeks women on his own as that could expose him to the risk of rejection which would be an injury to his validation needs. His pervasive anxiety reflects the tension inherent in this compromise and his heavy drinking and smoking are a secondary effect of all the anxiety.

His major maladaptive defenses are avoidance of emotionally risky situations, passive control via the avoidance, and subtle grandiosity with the trophy women. His adaptive defenses include openness, care and compassion, desire for insight and self-improvement, and intellectual defenses. Repression of the conflicts arising from the opposing core issues of great need for intimacy and the fear of intimacy (and thus being controlled), and the formation of a compromise to attempt to fix this, have both adaptive and maladaptive qualities. While they have protected him from a number of core issues to a degree, the drawbacks are that the compromise itself causes him to suffer from anxiety and from an inability to realize final intimacy as he is always walking a tightrope between the two sides of the compromise.

Treatment will include insight and support for behavioral change. While his behaviors are conscious, his core issues and the compromise formation are largely unconscious and need to be clearly shown to him. He has an insightful and understanding way about him and this can be utilized in this regard. By using insight to see the unreasonableness of his fears, as well as the compromise that he has made as a defense, he has been able to progress in intimacy with his girlfriend while tolerating his anxiety. He still suffers waves of high anxiety on occasion under the stress of intimacy pressures from his girlfriend.

The exact diagnosis in this case is not as straight forward as the previous cases. While he exhibits a mixture of Narcissistic and Obsessive traits as in the cases above, many psychiatrists would describe this man as suffering from a Neurosis, generally defined as the process of repression of psychological conflicts leading to anxiety and contradictory behaviors that attempt to make compromise between these conflicts. If his anxiety is severe, he might also fill the criteria for Generalized Anxiety Disorder, for which psychotherapy and possibly the addition of medication might be helpful.

The Therapeutic Alliance

At the end of the day when all the fancy psychotherapy theory is said and done, the therapist must still provide a compassionate and caring atmosphere in order to create a positive and trusting therapeutic alliance. These factors alone may help a great number of persons in emotional distress. After all, social soothing has been around for millions of years in the animal kingdom.

Reference Materials:

The book and journal article below can serve as a reference for some of the psychotherapeutic techniques described on this page. Further information can be sought on the internet through the Mental Health Search/Links page, in addition to reading material that is listed on the Mental Health Books page.

The Psychiatric Interview in Clinical Practice, by Roger A. MacKinnon M.D. and Robert Michels M.D.. W.B. Saunders Company, 1971.

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.

phone Inquiries on counseling and psychotherapy, or for psychiatric medication evaluation, can be addressed to Dr. Berger at Tel: 03-3716-6624 (+81-3-3716-6624 outside of Japan). Long distance/International professional phone consultation is also available. Please leave a message on the answering machine, most calls will be returned within a few hours. Also, please note that as your call may be forwarded to a mobile phone, you may need to wait a few seconds for transfer, and because of this there is no fax function.

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All pages copyright by Douglas Berger, M.D., Ph.D.