"psychotherapy integration in japan" shigeru iwakabe

Psychotherapy Integration in Japan

Shigeru IwakabeOchanomizu University

Psychotherapy in Japan is a relatively new area of practice growing rapidlyin the last 10 years, especially in the area of education as the problemsassociated with school-aged children such as bullying and truancy becameone of the major social challenges. The majority of Japanese psychothera-pists practice approaches developed in North America and Europe, andJungian theory has been influential to Japanese psychotherapists. Psycho-therapy integration in Japan often take a form of cultural integration thattakes two routes: adjusting and modifying technical procedures in the west-ern psychotherapy to suit Japanese client population and developing theo-retical concepts that are more in agreement with Japanese culture and itsunderlying worldview. Psychotherapists in Japan emphasize the importanceof a non-talking cure, or silent processes and often employ nonverbal taskssuch as drawing and sandbox. They have also developed innovative theo-retical constructs that emphasize the importance of healthy dependencebetween mother and child.

Keywords: cultural integration, parallel therapy, nonverbal tasks

(1) What is the current status of psychotherapy in general in yourcountry? How common or uncommon is it for people to go into psycho-therapy? What is the relative standing of psychotherapy and pharmacother-apy? How has the practice of psychotherapy been influenced by economicfactors such as managed care or insurance companies, government financedhealth service, etc.? Have there been changes in any of these in recent yearsor are there trends that are worth informing us of?

Psychotherapy is a relatively new area of practice in Japan, althoughsome indigenous forms of psychotherapy have been practiced since thebeginning of the last century, and major theories of psychotherapy such aspsychoanalysis and client-centered therapy were introduced with little

Shigeru Iwakabe, Ochanomizu University, Tokyo, Japan.Correspondence concerning this article should be addressed to Shigeru Iwakabe, Ocha-

nomizu University, Otsuka 2-1-1, Bunkyoku, Tokyo, Japan, 112-8610. E-mail:[email protected]

Journal of Psychotherapy Integration Copyright 2008 by the American Psychological Association2008, Vol. 18, No. 1, 103–125 1053-0479/08/$12.00 DOI: 10.1037/1053-0479.18.1.103

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delay from their inception in western countries. It is still generally uncom-mon for Japanese people to seek out psychological services. Social stigmaand shame still accompany the pursuit of help for psychological problemsand disorders in Japan. Traditionally, there has been a tendency in Japanto perceive symptoms of mental disorders as signs of weakness in one’s willor as a lack of self-discipline. Therefore, family members may have littlepatience for the troubled one: they may blame and criticize him or her forsuccumbing to psychological problems. Those who seek help are oftenconcerned about others’ finding out that they have a psychological prob-lem. Information about mental problems needs to be kept within the familyin order to protect the individual’s career choices, likelihood of promotion,and even the marriage prospects of other family members. As a result, theassistance of mental health professionals is often sought only after theproblem has become quite grave. Some clients seek services at facilitiesthat are far from their homes. Others request that all contact with thecounseling service be maintained through their personal mobile phone toconceal the fact that they receive therapy from family members.

Many Japanese people initially contact medical doctors for psychoso-matic complaints such as lowered concentration, chronic fatigue, sleepdisturbances, and suppressed appetite even when their problems are psy-chological in nature. After medical problems are ruled out, patients aresent to shinryo naika or a clinic of psychosomatic medicine. A diagnosis ofjiritsu shinkei shitchosho (imbalance in the functioning of the autonomicnerve) is often conferred to patients even when they are suffering psycho-logical disorders such as mood disorders, anxiety disorders, and evenpersonality disorders. There are at least two major advantages in using thisambiguous diagnostic category, unrelated to the more common diagnosticsystems such as Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition (DSM–IV) and International Classification of Diseases,10th Revision (ICD-10). First, the fact that these patients suffer frompsychological disorders is cleverly concealed to prevent patients frombecoming the target of potential social stigma. Second, since such a diag-nosis infers that these patients actually suffer from medical conditions, it isjustifiable not to provide them with lengthy and infeasible psychothera-peutic treatment.

The current medical insurance system does not give adequate weight topsychotherapy compared to that of more medically oriented procedures(Ono & Berger, 1995). The fee for psychotherapy conducted with a psy-chiatrist is approximately 32 U.S. dollars at a hospital and 35 U.S. dollarsat a small outpatient clinic, regardless of the length of the session. Psycho-therapy provided by certified clinical psychologists is subsidized by nationalmedical insurance plans only when it is provided in medical settings underthe direction of psychiatrists. Ultimately, patients diagnosed with having

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autonomic nerve imbalances are usually prescribed antianxiety and anti-depressant medications. They are then advised to rest, rather than discuss-ing and solving their problems in a psychotherapy setting, which would beeconomically less feasible for both patients and psychiatrists.

Furthermore, many psychiatrists still rely solely on pharmacologicaltreatment and do not consider psychotherapy as a treatment of choice.According to the survey conducted by Nishizono (1988), the overwhelmingmajority of psychiatrists considered that 15 minutes of contact is suffi-cient for most of their patients and that only 5% to 20% of their patientsrequired a full hour of psychotherapy during their meeting. The surveyalso showed that the majority of psychiatrists saw as many as 50 patientsa day.

Psychiatrists often defend their position by saying that many patientsdo not feel comfortable in opening up and exploring their personal life.Instead, they prefer to have an authority figure giving them concretedirectives derived from medical knowledge and they are satisfied withhaving minimal contact with their psychiatrists. However, an increasingnumber of patients are requesting counseling and psychotherapy as a partof their treatment. Unfortunately, many hospitals do not have sufficientresources to provide counseling services and their patients are placed onlong waiting lists. Many of the clients we see at our university clinic oftencomplain that their psychiatrists never spared enough time for them to talkabout what was on their minds. Exclusion from the current health insur-ance system also affects the practice of psychotherapy. Without the possi-bility of subsidization, Japanese psychologists do not consider independentpractice a viable career option.

In the last 10 years, the field of psychotherapy and counseling in Japan hasbeen undergoing a process of dramatic development. With the economicrecession, the social climate is quickly deteriorating. There is an increasedawareness of this social deterioration and with it a rapidly growing demand forpsychological services to respond to the crisis. For example, the number ofclinics of psychosomatic medicine, which are private psychiatric clinics thatpatients are referred to when it is suspected that their physical complaints havepsychological causes, increased from 662 to 1,573 in the three-year periodbetween 1996 and 1999 (Jamic Journal, 2002). During the last decade, therewas a sharp increase in the number of violent crimes committed by teen-agers, and problems associated with school-aged children (particularly ofschool refusal syndrome) became a major challenge faced by Japaneseeducators (Kameguchi & Shigematsu-Murphy, 2001). The most dramaticdevelopments in the field of psychotherapy are to be seen particularly inthe areas of child and adolescent psychotherapy and counseling conductedin schools and other educational settings.

In 1995, the Ministry of Education placed one school counselor in each

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public junior high school, where problems associated with school refusalsyndrome and bullying are most severe. This is the first national levelcounseling and psychotherapy service in Japan. In 2000, 2,250 junior highschools hosted one certified clinical psychologist. This means that 1 out of4 clinical psychologists work in school settings. Over 90% of so-calledschool counselors are certified clinical psychologists who perform a varietyof functions, from individual psychotherapy to family consultations.

Japanese psychologists tend to use the term counseling over psycho-therapy regardless of the nature of their work and their patient popula-tions. Differences in the conceptual and historical development betweenthe two fields have not been clear in Japan: many Japanese psychologistsare educated mainly with individual psychotherapy techniques based onprinciples of psychodynamic therapies and work in educational settings,carrying out a wide range of roles that would elsewhere be played by asocial worker, a school psychologist, a school counselor, and an educationalconsultant (Shimoyama, 2000). Nonetheless, as the term counseling gainswide public recognition equivalent to the daily usage of the term “therapy”in English, psychologists also adopt this term more frequently and widely.

It appears that psychologists refer to their service as counseling be-cause the term psychotherapy has stronger connotations of “treatment”than the term counseling. However, medical doctors are the only profes-sion nationally and legally qualified and licensed by the Ministry of Healthand Welfare to diagnose and treat patients. Clinical psychologists are boardcertified by the Japan Society of Certified Clinical Psychologists to providecounseling and assessment services; therefore, Japanese clinical psycholo-gists tend to avoid the connotation of treatment in the term psychotherapy,even when they apply principles of psychodynamic therapies in dealingwith patient’s intrapsychic problems and symptoms due to psychologicaldisorders. Psychiatrists, on the other hand, almost exclusively use the termpsychotherapy when they are the provider of such a service. They eventend to apply a different translation of the term, psychotherapy emphasiz-ing a more medical and psychoanalytic tone to their work.

Lastly, the professional association of clinical psychologists, who are themain providers of psychotherapeutic services as well as their educational andtraining system, is also in the process of rapid expansion and development.The Association of Japanese Clinical Psychology, which was founded in 1982,consisted of 1,936 members in 1989. The membership has increased rapidly inlast 10 years. by June of 2001, it had become the largest academic society ofpsychology in Japan, with 10,869 members. Training programs for clinicalpsychologists have mainly been developed in the last 10 years. In 1996, thenumber of accredited Master’s programs in clinical psychology was 14. In 2007,158 schools were accredited, and the number is still growing rapidly.

In sum, psychotherapy is still a new field in Japan, and it has seen its

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most dramatic development in the past 10 years. However, psychotherapyis yet to become the treatment of choice due to a medical insurance systemthat requires that psychiatrists take a more efficient, biological approachand keep face-to-face contact with each patient to a minimum. Socialattitudes toward those with mental problems and toward help seeking arealso obstacles to the expansion of psychotherapy in Japan. As a result,Japanese psychologists have moved toward educational and school settingsas their main area of practice, working with schoolchildren, their familymembers, and teachers as their main client populations.

(2) What are the most influential theories and orientations guiding psycho-therapeutic work in your country? What are your speculations about how theparticular culture, traditions, and values of your society have influenced theparticular approaches to therapy that predominate in your country?

Although indigenous psychotherapies widely known outside of Japansuch as Morita therapy and Naikan therapy have existed for over half acentury, the overwhelming majority of Japanese psychotherapists followmodels of psychotherapy developed in western countries. Psychoanalytictherapies and humanistic psychotherapies such as client-centered therapy,each of which has a relatively long history, are widely practiced throughoutJapan, followed by cognitive–behavioral therapies and family therapieswhich have more recently captured the attention of psychotherapists asinterest in short-term therapies increases. These theoretical schools form arespective academic association organizing annual meetings and have pub-lished a peer-reviewed journal since the beginning of the 1980s. Japanesepsychotherapists are eager to incorporate new developments and trendsfrom western countries. For example, after the Kobe-Awaji earthquake in1995, which hit Japan’s second most populated area causing nearly 5,500deaths, 35,000 injuries, and leaving 180,000 buildings badly damaged ordestroyed, Japanese psychologists became acutely aware of the need toreceive specialized training in the treatment of posttraumatic stress disor-der (PTSD) as well as crisis intervention. Experts of eye movement desen-sitization reprocessing (EMDR) were invited to provide a series of trainingworkshops in Japan. By 2001, over 330 psychologists and psychiatristsreceived training certificates. A recent upsurge of interest in narrativetherapies and social constructionism is also of note. In the past ten years,quite a few professional workshops on narrative therapies were held. Thepublication of books and articles on narrative therapies continues to in-crease, though the current popularity of narrative therapy is not associatedwith the specific clinical needs of psychotherapy practice in Japan.

What is particularly notable about the influence of various theories ofpsychotherapy is the popularity of Jungian psychology. The dominance ofJungian psychology stems from the pioneer work of a single Japanesepsychologist, Hayao Kawai, who, after trained at the Karl Gustav Jung


Institute in Switzerland, introduced and popularized psychotherapy andbuilt the foundation of clinical psychology in Japan. His contribution to thedevelopment of psychotherapy in Japan is immense. He was an extraordi-narily prolific writer who has put out over 70 books of his own and editedover 100 volumes in the past 40 years. Although he has written numerousprofessional books directed at practitioners and therapists-in-training onthe theory and application of psychotherapy based on Jungian principles,much of his work is directed toward a general audience and focuses on anunderstanding of Japanese culture through Jungian theory rather thanJungian psychotherapy itself. Using Jungian archetypes he analyzes every-thing from popular Japanese ancient folktales and myths to social andfamily problems currently prevalent in Japanese society (e.g., Kawai, 1996).In the past, when Japanese culture and people were examined from aperspective of western psychology, there was a tendency to depict Japanesepeople as deviations from western norms or as immature, inferior versionsof western people. Kawai made links between Japanese culture and psy-chology without such misleading characterizations. By doing so, he natu-ralized western psychology into Japanese culture. His books are read andappreciated by a wide audience. His contribution to the understandingJapanese culture through Jungian theory has been highly appraised bypsychologists as well as by other academics: he has received literary awardsand was appointed to be the Director General of the International Re-search Center for Japanese Culture in 1995 and of the Agency for CulturalAffairs in 2001. He also served as a committee member of the CentralCouncil for Education and of Administrative Reform, both of which arepart of the Government of Japan.

His contributions are not limited to publications on Jungian psychol-ogy and Japanese culture but also include an active involvement in thetraining and education of clinical psychologists in Japan. He showed noreluctance in traveling across the nation and giving workshops and partic-ipating as a commentator in case conferences for local clinical psychologistsand students. In these clinical case conferences, he was highly imaginative,convincing, and inspirational, making reference to ancient Japanese myths,artworks, and the biographies of public figures. He was also a very per-sonable man who was eager to socialize, interact, and mingle with youngstudents and local psychologists. Japanese psychologists look up to Kawainot only as the leader of Japanese psychology but also as an educator. Inother words, Kawai was a father-like figure who not only created thefoundation and identity of Japanese psychologists but also created a strongemotional connection with a large number of Japanese clinical psycholo-gists through these personal interactions.

Therefore, the relationship that Japanese psychotherapists have toJungian psychology is not simply a matter of theoretical allegiance. It

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represents an emotional connection to someone seen as a great educatorand informs their identity as Japanese psychologists. Indeed, Japanesepsychologists are more often exposed to and knowledgeable of Kawai’sinterpretation of Jung than Jung’s actual theories themselves. Their tie toJung is mediated by Kawai’s presence as a writer and as a cultural figure.Psychologists who are not Jungian themselves subscribe to many ofKawai’s ideas about Japanese culture and its influence on the psychologicallife of Japanese people.

The dominance of Jungian psychology in Japan is also associatedwith the history leading to the development of the current professionalassociation of clinical psychologists. The Japanese Association of Clin-ical Psychology was first established in 1964 and their first nationalmeeting held in 1965 with 978 attendants. At the annual board meetingheld in 1969, in which the future direction of the association wasdebated, board members were divided into two opposing groups. Onegroup advocated the reorientation of the association as a sociopoliticalgroup to protest the inhuman treatment of mental patients in psychiatrichospitals and their objectification and debasement through subjectingthem to demeaning psychological testing. The other group emphasizedthe rapid establishment of a national level licensing board as a primarygoal. Unable to resolve this fundamental difference, the associationeventually disintegrated. When it was reformed in 1973 by those mem-bers who had advocated political activism, the majority of members leftthe association. This incident put an end to the first attempt to movetoward the establishment of a licensing system and the national orga-nization of clinical psychologists.

Finally in 1982 a new association (the Association of Japanese ClinicalPsychology) was formed with 1277 members. Hayao Kawai was elected asthe first president of the association. The confusion created by the collisionof the two opposing groups within the first association of clinical psychol-ogy and the resulting turmoil among clinical psychologists still lingered.The theoretical orientations central to the association were Jungian psy-chology as well as other depth psychologies, such as object-relations the-ories. They focus on a symbolic understanding of the client’s inner worldwhile maintaining little connection with the empirical methods developedin academic psychology. The journal of the association mainly featuressingle case reports on the process of psychotherapy with little psychometricdata on the outcomes of treatment. Systematic studies using experimentaldesigns and quantitative methods are rare. Shimoyama (2001) points outthat a connection with the rest of academic psychology and the society wasunconsciously avoided to suppress fears of resurrecting the complex prob-lems associated with the licensing issues. Jungian psychology and thechoice of case reports as a main method of investigation helped to avoid


potential conflicts until the association of Japanese clinical psychologistsattained autonomous functioning.

(3) What is the current status of psychotherapy integration in yourcountry? How influential are integrative approaches? Among therapists whodo work integratively, what kinds or approaches to integration have beenmost important? How have both these developments (the relative importanceor unimportance of integration and the kinds of integrations pursued) beeninfluenced by the particular culture of your society or the nature of how theprofession of psychotherapy is organized in your country?

Psychotherapy integration is a relatively new theoretical concept tomany Japanese psychotherapists. There have not been many publica-tions introducing models of psychotherapy integration published inJapan and they are all recent (e.g., Hiraki, 1996; Murase, 2003). Thereis only one postgraduate training institute that offers courses and work-shops based on integrative thinking founded by Noriko Hiraki, one ofthe founders of Japanese family psychology. Most recently, major worksof integrative therapists such as Paul Wachtel and Les Greenberg havebeen translated into Japanese and several introductory reviews havebeen published. With Noriko Hiraki, Hiroko Nakagama, and TakeyoshiNozue, who have been very active in promoting the integration offamily, couple, and individual therapies in Japan, and Tetsuo Fuku-shima, who has written a series of articles on integration from a Jungianperspective, I organized a group to discuss issues associated with psy-chotherapy integration. Since 2005, we have held four meetings andover 100 practitioners and graduate students participated in the mostrecent meeting. Interest in psychotherapy integration is rising especiallyin psychologists and students in the younger generation. Although therehave not been many theoretical works to guide their integration, mostJapanese therapists practice some form of eclectic therapy heuristicallycombining concepts and techniques of psychodynamic, Jungian, client-centered, cognitive– behavioral, and family therapies. In particular, at-tempts to incorporate a systemic perspective in their work are common(e.g., Hiraki & Nozue, 2000; Kameguchi & Shigematsu-Murphy, 2001).This is due to the fact that many therapists work in school and educa-tional settings where in dealing with schoolchildren, the therapist needsto plan interventions systematically at levels of intrapsychic conflicts,interpersonal behaviors at school, the teacher–student relationship, andthe parent– child relationship.

Furthermore, in introducing western psychotherapies to Japan, wherethe cultural and social climates were thought to be vastly different, aspectsof a theory of psychotherapy or techniques were modified to better serveJapanese patient population. Psychotherapy integration in Japan, there-fore, appears in a form of cultural integration, which usually takes two

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distinct routes. One is a modification or incorporation of technical proce-dures and treatment structures that are more suitable and effective in theclinical reality in Japan. The other is to develop theoretical concepts thatare more in agreement with Japanese culture and its underlying easternphilosophies. I call these attempts cultural integration because modifica-tions and adjustments are made primarily to assimilate psychotherapy intoJapanese culture.

MODIFICATIONS OF THERAPEUTIC TECHNIQUES ANDTREATMENT STRUCTURES

There are numerous attempts to modify therapeutic techniques. Here,I would like to focus on the two areas that are most widely discussed andpracticed: (1) incorporation of nonverbal tasks and (2) mother-child par-allel therapy.

Nonverbal Tasks

Many Japanese therapists incorporate in the part of their work non-verbal expressive tasks using media such as the sandbox, painting anddrawing, and clay sculpture. In particular, the incorporation of sandboxplay is most commonly attempted by Japanese therapists. In sandbox play,which was originally developed by Dora Maria Kalff, patients are encour-aged to play freely in a miniature sandbox, placing and arranging miniaturepeople, animals, houses, and objects as various as cars and religious statues.The resulting tableau is thought to provide a window into the inner worldof the patient, as well as a path through which the patient can express theirfeelings. The popularity of this technique may be demonstrated by thelarge membership of the Japanese Association of Sandbox Therapy: therewere 1,400 members in 1999, and membership is still growing. The over-whelming majority of members incorporate the sandbox in their work asone technique rather than as the sole method of practice. The procedure isused not only for children but also for teenagers and even adult patients.

The popularity of sandbox techniques is reflective of the clinical realityof working with Japanese patients, many of whom are often not comfort-able discussing personal problems or verbally expressing their feelings in aface-to-face encounter. Culturally based beliefs about language and verbalcommunication also underlie and contribute to the integration of suchtechniques in therapeutic practice. Until fairly recently, little value wasgiven in Japanese culture to talking about everything or pilling one guts.Traditionally, it was considered more virtuous to keep one’s thoughts and


feelings to oneself. Accordingly, some of the most influential Japanesetherapists do not believe that language as a medium of self-expressioncaptures and communicates how one really feels any better than do othermethods of expression such as painting, music, and sandbox. Furthermore,it is theorized that these indirect expressions allow a more intuitive under-standing and sharing through the sensibilities. Inner feelings may be morevividly and directly communicated by images evoked through these media.Conspicuously present throughout these media are symbolic themes andpatterns that are thought to more concisely communicate the complex andpolysemous nature of one’s feelings and situations, even though the mean-ing of what is expressed may not be explained or even understood. In sum,the use of nonverbal therapeutic tasks as exemplified by sandbox playpoints to underlying cultural beliefs about the value of verbal interactions(Miki & Kuroki, 1998).

Parallel Therapy

In the treatment of children, adolescents, and young adults, therapistsoften invite the patient’s mother to have counseling sessions. These sessionsare not occasional information-gathering sessions to monitor patient behaviorsoutside the sessions or to report the progress of therapy back to the mother,but are weekly psychotherapy sessions with a separate treatment contract andstructure from that of the child. These sessions are referred to as paralleltherapy, or mother-child parallel therapy where the two distinct therapies startconcurrently (Omata, 1999). In many university counseling centers and othertraining facilities, it is often the case that the counselor trainee sees the child,while his or her supervisor works with the mother in a different room con-currently to facilitate communication between the two therapists. In othercases, the same psychotherapist may work with both the mother and her child.When the patient is unwilling to come to therapy or when the mother does notfeel she has the authority to order her child to seek professional help becauseshe is afraid that her child will act violently toward her or the child will beupset by her overinvolvement, therapy may be carried out alone with themother without the presence of the identified patient. This type of therapy isparticularly common with the mother of a child or a young adult who, after aduration of absenteeism from school or work, has withdrawn to his or herbedroom with almost no interaction with people other than his or her familymembers (hikikomori).

There are several purposes in parallel therapy beyond information gath-ering about the child developmental background for psychological assessment.First, it serves a psychoeducational purpose by providing the mother with

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appropriate information about parenting, child development, and the natureof her child problems. Second, by maintaining a good therapeutic relationshipwith the mother, the therapist can assure continued therapy with the child, asit is usually the mother and not the child who decides whether to continue orterminate therapy. Third and most importantly, parallel therapy provides themother with the opportunity to receive personal therapy of her own. Many ofthe mothers who accompany their children to psychotherapy have little if anysocial network and their marital relationships may also be unstable. Someperceive themselves as failures as mothers and as a result experience suchdistress that it becomes difficult for them to meet the needs of their children.Others direct exaggerated anger externally at schoolteachers or even mentalhealth practitioners for their incompetence and further alienate themselvesfrom potential sources of help. Therefore, Japanese therapists often give equalemphasis to treating the mother with the goals of establishing her psycholog-ical adaptation and relative independence from her child, resolving her ownpersonal issues and relieving anxiety, shame, and perhaps the guilt of failing tobe a good enough mother. In sum, Japanese therapists tend to assume thatwhen there are certain problems with children, adolescents, and even youngadults, it is necessary and desirable to treat the mother as well because themother–child relationship may not be functioning properly. Parallel therapymay be based on the assumption that successful child and adolescent psycho-therapy depends on the establishment of a stable relationship between childand mother. This prevalent view stems from theoretical works of Japanesepsychoanalysts who emphasize the importance of mother–child relationships,which we will turn to next.

DEVELOPING THEORETICAL CONCEPTS

Another route of cultural integration is the development of a theoret-ical concept that facilitates the application of western models of psycho-therapy to a Japanese context. I would like to discuss two theories: Kosa-wa’s Ajase complex and Doi’s concept of dependence (or amae). Both ofthese concepts sprang out of psychoanalysis and emphasize the strongemotional ties between mother and child in Japan. However, Kosawa andDoi approach psychotherapy in almost opposite ways.

Theory of Amae

Doi’s theory of dependence captured a wide international audienceinterested in Japan and Japanese culture with the translation of the Anat-


omy of Dependence (1973), which was published in several languages.Doi’s work sparked many subsequent works on Japanese culture andpsychology. During his training analysis at the Menninger Institute in SanFrancisco, Doi experienced difficulties in finding the right word in Englishto communicate the nuance of his feeling of amae. Although it could beapproximated to the concept of dependence, he believed that no wordquite captured its nuances in English. Doi found the origin of amae in themother-infant relationship, and defined amae as the feeling that all normalinfants at the breast harbor toward the mother, the desire to be passivelyloved, the unwillingness to be separated from the warm mother-child circleand cast into a world of objective reality (1973). To form an attachmentrelationship, the infant needs to perceive the mother as an external objectseparate from himself or herself and seek her for both physiological andpsychological satisfaction; therefore, Doi considered the need for depen-dency to be as basic and instinctual as libido. Doi himself has pointed outthe similarities between his concept of amae and Michael Balint’s passiveobject love.

Amae as a Japanese word is a deverbal noun form of amaeru, equivalentto such words as coaxing, fawning, wheedling, and so forth. The verb, amaeru,is commonly used to describe the child behavior of sucking up or laying up totheir parents to gain their indulgent attention and to be spoiled by them. It isalso used to describe a wide range of adult behaviors that appeal to thematernal generosity of the other in order to gain forgiveness, attention, orcaring by playfully and sometimes manipulatively presenting oneself as a childor someone who merits indulgence. According to Doi, amae is present even inadult interpersonal relationships, and one’s capacity to construct a mutuallydependent relationship is central to healthy psychological development inJapan. His linguistic analysis revealed that amae is so pervasive that many ofJapanese words describing emotions are variant forms of expression of thisdependency need. This contrasts sharply with western models of healthypersonality and psychological development, including Freudian psychoanaly-sis, that give little significance to the adaptive role of interdependence. Per-sonality development is often portrayed as the development of autonomy andindependence while a dependency need, which is discussed in relation topathological tendencies, is something that needs to be controlled and managedas the person matures.

Doi’s clinical practice also points to the importance of amae in thetreatment of Japanese patients. A variety of psychological maladjustments asobserved in his clinical experience in Japan were associated with distortedforms of the dependency need and failure to build appropriate interpersonalrelationships for satisfying one’s dependency need. Doi pointed out that forpsychotherapy to be successful with Japanese patients, amae or a dependencyneed has to be brought into awareness. Furthermore, the patient needs to

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learn to relate to others by building a sense of trust rather than being uncon-sciously driven by one’s dependency need. Doi’s analysis goes beyond linguis-tic analysis of the word amae by attempting to explain the whole structure ofJapanese society and culture, proposing that amae operates in socialstructures such as the Emperor system and even in the typical behaviorof Japanese people in front of western individuals.

Kosawa’s Ajase Complex

One of the first attempts to develop a theoretical concept to modifytheories of western psychotherapy was carried out by Heisaku Kosawa.Kosawa was one of the first psychoanalysts to establish independent prac-tice in Tokyo in the 1930s and became the central figure of psychoanalyticactivity after World War II. He left Japan to study at the Vienna Psycho-analytic Institute between 1932 and 1933 and received supervision fromRichard Sterba and Paul Federn. During his visit to Vienna, Kosawadelivered to Freud a treatise entitled the Ajase complex; two varieties ofguilt consciousness, in which critical distinction is made between Japaneseor western guilt and eastern guilt using the Buddhist legend of PrinceAjatasattu (ajase in Japanese). Kosawa felt that the Oedipus complexneeded to be replaced with the Ajase complex when applying psychoanal-ysis to Japanese patients.

Kosawa derived his theory of the Ajase complex from two Buddhistsources. As I will explain later, the original story line was vastly modified and,as many critics point out, his version of the story is a forceful appropriation(Kitayama, 1993). I would like to present the most recent version by Kosawathat was later modified by his student, Keigo Okonogi, because this version isthe most widely known and discussed (Okonogi, 2001).

Queen Vaidehi, wife of King Binbashara in ancient India, was childlessand feared that unless she bore a child to the throne, the king love wouldfade as her beauty declined with age. Out of a desperate desire to bear aprince, she consults a prophet, who informs her that a male child will beconceived upon the death of the ascetic three years later. Too anxious towait out the birth of a prince, Queen Vaidehi murders the ascetic, who,right before he breathes his last, reveals his curse: he will be reincarnatedas the son of the king, who will someday murder his own father. In thatmoment, the queen conceives the prince, Ajatasattu, who was alreadymurdered once by his own mother before his birth. Fearful of the asceticcurse, Queen Vaidehi tries to murder the prince by delivering him from thetop of a tall tower. The prince survives with only a broken finger and growsup to be a wholesome boy. As an adolescent he finds out about the secret


of his birth. Disillusioned with his mother, he attempts to murder her.However, tormented by the intensity of the guilt he feels over the at-tempted matricide, he is overcome by a skin disease. No one but his motherwill approach and nurture him because of the foul odor emanating from hissores. In spite of his mother patient nursing, the prince condition does notimprove. The mother seeks the help of the Buddha and confesses hertroubles. Through her encounter with the Buddha, she achieves insight intoher conflicts, and eventually her son recovers from the vile illness. PrinceAjatasattu later became known as a wise king.

This Buddhist tale was believed to show a psychological processleading to the restoration of a sense of oneness with the mother. Thechild is embraced by the mother’s forgiveness and devoted nurturing inspite of his intention to kill her. As the child experiences a sense ofbeing one with the mother in fighting the illness, a sense of guiltemanates from the within. Okonogi calls this type of guilt autonomousguilt or spontaneous guilt and contrasts it against the patricidal Oedipalguilt that arises from the fear of punishment and results in the separa-tion of the child from his mother. Whereas the Oedipus complexunderscores the sexual nature of the mother– child relationship thatneeds to be severed, this Buddhist tale emphasizes the nongenitalnature of the mother– child relationship reestablished.

Kosawa theorized that neurosis as seen in Japanese patients is apsychological state in which a person has to repress his or her psychologicalneed for dependency on the mother because he cannot believe the moth-er’s bottomless love. Therefore, Kosawa concludes that psychoanalytictreatment in Japan requires undoing the repression of a dependency needfor the mother and the restoration of a sense of identity with the mother(Okonogi, 2001). In other words, Kosawa practice of psychoanalysis in-volved accepting the patient’s transferential feelings of dependence andresponding with limitless maternal affection so that his patients can expe-rience a sense of oneness with the therapist.

Later, Okonogi added another interpretation of the Ajase complex:Ajase rage against his mother originated from discovery of her selfish-ness in having used him in order to cling onto her husband, KingBinbashara. Okonogi terms this rage of a child at the discovery of his orher origin in the parent sexual relationship misho-on or prenatal re-sentment, and points out that the Ajase complex illuminates not onlychildren’s ambivalence toward their mothers, but also women ambiva-lence toward maternity.

Both Doi and Kosawa emphasize the mother-child relationship and therole of dependence in the Japanese psyche. However, Doi treatmentmethod departs from that of Kosawa in that he does not consider theestablishment of a dependent relationship between the therapist and the

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patient desirable. To the contrary, he advocates that the amae or a depen-dency need be brought into awareness and replaced by a more consciousprocess of building a sense of trust. Doi was originally a student of Kosawa.He left Kosawa because he disagreed with the treatment method Kosawaused, which deviated from the standard practice of psychoanalysis(Takeda, 1988).

In sum, these attempts consistently emphasize the importance of themother–child relationship in Japan. It appears that these theoretical andclinical developments are attempts to both assimilate western psychotherapyinto Japanese culture and also to uncover cultural biases inherent in thesetheories.

Although the purpose of these attempts is to modify theoretical con-cepts and techniques to fit a Japanese client population, it does not nec-essarily follow that they portrait the psychology of Japanese people accu-rately. Taketomo, for example, pointed out that Doi arbitrarily selectedand discussed only one aspect from the various definitions given by lexicalsources, emphasizing a unified Japanese national character, while over-looking the metacommunicational processes associated with a more com-mon usage of the term (1986). Nagayama questions the clinical value ofamae because its definition is too ambiguous to guide clinical interventions(2001). In turn, Kosawa Ajase complex has also been criticized for itsarbitrariness in mixing two sources of sutra and changing the storyline.Kosawa revised and modified the story of Ajase to the extent that it nolonger resembled the original story, which depicted father-son hostilityresulting in patricide similar to the story of Oedipus (Kitayama, 1993;Okonogi, 2001). Although these attempts certainly capture some of thecultural characteristics crucial to applying psychotherapy to Japanese pa-tients, it appears that there is a tendency or bias toward building a coher-ent, historically consistent, unchanging picture of Japanese people as awhole. Dale (1970) points out that Japanese theories of psychology such asthese are more the concern of nihonjinron, the appropriation of academicdiscourse to demonstrate the uniqueness of Japanese culture and people.Japanese psychologists often emphasize the importance of understandingthe uniqueness of an individual using detailed case studies. However, whenit comes to a cross-cultural comparison between Japanese and westernculture, they are quick to make the assumption that all Japanese peoplepossess similar psychological characteristics or exhibit similar psychologicalprocesses.

Because of this tendency toward the assertion of a unified nationalcharacter inherent to most attempts at cultural integration, it is importantfor Japanese therapists to question whether cultural integration is alwaysdesirable. Psychotherapy may be appealing to some patients preciselybecause it is foreign and different from what Japanese people usually do.


Andrew Grimes, a British psychotherapist practicing in Tokyo, observedthat some Japanese prefer to talk about their problems in English tonon-Japanese therapists (Grimes, n.d.). Cultural codes of behavior associ-ated with speaking Japanese make it difficult for them to be emotionallyexpressive and direct. For such clients, expressing oneself in a foreignlanguage can be a liberating experience in which they acquire new ways oflooking at their life and handling their problems. In other words, culturalintegration may prematurely strip away the novelty of cross-cultural expe-rience inherent in psychotherapy.

In sum, cultural integration offers a unique contribution to the projectof psychotherapy integration by modifying techniques and theoretical con-cepts to better serve culturally different populations. Cultural integration isalways attempted in some form or another when a western theory ofpsychotherapy is imported. However, what has been overlooked are themethod and process of these integration attempts and the potential pitfallsdue to modifications. It will be beneficial for Japanese therapists to exam-ine how these attempts are carried out and what the potential benefits aswell as pitfalls of these attempts are.

(4) What seem to you the most distinctive things about how psychother-apy is practiced and thought about in your country? What might those of usoutside your country be least likely to know or appreciate?

One of the most distinctive things about the practice and theory ofpsychotherapy in Japan is the relatively undermined value of verbal com-munication and understanding, which runs counter to the common char-acterization of psychotherapy as the talking cure. Indeed, Japanese thera-pists seem to value instead a non-talking cure, in which change ishypothesized to occur through silence, nonverbal interactions, and solitaryintrospection, even when applying western psychotherapies. The incorpo-ration of nonverbal techniques such as drawing and sandbox play that Ihave briefly explained in the answer to the Question Three relies on justsuch routes to change. For example, Hironaka defines the primary role ofthe therapist in applying the sandbox technique as just to be or to stay withthe client, and to receive and appreciate what is expressed in the sandboxas if it were a piece of art (Hironaka, 1998, p. 112). The client, engaged insandbox play, does not need to be encouraged to explain verbally what heor she has made or what he or she is doing. Neither are therapists encour-aged to communicate their understanding or interpretation verbally.

The emphasis on a nontalking cure is also associated with a distincttherapeutic relationship stance quite different from those commonly de-lineated by western models of psychotherapy. This may be further exem-plified by indigenous therapies such as Morita therapy and Naikan therapyin which not verbalizing one’s ideas and not talking about problems are anintegral part of the therapy (I would like to describe these therapies briefly

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to illustrate this point. Please refer to Reynolds (1976) for a more completediscussion of these therapies.) Morita therapy, which was developed as atreatment for neurosis and conditions similar to current definitions ofobsessive–compulsive disorder, is an inpatient treatment method that usu-ally continues for one month. The process of Morita therapy can be dividedinto four stages, each running for approximately one week. In the firststage, patients stay in bed and are prohibited from engaging in activitiessuch as seeing people (including their family members), talking, reading,smoking, or drinking, all of which might divert their attention from theirillness. The goal of this stage is for patients to learn to endure and accepttheir obsessive thoughts as part of their nature without fighting them orengaging in a futile attempt to analyze and achieve a solution to them. Thesecond stage consists of solitary, light manual tasks such as gardening andcarpentry work. In the third stage, patients are assigned an increasedworkload of similar manual tasks in order to further cultivate a desire forand joy in work. In the final phase, which is preparation for return tosociety, patients start commuting to their respective places of work orschool.

Throughout the treatment, interaction between therapist and patient iskept to a minimum. When the patient inquires about the meaning of a taskor questions its effectiveness, the therapist task is to tell them not toquestion, and not to fight anxiety or fear but to bear it and accept the factthat they have such feelings. Patients keep a daily log of their thoughtsthroughout the day. Therapists, however, only give encouragement and donot comment on the content of the log. In Morita therapy, change ishypothesized as occurring not from understanding the nature of one’sproblems and mastering them, but from accepting and learning to leadone’s life with the problems and symptoms. Therefore, patients do not talkabout their thoughts and feelings, but instead learn to live without beingcaught in the struggle to control them. The focus on manual labor andminimal interaction between therapist and patient makes it impossible forpatients to focus directly on solving the problems for which they soughttreatment, while at the same time providing them with a surplus of time inwhich they have to face such problems by themselves. This paradoxicalsetting defeats patients’ attempt to solve their problems and opens up adifferent avenue of change: learning to bear and coexist with their symp-toms.

A similar relationship stance and course of change are portrayed inNaikan therapy. Naikan therapy, which was developed by Ishin Yoshimotoin 1937, is a structured method of self-reflection aimed at understandingand appreciating the fundamental nature of human existence throughexamining one interpersonal relationships with significant others (Naikanmeans introspection or looking inward. The most traditional format for


Naikan therapy is a 1-week retreat in which one reflects upon the events ofone entire life for 15 hours each day. Clients are placed in a large room andare each surrounded and divided by folding screens. Clients are prohibitedfrom chatting with other participants, making phone calls, leaving theroom, or even following the events of the outside world by watchingtelevision or reading the newspaper. Meals are carried to the place wherethey sit and introspect. Clients sit facing the wall alone in a room and aredirected to think about three questions: (1) What have I received fromsignificant others, such as parents, siblings, teachers, and colleagues; (2)What have I given to them; and (3) What troubles and difficulties have Icaused them?

The introspection promoted in Naikan therapy is meant to illuminateaspects of one’s life in which one has been helped, supported, and forgivenby others in spite of the troubles that one has caused them. The profoundsense of gratitude and appreciation of others that is said to result oftenleads to an intense emotional experience in which one realizes how self-centered and self-absorbed one has been. This feeling is meant to lead toa recognition of the joy and happiness of daily life and a feeling ofconnectedness with others. The interaction between therapist and patientis limited to the routine transaction of inquiring about the progress ofintrospection. Naikan therapists visit each patient for only three to fiveminutes every two hours. They do not ask after the details of introspectionor any feelings evoked by it. Similar to Morita therapists, Naikan therapistsuse set phrases to provide encouragement and to thank patients for sharingtheir thoughts.

In both Morita and Naikan therapy, therapists do not sit face-to-facewith patients, but rather merge somewhat into the therapeutic setting.Neither Morita nor Naikan therapy provides their patients with an oppor-tunity to directly express their feelings to the therapist. Nagayama pointsout that this relationship stance allows Morita therapists to maintain ade-quate distance from the patients, to be free from becoming the target oftransference feelings, and to empathize with patient feelings that arise fromemotional involvement in performing the assigned tasks (2001). The ther-apeutic relationship is mediated by the therapeutic task: the therapistempathy is expressed toward the patient involvement in the therapeutictask, not toward the patient as he or she suffers from the problems thatbrought him or her to therapy. Change is said to occur when the patientdiscovers the functioning aspects of his or her life. In Morita therapy, thisis the patient perseverance in continuing to work despite troublingthoughts and feelings, whereas in Naikan therapy, it is the discovery of thepreviously unrecognized affection and caring of significant others.

Perhaps I need to clarify that neither Morita therapy nor Naikantherapy is a major force in Japan. Both therapies have a relatively long

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history and certainly reflect aspects of traditional Japanese culture. How-ever, it does not follow that they are more effective or more suitable to theJapanese population than are western therapies. A great many Japanesepeople, particularly of the younger generations, will perceive both the tasksand the relationship styles in these indigenous therapies to be old-fashioned and incompatible with their way of life. The strong emphasis ontraditional Japanese culture and philosophy in both Morita and Naikantherapies may appear just as foreign to contemporary Japanese people aswestern therapies that are applied without any modification.

However, Japanese therapists appear to assume that the route ofchange described by these therapies is also accessible and viable even whenpracticing western therapies. Verbal interactions easily give way to theclient silent introspection with the therapist simply being with the patientwithout attempting to inquire or understand what goes on in his or hermind. Many clinicians write that the most important work is being donewhen the patient is simply thinking and experiencing in the presence of thetherapist.

I watched a demonstration tape conducted by one of the primaryfounders of client-centered therapy in Japan. It is the only demonstrationavailable by a Japanese client-centered therapist. I was puzzled by his styleof therapy, which was not even remotely similar to what I learned asclient-centered therapy in my training. (I grew up in Japan but received allof my clinical training and academic degrees in psychology in Canada.) Assoon as the session started, the therapist closed his eyes. Although heopened his eyes from time to time and directed his gaze in the clientgeneral direction, it was not clear whether he was actually looking at theclient. He certainly demonstrated Rogerian reflection, but very rarely.Mostly he sat with his eyes closed and nodded his head. Even when theclient seemed to have achieved some sort of understanding of his feelings,the therapist simply nodded and another bout of silence began. The clientlooked at the therapist more often, but mostly looked down and kepttalking. Verbal communication and understanding seem to play a small partcompared to silence, which can tell us that something important is happening,though it does not tell us what important thing is happening. It appeared thatthe emphasis was on a kind of silent process, and that not facilitating the clientexperience or verbalizing the client feelings took the place of the wholepurpose of therapeutic interaction in client-centered therapy.

Japanese indigenous therapies and western psychotherapies such asclient-centered therapy are quite different in terms of underlying world-views, treatment structures, therapeutic process, and so forth. Nonetheless,it is relatively easy for Japanese therapists to envision the avenue of changedescribed by Morita therapy or Naikan therapy while practicing and fol-lowing western models of psychotherapy. Changes in these therapies res-


onate well with common cultural ideals of living in a state of reconciliationwith life adversities as opposed to pursuing one’s ideals of happiness andsatisfaction. Some Japanese patients experience changes similar to the onesdescribed in Naikan therapy, even though they receive client-centeredtherapy and other nondirective therapies with the therapist taking a tradi-tional stance to promote the patient autonomy and independence devel-opment. They feel a stronger attachment toward family members (some-times in spite of continued or escalating abuse and mistreatment) andrenewed interest in their work and daily life, yet with little sign of adeepened understanding of or improvement in their living circumstances.

The peculiar mixing of two almost contradictory ways of approachingpatients is reflective of one aspect of modern Japanese society and itsculture. Japanese society has maintained some of its traditional culture andthinking, but it is also a capitalist nation with a highly developed economyand the associated value system similar to modern western nations. Bothaspects seem to coexist, sometimes with no sense of contradiction orincongruence.

(5) As you have come into contact with therapists from other societiesthan your own (, e.g., at meetings such as this), what kinds of things havestruck you about the differences in the assumptions and attitudes that theybring to their work in comparison with your own?

What struck me in this roundtable was not irreconcilable differences inthe cultural assumptions and attitudes that therapists from different coun-tries bring to psychotherapy and its integration, but how much we dedicateourselves to and share of the culture of psychotherapy and psychotherapyintegration. We all are eager and willing to open a dialogue and to gobeyond various boundaries to learn and enrich our knowledge of psycho-therapy. Difference is perceived not as a barrier but an opportunity forlearning and discovery. Mutual interest and willingness to learn fromdifference facilitate our communication and help us overcome the barrierof language as well. This process also leads to a self-reflective stance inexamining and articulating one’s own cultural and personal assumptions.At the same time, psychotherapy integration appears to be a commonlanguage and a culture of its own.

Nonetheless, there are striking differences in attitudes toward the roleof scientific research in psychotherapy between therapists in Japan and inthe countries of other presenters. In both cases, the health insurancesystem interacts and strengthens the attitude toward science. In all thepresenter’s home countries, the services of psychologists are covered byhealth insurance. Psychotherapy is recognized as a valid form of treatmentand is incorporated in the treatment of many psychological disorders.Furthermore, the form and nature of their service is to some extentdetermined by the health insurance system. A social and governmental

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demand for accountability drives psychologists to demonstrate the efficacyand effectiveness of psychotherapy. This creates a close link betweenpsychotherapy and scientific research, and moves psychotherapy towardthe establishment of a variety of empirically supported treatments. Psy-chotherapists in many countries are willingly, and even at times unwillingly,working to establish and negotiate the bridge between science and thepractice of psychotherapy.

This may be one of the main factors driving common forms of psy-chotherapy integration that assimilate aspects of cognitive therapiesinto other systems of psychotherapy, such as psychodynamic therapyand experiential therapy. The tendency is more conspicuous with technicaleclecticism that purports to systematically reorganize techniques of psy-chotherapy based on research evidence rather than on philosophical ideasand beliefs. It appears that the connection with cognitive therapies repre-sents both an actual and a symbolic link to science, academic psychology,and accountability.

On the other hand, in Japan where there is little connection with themedical insurance system, the development of psychotherapy appears tohave taken a different direction. Psychotherapy has moved toward estab-lishing a connection with anthropology, literature, and art to borrow var-ious forms of expressive methods that allow us to access the natural growthtendency within us without changing its course. Human nature is concep-tualized as something that defies natural science and logical reasoning.Those psychologists who established the foundation of clinical psychologyin Japan were unwilling to open their work to scientific examinationbecause, as I explained in the answer to Question Two, such a tie mayshake the establishment of professional identity of clinical psychologists inJapan. As a result, Japanese psychotherapists are relatively free from thesocial demand for effectiveness and accountability. However, their practiceis turning into an esoteric pursuit that is opaque even to psychotherapiststhemselves. Although not all Japanese psychotherapists share this view ofscience, this attitude toward science is still the dominant one in Japan.

It is true that psychotherapy has a longstanding ambivalent relation-ship with scientific research even in North America, where empiricalinvestigation of process and outcome of psychotherapy has been mostactively conducted: there are many psychologists who are pessimistic aboutbridging the gap between the research and the practice of psychotherapy.However, the dominant attitude of Japanese therapists toward science is aperilous one. It isolates Japanese psychotherapists from the developmentsof the rest of the world, which is not desirable even if such isolation mayhelp encourage the building of uniquely Japanese psychotherapies. Inaddition, it may also hinder psychotherapy from gaining social recognition.I feel that it is important for Japanese psychotherapists to examine this


closed attitude toward science and explore potential avenues for incorpo-rating scientific research into psychotherapy in order to make a greatercontribution to society.

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