- Email: [email protected]
Approach of family therapy for psychosomatic diseases in Japan
International Congress Series 1287 (2006) 158 – 163
www.ics-elsevier.com
Approach of family therapy for psychosomatic diseases in Japan Satoru Yoshikawa * Ryukoku University, Department of Literature, Ohmiya, Shichijyo, Shimogyo-ku, Kyoto-city, Kyoto-fu 600-8268, Japan
Abstract. Family therapy is practiced for psychosomatic diseases in Japan. According to the statistical data and concrete cases of family therapy for psychosomatic patients and the family, the approach can be evaluated and very effective. D 2006 Published by Elsevier B.V. Keywords: Family therapy; Psychosomatic disease
1. Introduction In the US, it is well known that the family therapy approach for eating disorder is practiced by the research of Minuchin et al. In Japan, the approach is practiced for psychosomatic patients, too. Mostly, family therapy for psychosomatic disease is practiced by psychiatrist, psychosomatic doctor and psychotherapist; it is rare for doctor to practice family therapy. It is because consultation takes time and is difficult by the Japanese conditions depending on the insurance, medical examination and the treatment system. Most of doctor’s consultation time varies between 10 and 15 min. It is difficult to practice family therapy in such a short time. Therefore, the treatment is done by the psychotherapist. 2. Investigation The author shows 142 cases family therapy practices. They are the cases in Systems Approach Institute and Communication Care Center from 1999 to 2003. The therapist was the author, and the treatments were done by the doctor. * Tel.: +81 755018101; fax: +81 755018109. E-mail address: [email protected]. 0531-5131/ D 2006 Published by Elsevier B.V. doi:10.1016/j.ics.2006.01.066
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
159
Fig. 1. Percentages of main contents of 719 cases that 8 staffs took charge in 3 institutions.
Fig. 1 shows 719 examples that eight staffs practiced therapy at three institutions such as Systems Approach Institute, Communication Care Center and so on. According to the classification of DSM-4-TR, the main contents of consultation are psychotic disorders, mood disorders, anxiety disorders, somatoform disorders, eating disorders, and personality disorders, etc. There are also other cases such as couple therapy and familial complications in the group of classification impossible. The therapies practiced are behavior therapy, hypnotic therapy relaxation, dosa therapy,1 etc. (Fig. 2A). Hence, it is clear that the author practice family therapy mainly. The author shows 143 examples of family therapy practices. These are the cases such as panic disorder, eating disorder, somatoform disorder, chronic pain disorder, circulatory organ disease and other psychogenic internal diseases. As for panic disorder, eating disorder and somatoform disorder, the ratio in women is high. As for chronic pain disorder and other psychogenic internal diseases, the ratio in men is high (Fig. 2B). Fig. 3 shows the time progress from the onset of the disease to the opening of therapy. As these were the cases with doctors of psychosomatic medicine, many cases took a long time until the opening of therapy. As for especially panic disorder, somatoform disorder and chronic pain disorder, many cases started therapy after a progress of more than 5 years. Fig. 4A is about the persons who visited the therapy. They are classified in the cases that only the patient him/herself visited the therapy, the cases that the family of a patient participated in a therapy in some form and the cases that only the family visited the therapy without visit of the patient. In most of the cases, somebody from the family visited with a patient. However, some cases are practiced therapy by the visit of only family. It is regarded that such cases have difficulty of consultation by a doctor since it is supposed that a patient him/herself sees a doctor. Also, some are the cases especially seen in the family therapy that does not assume a patient as an object of therapy. 1
Dosa therapy is a method similar to psychological rehabilitation; it is a technique that calls self-awareness of physical chronic strain, and learns not to outrun the useless power by oneself.
160
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
Fig. 2. (A) A chart of mental healings practiced by the author on panic disorder, eating disorder, somatoform disorder, chronic pain disorder, circulatory organ disease and other psychogenic internal diseases. The healings are relaxation, cognitive therapy, behavior therapy and family therapy. (B) A chart of man and woman ratio of 143 examples of family therapy practices, and classified in each disorder and illness.
Fig. 4B shows the classification of methods of family therapy. Here, they are classified in methods such as Structural Family Therapy, Strategic Family Therapy, Milan Systemic Approach, Solution Focused Approach and Narrative Therapy. Strategic Family Therapy and Solution Focused Approach take priority when it is used for panic disorder and psychogenic internal disease. For chronic pain disorder, the narrative therapy is used more. Fig. 5 shows the classification of convalescence of therapy. Here the author classified a state of convalescence to four. They are [recovery] as completely returning to normal dairy life, [improvement] as being able to have daily life without any big difficulty, [partial improvement] as being able to have daily life but with some problems remained and [worse] as recurrence of the disease. On the whole, 95% of all the cases were largely improved. A recurrence and aggravation of disease were seen in some examples. As for symptoms, 75% of cases of panic disorder were largely recovered and 90% of them were improved as they had no difficulty on daily life; 70% of cases of eating disorder were improved but in some cases, symptoms such as binge eating and vomiting remained. Compared with other diseases, improvement of somatoform disorder is so remarkable that 80% of them recovered. As for chronic pain disorder, 75% of the cases improved as they had no difficulty on the daily life.
Fig. 3. A chart of the time progress from the onset of the disease to the opening of therapy on 143 examples.
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
161
Fig. 4. (A) A chart of involvement of family as visitors for the therapy, about 143 examples. (B) A chart of the classification of methods of family therapy practiced for 143 examples.
In this way, family therapy in a team treatment with doctors seems to be very effective. First, the patient can receive mediation and physical care by the doctor. Secondly, not only the patient him/herself but also members of the family are mentally cared by family therapy. Thirdly, communication between the doctor and the therapist functions so effectively that the mental burden of patient and the family can be lightened. 3. Case 1 The first case is an example of only patient herself as a visitor. The patient is 31-year-old female office worker. Her main complaint is bI have terrible atopic dermatitis and feel depressed. I have no idea of what I can do to make me better.Q Family members are a patient, a son and her parents as neighborhood. [Treatment progress] The patient stated, bThe atopy becomes terrible and I consider that it is because of something psychogenic. Something is caught on my heartQ. During the second therapy, the patient talked about distrust of mother and the damage of sexual crime that she had when she was an elementary school student. The therapist
Fig. 5. A chart of convalescence of therapy classified into four states.
162
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
showed consideration so that she would not reproach herself. The therapist told her that the fear might have become strong by talking, but that such state surely changed. By the third therapy, flashback, suicide desire, fretfulness and fear reaction made her exhausted. The therapist admired her that she could play the perfect role as a mother for her son and confirmed that her fear reaction became less when she coped with her son. As she talked again about her feeling of imperfection as mother, the therapist suggested her to tell her mother that she had wanted the mother to give her mental care after the accident. By the fourth therapy, she told her parents about her suffering; then, parents changed their attitude and she began to feel relieved. About the ninth therapy, the flashback disappeared. She got well and she could keep contact with her son and parents naturally. The therapy was concluded at the tenth therapy when she said that she could do her best by herself hereafter. At the follow-up about 2 months later, she led a social life well and without a problem, only seeing a doctor so as to refrain from taking medicine. 4. Case 2 This case is an example of a whole family as visitors. The patient is a second grader in high school (eleventh grade), female. Her main complaint is school refusal by somatoform disorders such as non-ulcer dyspepsia, irritable bowel syndrome and psychogenic fever. Family members are father, mother, patient, younger brother, and father’s grandmother. Medical history: The patient was highly evaluated child with the hardworking and leadership since elementary school. After the summer vacation of the high school, she kept running a fever of around 388 and had an acute stomachache. As she minded that she could not attend school because of fever and pain, she tried to endure them and went to school, but it was impossible for diarrhea. [Treatment progress] From the beginning, the parents visited with her. Parents wanted her not to overdo, until her physical conditions improved. During therapy, it was seen that when she unusually did a negative remark, the family overly followed it with a comment to make it look good. Then, therapist prevented the family from doing it, promoted her to act her age autonomously, and made her in superfluous adaptation talk to parents about her needs of their support. The therapist talked to parents bShe always continued various things as much as she could. It has been evaluated as her ability, though it has been because of her efforts. She has kept doing it as she was oppressed with anxiety, persuading herself to do so. She cannot stop it by herself anymore.Q Immediately after the explanation, she began to cry, shouting, bI can’t stand it anymore! All the time, I’m scared that I might be said bYou are already useless!N sooner or later.Q Parents saw her state and talked to her, bIt is OK. We are so sorry. You don’t have to overdo anymore. Take it easy. We want nothing else if only you are well. We even don’t care about the school.Q From the next day, she became ever selfish. She asked her mother to do unreasonable things, had father feed her at breakfast, and kept being absent from school for 2 weeks, and doing nothing. Then, immediately, she went to school. However, she behaved as if she
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
163
were another person. For example, she chattered with other students during a class, acted unnaturally before teachers, refused to do homework, had a terrible quarrel with friends and so on. Parents knew it and worried about her. However, the therapist emphasized only the aspect that she could do well. After waiting and seeing what happens for several weeks, therapist directed parents to begin to add some limit. Later on, in daily life, she improved her selfish manner to some extent, all the problems disappeared and she entered a university afterwards. 5. Consideration Now, the effectiveness of family therapy for psychosomatic cases can be concluded as follows. 1. The object of service as support is not only bthe patient him/herselfQ, but also magnified to bthe family and the persons concernedQ. Accordingly, it becomes possible for the family to participate in daily support for the patient. 2. A viewpoint of social working is introduced and social resources can be utilized. It is possible to utilize social resources included family for treatment. 3. Motivation of the patient and the family for treatment is reinforced by family therapy. The family can participate in treatment that would have been left to the patient alone so far. For these reasons, the family therapy makes it easy to empower the bfamily who worry about the patientQ. It can utilize family’s daily concern for the patient as remedial resources. Then as the outcome, educational effects are obtained such as consultation liaison with doctor of treatment abreast and education itself about psychosomatic correspondence. Above all, the most important contribution of the family therapy is that bimprovement of patient’s Quality of LifeQ which has been considered is enabled easily. However, as far as the social support for the total number of patients is concerned, the system of the specialized field constructed by doctors and all concerned is still insufficient in Japan. When the Japanese original cultural background is considered, the characteristics of each family are not small enough to be ignored. If it is so, it is not enough to see a patient as an individual person, but we should extend our outlook to the family. It is necessary to evaluate a family as effective social resource to the patient who has psychosomatic symptoms functionally. This means it is necessary for us to reconsider the importance of family therapy in psychosomatic medicine.
www.ics-elsevier.com
Approach of family therapy for psychosomatic diseases in Japan Satoru Yoshikawa * Ryukoku University, Department of Literature, Ohmiya, Shichijyo, Shimogyo-ku, Kyoto-city, Kyoto-fu 600-8268, Japan
Abstract. Family therapy is practiced for psychosomatic diseases in Japan. According to the statistical data and concrete cases of family therapy for psychosomatic patients and the family, the approach can be evaluated and very effective. D 2006 Published by Elsevier B.V. Keywords: Family therapy; Psychosomatic disease
1. Introduction In the US, it is well known that the family therapy approach for eating disorder is practiced by the research of Minuchin et al. In Japan, the approach is practiced for psychosomatic patients, too. Mostly, family therapy for psychosomatic disease is practiced by psychiatrist, psychosomatic doctor and psychotherapist; it is rare for doctor to practice family therapy. It is because consultation takes time and is difficult by the Japanese conditions depending on the insurance, medical examination and the treatment system. Most of doctor’s consultation time varies between 10 and 15 min. It is difficult to practice family therapy in such a short time. Therefore, the treatment is done by the psychotherapist. 2. Investigation The author shows 142 cases family therapy practices. They are the cases in Systems Approach Institute and Communication Care Center from 1999 to 2003. The therapist was the author, and the treatments were done by the doctor. * Tel.: +81 755018101; fax: +81 755018109. E-mail address: [email protected]. 0531-5131/ D 2006 Published by Elsevier B.V. doi:10.1016/j.ics.2006.01.066
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
159
Fig. 1. Percentages of main contents of 719 cases that 8 staffs took charge in 3 institutions.
Fig. 1 shows 719 examples that eight staffs practiced therapy at three institutions such as Systems Approach Institute, Communication Care Center and so on. According to the classification of DSM-4-TR, the main contents of consultation are psychotic disorders, mood disorders, anxiety disorders, somatoform disorders, eating disorders, and personality disorders, etc. There are also other cases such as couple therapy and familial complications in the group of classification impossible. The therapies practiced are behavior therapy, hypnotic therapy relaxation, dosa therapy,1 etc. (Fig. 2A). Hence, it is clear that the author practice family therapy mainly. The author shows 143 examples of family therapy practices. These are the cases such as panic disorder, eating disorder, somatoform disorder, chronic pain disorder, circulatory organ disease and other psychogenic internal diseases. As for panic disorder, eating disorder and somatoform disorder, the ratio in women is high. As for chronic pain disorder and other psychogenic internal diseases, the ratio in men is high (Fig. 2B). Fig. 3 shows the time progress from the onset of the disease to the opening of therapy. As these were the cases with doctors of psychosomatic medicine, many cases took a long time until the opening of therapy. As for especially panic disorder, somatoform disorder and chronic pain disorder, many cases started therapy after a progress of more than 5 years. Fig. 4A is about the persons who visited the therapy. They are classified in the cases that only the patient him/herself visited the therapy, the cases that the family of a patient participated in a therapy in some form and the cases that only the family visited the therapy without visit of the patient. In most of the cases, somebody from the family visited with a patient. However, some cases are practiced therapy by the visit of only family. It is regarded that such cases have difficulty of consultation by a doctor since it is supposed that a patient him/herself sees a doctor. Also, some are the cases especially seen in the family therapy that does not assume a patient as an object of therapy. 1
Dosa therapy is a method similar to psychological rehabilitation; it is a technique that calls self-awareness of physical chronic strain, and learns not to outrun the useless power by oneself.
160
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
Fig. 2. (A) A chart of mental healings practiced by the author on panic disorder, eating disorder, somatoform disorder, chronic pain disorder, circulatory organ disease and other psychogenic internal diseases. The healings are relaxation, cognitive therapy, behavior therapy and family therapy. (B) A chart of man and woman ratio of 143 examples of family therapy practices, and classified in each disorder and illness.
Fig. 4B shows the classification of methods of family therapy. Here, they are classified in methods such as Structural Family Therapy, Strategic Family Therapy, Milan Systemic Approach, Solution Focused Approach and Narrative Therapy. Strategic Family Therapy and Solution Focused Approach take priority when it is used for panic disorder and psychogenic internal disease. For chronic pain disorder, the narrative therapy is used more. Fig. 5 shows the classification of convalescence of therapy. Here the author classified a state of convalescence to four. They are [recovery] as completely returning to normal dairy life, [improvement] as being able to have daily life without any big difficulty, [partial improvement] as being able to have daily life but with some problems remained and [worse] as recurrence of the disease. On the whole, 95% of all the cases were largely improved. A recurrence and aggravation of disease were seen in some examples. As for symptoms, 75% of cases of panic disorder were largely recovered and 90% of them were improved as they had no difficulty on daily life; 70% of cases of eating disorder were improved but in some cases, symptoms such as binge eating and vomiting remained. Compared with other diseases, improvement of somatoform disorder is so remarkable that 80% of them recovered. As for chronic pain disorder, 75% of the cases improved as they had no difficulty on the daily life.
Fig. 3. A chart of the time progress from the onset of the disease to the opening of therapy on 143 examples.
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
161
Fig. 4. (A) A chart of involvement of family as visitors for the therapy, about 143 examples. (B) A chart of the classification of methods of family therapy practiced for 143 examples.
In this way, family therapy in a team treatment with doctors seems to be very effective. First, the patient can receive mediation and physical care by the doctor. Secondly, not only the patient him/herself but also members of the family are mentally cared by family therapy. Thirdly, communication between the doctor and the therapist functions so effectively that the mental burden of patient and the family can be lightened. 3. Case 1 The first case is an example of only patient herself as a visitor. The patient is 31-year-old female office worker. Her main complaint is bI have terrible atopic dermatitis and feel depressed. I have no idea of what I can do to make me better.Q Family members are a patient, a son and her parents as neighborhood. [Treatment progress] The patient stated, bThe atopy becomes terrible and I consider that it is because of something psychogenic. Something is caught on my heartQ. During the second therapy, the patient talked about distrust of mother and the damage of sexual crime that she had when she was an elementary school student. The therapist
Fig. 5. A chart of convalescence of therapy classified into four states.
162
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
showed consideration so that she would not reproach herself. The therapist told her that the fear might have become strong by talking, but that such state surely changed. By the third therapy, flashback, suicide desire, fretfulness and fear reaction made her exhausted. The therapist admired her that she could play the perfect role as a mother for her son and confirmed that her fear reaction became less when she coped with her son. As she talked again about her feeling of imperfection as mother, the therapist suggested her to tell her mother that she had wanted the mother to give her mental care after the accident. By the fourth therapy, she told her parents about her suffering; then, parents changed their attitude and she began to feel relieved. About the ninth therapy, the flashback disappeared. She got well and she could keep contact with her son and parents naturally. The therapy was concluded at the tenth therapy when she said that she could do her best by herself hereafter. At the follow-up about 2 months later, she led a social life well and without a problem, only seeing a doctor so as to refrain from taking medicine. 4. Case 2 This case is an example of a whole family as visitors. The patient is a second grader in high school (eleventh grade), female. Her main complaint is school refusal by somatoform disorders such as non-ulcer dyspepsia, irritable bowel syndrome and psychogenic fever. Family members are father, mother, patient, younger brother, and father’s grandmother. Medical history: The patient was highly evaluated child with the hardworking and leadership since elementary school. After the summer vacation of the high school, she kept running a fever of around 388 and had an acute stomachache. As she minded that she could not attend school because of fever and pain, she tried to endure them and went to school, but it was impossible for diarrhea. [Treatment progress] From the beginning, the parents visited with her. Parents wanted her not to overdo, until her physical conditions improved. During therapy, it was seen that when she unusually did a negative remark, the family overly followed it with a comment to make it look good. Then, therapist prevented the family from doing it, promoted her to act her age autonomously, and made her in superfluous adaptation talk to parents about her needs of their support. The therapist talked to parents bShe always continued various things as much as she could. It has been evaluated as her ability, though it has been because of her efforts. She has kept doing it as she was oppressed with anxiety, persuading herself to do so. She cannot stop it by herself anymore.Q Immediately after the explanation, she began to cry, shouting, bI can’t stand it anymore! All the time, I’m scared that I might be said bYou are already useless!N sooner or later.Q Parents saw her state and talked to her, bIt is OK. We are so sorry. You don’t have to overdo anymore. Take it easy. We want nothing else if only you are well. We even don’t care about the school.Q From the next day, she became ever selfish. She asked her mother to do unreasonable things, had father feed her at breakfast, and kept being absent from school for 2 weeks, and doing nothing. Then, immediately, she went to school. However, she behaved as if she
S. Yoshikawa / International Congress Series 1287 (2006) 158–163
163
were another person. For example, she chattered with other students during a class, acted unnaturally before teachers, refused to do homework, had a terrible quarrel with friends and so on. Parents knew it and worried about her. However, the therapist emphasized only the aspect that she could do well. After waiting and seeing what happens for several weeks, therapist directed parents to begin to add some limit. Later on, in daily life, she improved her selfish manner to some extent, all the problems disappeared and she entered a university afterwards. 5. Consideration Now, the effectiveness of family therapy for psychosomatic cases can be concluded as follows. 1. The object of service as support is not only bthe patient him/herselfQ, but also magnified to bthe family and the persons concernedQ. Accordingly, it becomes possible for the family to participate in daily support for the patient. 2. A viewpoint of social working is introduced and social resources can be utilized. It is possible to utilize social resources included family for treatment. 3. Motivation of the patient and the family for treatment is reinforced by family therapy. The family can participate in treatment that would have been left to the patient alone so far. For these reasons, the family therapy makes it easy to empower the bfamily who worry about the patientQ. It can utilize family’s daily concern for the patient as remedial resources. Then as the outcome, educational effects are obtained such as consultation liaison with doctor of treatment abreast and education itself about psychosomatic correspondence. Above all, the most important contribution of the family therapy is that bimprovement of patient’s Quality of LifeQ which has been considered is enabled easily. However, as far as the social support for the total number of patients is concerned, the system of the specialized field constructed by doctors and all concerned is still insufficient in Japan. When the Japanese original cultural background is considered, the characteristics of each family are not small enough to be ignored. If it is so, it is not enough to see a patient as an individual person, but we should extend our outlook to the family. It is necessary to evaluate a family as effective social resource to the patient who has psychosomatic symptoms functionally. This means it is necessary for us to reconsider the importance of family therapy in psychosomatic medicine.