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Culture and psychotherapy in Japan
Insight
Feature Culture and psychotherapy in Japan
Phil Hill/Science Photo Library
Long after the global community turned its attention away from Japan’s “3/11” (an earthquake, tsunami, and nuclear reactor meltdown in March, 2011), a Zen Buddhist monk was to be found cruising around the desolation in northern Japan in a pick-up truck. A sign on the roof of the truck read “Café de Monk”. Taiō Kaneta was meeting Japan’s triple disasters with a triple entendre: a Buddhist monk playing Thelonious Monk records in a mobile pop-up café, listening to people’s monku—their “complaints” about life. Kaneta’s café, still running today, was part of a wider set of coordinated medical, therapeutic, and interfaith relief initiatives developed in the spring of 2011. Grouped under the umbrella of Kokoro no Sōdanshitsu (“counselling room for the heart”), they were the fruits of a sophisticated national conversation in Japan about how psychological distress is best understood, talked about, and treated. Junko Kitanaka, a professor of anthropology at Keio University (Tokyo, Japan), points to a previous earthquake disaster in Kobe, Japan, in 1995, as helping to kick-start this conversation. People began to talk about survivors’ need for kokoro no kea: “care for the heart”. The sheer openness of the phrase helped it to catch on. Kokoro (“heart”) helpfully steers clear of conceptual complications and professional turf wars regarding the nature and causation of mental illnesses. Kea (“care”) is a value and aspiration to which all can happily sign up. Largely missing from the growing public awareness about mental health that followed from this, however—at least from a Western perspective—has been psychotherapy and counselling. Funding is a factor. Japan’s national health insurance model is based on partial reimbursement of doctors for provision of specific tests and treatments, with patients paying a proportion of the costs themselves. For many years, outpatient psychotherapy was only covered if it was provided by a psychiatrist, but there are too few psychiatrists, with too little time to spare in each working day, to make sustained psychotherapy a practical option. The long-awaited passing into law, earlier this year, of a national licensing system for psychologists may partially alleviate these problems. However, as Andrew Grimes, a British clinical psychologist based in Tokyo, points out, the extent to which counselling and psychotherapy will be covered by Japanese health insurance as a result of licensing remains to be seen. Beyond the question of how psychotherapy will be paid for lies an even more fundamental one: “What is psychotherapy for?” 102
Toshihide Kuroki, a psychiatrist in Fukuoka, points out that although cognitive behavioural therapy has been expanding in Japan since gaining limited health insurance coverage back in 2010, many Japanese doctors remain opposed to it on the basis that the therapy tries to offer psychological solutions to what they regard as physical problems. Psychotherapy did exist in Japan during the early decades of the 20th century. But it developed away from the medical departments of prestigious universities that might have given it clout with government funders and kudos with the Japanese population at large. And while a lengthy love affair with talking therapies began in Europe and the USA, Japan’s early equivalents seemed to be based almost on a repudiation of words. The psychiatrist Morita Shōma, who founded Morita therapy, thought that trying to use the mind to control the mind was philosophically nonsensical and therapeutically self-defeating. A residential Morita therapy designed to treat what he called nervosity involved a week of bed rest, followed by increasingly demanding physical tasks. The aim was not to delve into a person’s troubles. The patient would learn to accept nature—including his or her own nature—the way that it was, steadily integrating that acceptance into everyday life until his or her anxieties were less easily and extensively triggered. Two other therapies, both of which drew inspiration from Japanese Buddhism, dealt in words but treated them as a means to an end rather than as carriers of precious knowledge. Kosawa Heisaku, who studied briefly with Sigmund Freud and his colleagues in Vienna, Austria, created a form of psychoanalysis that featured no religious references but whose ultimate aim was to produce in the client a profound sense of his or her dependence upon, and loving acceptance by, a transpersonal power that Kosawa understood as Amida Buddha. Yoshimoto Ishin’s residential Naikan therapy, adapted from a Buddhist meditation practice, interspersed long periods of solitary reflection with verbal exchanges between client and “guide”. These exchanges were brief and ritualised, intended as a short report rather than an open, probing conversation. The therapy’s healing effect came from the deep gratitude to others that sustained reflection naturally produced. Although these therapies answered the needs of small numbers of people at the time, none of them achieved widespread recognition in Japan, and later Western commentators were a little too enthusiastic in www.thelancet.com/psychiatry Vol 4 February 2017
Insight
www.thelancet.com/psychiatry Vol 4 February 2017
environment, or the cosmos, and its emergence might occur far more as a result of non-discursive than through discursive activity in the counselling room. Critics and supporters alike of early Japanese psychotherapies ended up engaging in various outdated forms of psychological typecasting by nationality, gender, or class. More promisingly, however, over the years there has been a growing willingness to assess people’s symptoms and needs in as broad a context as possible—from the personal to the political to the existential—in order to tailor treatments accordingly. This shift in approach seems to have been key to the success of Taiō Kaneta’s Café de Monk and other interventions in Japan’s rural northern region of Tohoku in the aftermath of 3/11. A predominantly elderly population unfamiliar with—or, in some cases, rather hostile to— psychiatric or psychological paradigms was met instead with company and conversation, courtesy of familiar Buddhist and other religious institutions operating in carefully non-proselytising mode, with robes exchanged for work clothes as a clear sign of intent. In a time of dramatic change in how mental illness is discussed in Japan, against a backdrop of economic difficulties and mounting demographic challenges of an ageing population, predicting the extent of government support for, and public interest in, psychotherapy is not easy. But disaster relief efforts, and the wider recognition of—and responses to—mental illnesses, are indicative of a society that is well resourced in facing its uncertain future.
Christopher Harding
Sputnik/Science Photo Library
seeing these therapies as Eastern or uniquely Japanese approaches. In fact, all three approaches have probably had as much influence outside as inside Japan. There are Morita and Naikan practitioners in Europe and the USA, while the work of Mark Epstein (in his 1995 book Thoughts Without A Thinker: Psychotherapy from a Buddhist Perspective) and others has gone a good deal further than Kosawa’s in exploring the relationship between psychoanalysis and Buddhism. What these early Japanese therapies show, however, is that questions with apparently obvious answers such as “what is psychotherapy for?” regularly need to be asked afresh, and will probably receive differing answers depending on time and place. For Yasuhiro Oyama, associate professor of clinical psychology at Kyoto University, a case in point is Carl Rogers’ client-centred therapy (CCT). CCT took off in Japan soon after World War 2, with Japanese supporters seeing its individualised, humanistic approach to the mind and to education as timely for a country emerging from a period of social and political repression. However, Japanese practitioners soon recognised that being authentic and being autonomous are not necessarily the same thing. Some Japanese practitioners of CCT, says Oyama, are shocked when they first see video footage of Carl Rogers counselling a client. He sometimes interrupts, he clearly seeks to persuade, and the frequent use of “I” and “you”—intended to put the counsellor’s empathy to work in aiding the client’s own process of reflection— maintains boundaries that are less pronounced in much Japanese CCT. By contrast, in a Japanese CCT session the counsellor might simply repeat and affirm what the client says; Oyama says this can result in a sense of counsellor and client sharing in the same emotion. Whether or not this represents a therapeutic success obviously depends on the individual, but it also depends on one’s understanding of the goal of therapy. If therapy is primarily about fostering a stronger and more effective autonomous self, through a client learning to step outside their own self, narrate their experiences, and reach new insights, then Japanese practitioners who work in the way described above might be regarded as failing. Kosawa Heisaku was criticised on similar grounds in his own time by an American psychoanalyst who charged that rather than loosening people’s “inner thongs” he was tying them tighter. But as Laurence Kirmayer, professor of social and transcultural psychiatry at McGill University (Montreal, Canada) points out, there are other ways to understand the ideal self and to work towards it. Such a self might be oriented more towards a community, or the
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Feature Culture and psychotherapy in Japan
Phil Hill/Science Photo Library
Long after the global community turned its attention away from Japan’s “3/11” (an earthquake, tsunami, and nuclear reactor meltdown in March, 2011), a Zen Buddhist monk was to be found cruising around the desolation in northern Japan in a pick-up truck. A sign on the roof of the truck read “Café de Monk”. Taiō Kaneta was meeting Japan’s triple disasters with a triple entendre: a Buddhist monk playing Thelonious Monk records in a mobile pop-up café, listening to people’s monku—their “complaints” about life. Kaneta’s café, still running today, was part of a wider set of coordinated medical, therapeutic, and interfaith relief initiatives developed in the spring of 2011. Grouped under the umbrella of Kokoro no Sōdanshitsu (“counselling room for the heart”), they were the fruits of a sophisticated national conversation in Japan about how psychological distress is best understood, talked about, and treated. Junko Kitanaka, a professor of anthropology at Keio University (Tokyo, Japan), points to a previous earthquake disaster in Kobe, Japan, in 1995, as helping to kick-start this conversation. People began to talk about survivors’ need for kokoro no kea: “care for the heart”. The sheer openness of the phrase helped it to catch on. Kokoro (“heart”) helpfully steers clear of conceptual complications and professional turf wars regarding the nature and causation of mental illnesses. Kea (“care”) is a value and aspiration to which all can happily sign up. Largely missing from the growing public awareness about mental health that followed from this, however—at least from a Western perspective—has been psychotherapy and counselling. Funding is a factor. Japan’s national health insurance model is based on partial reimbursement of doctors for provision of specific tests and treatments, with patients paying a proportion of the costs themselves. For many years, outpatient psychotherapy was only covered if it was provided by a psychiatrist, but there are too few psychiatrists, with too little time to spare in each working day, to make sustained psychotherapy a practical option. The long-awaited passing into law, earlier this year, of a national licensing system for psychologists may partially alleviate these problems. However, as Andrew Grimes, a British clinical psychologist based in Tokyo, points out, the extent to which counselling and psychotherapy will be covered by Japanese health insurance as a result of licensing remains to be seen. Beyond the question of how psychotherapy will be paid for lies an even more fundamental one: “What is psychotherapy for?” 102
Toshihide Kuroki, a psychiatrist in Fukuoka, points out that although cognitive behavioural therapy has been expanding in Japan since gaining limited health insurance coverage back in 2010, many Japanese doctors remain opposed to it on the basis that the therapy tries to offer psychological solutions to what they regard as physical problems. Psychotherapy did exist in Japan during the early decades of the 20th century. But it developed away from the medical departments of prestigious universities that might have given it clout with government funders and kudos with the Japanese population at large. And while a lengthy love affair with talking therapies began in Europe and the USA, Japan’s early equivalents seemed to be based almost on a repudiation of words. The psychiatrist Morita Shōma, who founded Morita therapy, thought that trying to use the mind to control the mind was philosophically nonsensical and therapeutically self-defeating. A residential Morita therapy designed to treat what he called nervosity involved a week of bed rest, followed by increasingly demanding physical tasks. The aim was not to delve into a person’s troubles. The patient would learn to accept nature—including his or her own nature—the way that it was, steadily integrating that acceptance into everyday life until his or her anxieties were less easily and extensively triggered. Two other therapies, both of which drew inspiration from Japanese Buddhism, dealt in words but treated them as a means to an end rather than as carriers of precious knowledge. Kosawa Heisaku, who studied briefly with Sigmund Freud and his colleagues in Vienna, Austria, created a form of psychoanalysis that featured no religious references but whose ultimate aim was to produce in the client a profound sense of his or her dependence upon, and loving acceptance by, a transpersonal power that Kosawa understood as Amida Buddha. Yoshimoto Ishin’s residential Naikan therapy, adapted from a Buddhist meditation practice, interspersed long periods of solitary reflection with verbal exchanges between client and “guide”. These exchanges were brief and ritualised, intended as a short report rather than an open, probing conversation. The therapy’s healing effect came from the deep gratitude to others that sustained reflection naturally produced. Although these therapies answered the needs of small numbers of people at the time, none of them achieved widespread recognition in Japan, and later Western commentators were a little too enthusiastic in www.thelancet.com/psychiatry Vol 4 February 2017
Insight
www.thelancet.com/psychiatry Vol 4 February 2017
environment, or the cosmos, and its emergence might occur far more as a result of non-discursive than through discursive activity in the counselling room. Critics and supporters alike of early Japanese psychotherapies ended up engaging in various outdated forms of psychological typecasting by nationality, gender, or class. More promisingly, however, over the years there has been a growing willingness to assess people’s symptoms and needs in as broad a context as possible—from the personal to the political to the existential—in order to tailor treatments accordingly. This shift in approach seems to have been key to the success of Taiō Kaneta’s Café de Monk and other interventions in Japan’s rural northern region of Tohoku in the aftermath of 3/11. A predominantly elderly population unfamiliar with—or, in some cases, rather hostile to— psychiatric or psychological paradigms was met instead with company and conversation, courtesy of familiar Buddhist and other religious institutions operating in carefully non-proselytising mode, with robes exchanged for work clothes as a clear sign of intent. In a time of dramatic change in how mental illness is discussed in Japan, against a backdrop of economic difficulties and mounting demographic challenges of an ageing population, predicting the extent of government support for, and public interest in, psychotherapy is not easy. But disaster relief efforts, and the wider recognition of—and responses to—mental illnesses, are indicative of a society that is well resourced in facing its uncertain future.
Christopher Harding
Sputnik/Science Photo Library
seeing these therapies as Eastern or uniquely Japanese approaches. In fact, all three approaches have probably had as much influence outside as inside Japan. There are Morita and Naikan practitioners in Europe and the USA, while the work of Mark Epstein (in his 1995 book Thoughts Without A Thinker: Psychotherapy from a Buddhist Perspective) and others has gone a good deal further than Kosawa’s in exploring the relationship between psychoanalysis and Buddhism. What these early Japanese therapies show, however, is that questions with apparently obvious answers such as “what is psychotherapy for?” regularly need to be asked afresh, and will probably receive differing answers depending on time and place. For Yasuhiro Oyama, associate professor of clinical psychology at Kyoto University, a case in point is Carl Rogers’ client-centred therapy (CCT). CCT took off in Japan soon after World War 2, with Japanese supporters seeing its individualised, humanistic approach to the mind and to education as timely for a country emerging from a period of social and political repression. However, Japanese practitioners soon recognised that being authentic and being autonomous are not necessarily the same thing. Some Japanese practitioners of CCT, says Oyama, are shocked when they first see video footage of Carl Rogers counselling a client. He sometimes interrupts, he clearly seeks to persuade, and the frequent use of “I” and “you”—intended to put the counsellor’s empathy to work in aiding the client’s own process of reflection— maintains boundaries that are less pronounced in much Japanese CCT. By contrast, in a Japanese CCT session the counsellor might simply repeat and affirm what the client says; Oyama says this can result in a sense of counsellor and client sharing in the same emotion. Whether or not this represents a therapeutic success obviously depends on the individual, but it also depends on one’s understanding of the goal of therapy. If therapy is primarily about fostering a stronger and more effective autonomous self, through a client learning to step outside their own self, narrate their experiences, and reach new insights, then Japanese practitioners who work in the way described above might be regarded as failing. Kosawa Heisaku was criticised on similar grounds in his own time by an American psychoanalyst who charged that rather than loosening people’s “inner thongs” he was tying them tighter. But as Laurence Kirmayer, professor of social and transcultural psychiatry at McGill University (Montreal, Canada) points out, there are other ways to understand the ideal self and to work towards it. Such a self might be oriented more towards a community, or the
103