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Poetry therapy for schizophrenia: a linguistic psychotherapeutic model of renku (linked poetry)
The Arts in Psychotherapy 28 (2001) 319 –328
Poetry therapy for schizophrenia: a linguistic psychotherapeutic model of renku (linked poetry) Hiroshi Tamura, M.D.* Nakayama Hospital and Tokyo Women’s Medical University, 54-23, Wakamiya 2 chome, Nakano-ku, Tokyo, 165-0033, Japan
cussed and a linguistic psychotherapeutic model will be proposed.
Introduction Disturbances of association are suggested to be fundamental characteristics in schizophrenia (Bleuler, 1950). Schizophrenics may have pathological semantic systems that are less socially conditioned. In fact, schizophrenics often fail to understand the meaning of words in context and cannot communicate their intended meaning to others (Cutting, 1985). Language impairments may also precipitate thought disorders, including misjudgment of experience, delusions, and a distorted worldview, because human cognitive ability is enhanced by the linguistic aspects of thought (Lieberman, 1984). The current psycholinguistic approach suggests that chronic schizophrenics have language impairments at the levels of semantics, cognition, and pragmatics. The semantic and cognitive levels can be regarded as deeper structures that operate association and thought, while the pragmatic level is viewed as the study of meaning in context pertinent to communication and the relations between signs and their users. I will present two cases of chronic schizophrenia significantly improved after participating in renku, a Japanese traditional poetic form, used in one-to-one therapeutic sessions. The unique character of renku is its dialogue in form. A series of exchanges of stanzas seem to treat schizophrenic language impairments as well as disordered reality testing. The therapeutic functions of poetic language in renku will be dis-
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Renku, a Japanese traditional poetic form The origins of renku called renga dates back to the 12th century in Japan. The oldest formal linkingrules we have were defined by Nijoˆ Yoshimoto in 1372. Modern renku was founded by Matsuo Bashoˆ in the late 17th century, who also founded haiku (hokku), which was the opening stanza of renku. Renku is written by more than two people as follows: the first person composes an opening stanza, a three-line stanza with onji or Japanese syllables arranged in the pattern 5-7-5. The second person replies with a two-line stanza arranged in 7-7. Then the next responds to the 7-7 with another 5-7-5. This pattern, 5-7-5/7-7/5-7-5/7-7/. . . is repeated until some fixed number will be completed. A kasen form with thirty-six stanzas and a half-kasen containing eighteen stanzas, are the common forms of modern renku. Techniques for linking (tsukeai) changed from era to era. In the Teimon School organized by Matsunaga Teitoku circa 1625, the main idea of linking is word association. The Danrin School led by Nishiyama Soˆin circa 1673 claims that the linking is based on the whole meaning of the previous stanza. The Bashoˆ School developed the linking into subtle and various manners that depended mainly on the images of the immediate stanza, and “on the psychic archetypes and actual situations from life which the images represent” (Higginson, 1985, p. 195). Mukai Kyorai, one of Bashoˆ’s disciples, states in his book Kyoraishoˆ
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(1702–1704) that Bashoˆ exemplified four linking manners: “reflection” (utsuri), “echo” (hibiki), “scent” (nioi), and “rank” (kurai). Bashoˆ also regarded wit and humor as an essential factor in linking (Imoto & Imaizumi, 1982). It is of utmost importance that each stanza be linked in imagery to the one just preceding. There are rather complicated linking guidelines that define things so as to avoid repeating similar topics. For example, there are rules that limit the number of stanzas referring to the same seasons in succession. There are also rules for the positions of the moon and blossom within the whole renku. Nature and seasons are the central framework in renku, as are other topics, such as love, nostalgia, religion, illness, life and death, travel, history, and other human affairs. Such linking guidelines are not meant to obstruct creativity, but to give participants a suitable framework of images and to facilitate the composition of a following stanza. The role of the renku leader (sabaki) is the key to the participants’ peace of mind and willingness to participate. The sabaki takes all responsibility for gently leading and imparting the guidelines. The therapist of course has this role in renku therapy. Prosody, which is the matter of suprasegmental phonological features of language (e.g., rhythm, pause, tempo, stress, and pitch), is also an indispensable element in poetry. Since there is pitch accent but not stress accent in Japanese language, the sound of each syllable or onji is the same in length. Japanese syllables are very short, and there is a tendency for two syllables to form a minimal meaning unit (Kindaichi, 1978). Lines arranged in odd syllables, five or seven, are common in Japanese poetry. Sounds are perceived with rhythmical breaks and silence, producing poetic effects, which may be as familiar and comforting as nursery rhymes in the Western world. Thus, Japanese words arranged in these syllable patterns sound poetic. In addition, there are no rules governing rhyme in renku. As the sound system between Japanese and English is quite different, it is difficult to keep the syllable pattern in an English translation. Renku has been attempted in English, and the long stanza in renku is commonly written in three lines while the short stanza is written in two lines.
Renku as psychotherapy I usually use an 18-stanza format originating from half-kasen for renku therapy because of its suitable length in various clinical settings. Linking rules are simplified to suit each patient. Nature and events relevant to the present season and patients’ everyday life are the main content topics of stanzas, which
serve to promote reality-oriented thinking. Despite linking guidelines mentioned above, I will rarely ask patients to write something about seasons they are not in, because it might be difficult and less therapeutic for them to do so. As sessions proceed, patients will experience the actual change of seasons and they will express seasonal feelings naturally in their stanzas. Patients will be given enough time, normally a few days for in-patients and two weeks for out-patients, to write a stanza, while the therapist writes the stanza during the session. Rules governing season changes can also be used as a collaborative and therapeutic task in a group setting. Gorelick (1987) regards the group poetry therapy as a miniature theater-in-the-round in which the participants take dual roles of protagonist and audience as they reflect and create a here-and-now reality for one another.
Case study Case 1 Yukiko is a 20-year-old single female with chronic schizophrenia. She lives with her mother and younger sister, and her father, who because of his work, is home only at weekends. Her mother has a sixteen-year history of affective disorders and had been hospitalized with psychotic symptoms in her manic episode and participated in group renku therapy organized by the author. She was diagnosed as schizophrenia at the age of 14. She showed an insidious onset and developed symptoms such as social withdrawal, lack of conversation, confusion, underactivity, auditory hallucinations, and delusions of reference. Antipsychotic medication was effective in relieving her hallucinations and delusions. However, negative symptoms did not improve. She had difficulties in getting along with her classmates, and since leaving high school, she became more isolated. It was her routine to watch videos (e.g., animated comics with a teenage heroine), to listen to popular music late at night, and to get up in the afternoon. She also liked to spend time at home by herself without doing anything. Psychotherapeutic treatment by a previous psychiatrist ended without effective contact being achieved. Yukiko was referred to the author when she was 18. During first examination, her mental state was characterized as blunted affect, no eye contact, disturbances of association, and a tendency to prefer fantasy to reality. She looked much younger than she was. She was seen biweekly and her medication, haloperidol, was replaced with mosapramine hydro-
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chloride, which improved her blunted affect somewhat. Three months later, she was asked to write haiku as homework. The instruction went as follows: “Can you write haiku describing your current life and seasonal feeling?” pushing my way through New year’s visit to the shrine my wishes . . .
She tried to describe her New Year with encouragement and assistance from her mother. It was not an easy task for her to write haiku, but she came to recognize seasonal feelings and topics in her everyday life that worked to extend her interests to the real world. However, she often seemed to live in her fantasy world. Setsubun day I couldn’t perform bean-scattering so, scolded my mother
Yukiko
This is her first haiku written by herself. She looked forward to performing Setsubun, one of the Japanese annual events, which involves praying for good health and fortune for the year, but her mother forgot to buy soybeans for the performance. So, she scolded her mother for that. Though a little later, she was able to laugh it away with the above haiku. This event got her more interested in writing haiku. even mustard flowers my mother cooks for dinner
1-2. 1-3.
1-4.
1-11.
1-12. 1-13.
Yukiko
“New Sandals”: excerpt from 1st renku these new sandals I bought make me feel it’s summer now Yukiko looking at the bubbles in an ice-cream soda the author when shopping tires me what makes me better is ice-cream soda Yukiko feeling secure today with my umbrella the author
The form is half-kasen with eighteen stanzas. Her stanzas were not difficult to interpret in general. The second stanza showed how to link stanzas with a simple word association between “summer” and an
a cool sea breeze in the evening the blue sea I wanna swim on Joˆ do-ga-hama beach footprints in the sand soon wiped off pampas grass looks great with full moon
the author
Yukiko the author
Yukiko
She created her images of the “sea”(1-11) from the author’s stanza (1-10) plus her memories of the beach lately visited. “Moon (autumn)” as a given topic and “pampas grass” is collocations (1-13). When she understood the linking between her stanza and the author’s well, she expressed happy feelings. Five months after beginning renku, her paucity of speech began to improve so that she felt like talking to the author about her interests. It became her routine to help her mother in housekeeping.
2-1.
Through 10 sessions of haiku therapy, her emotional responses began to improve. She started to play a small part in kitchen work, and she often wrote haiku about this. Accordingly, I suggested that she started renku. I introduced it as a poetic association game. 1-1
“ice-cream soda” (1-2). She expressed the slightest response to the author’s stanza, however, she tried to describe her images by employing the “ice-cream soda” in the preceding stanza (1-3). This closeness in association is often seen at the early stage as a positive response to renku therapy. 1-10.
Yukiko
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2-2. 2-3.
“New Millennium’s Day”: excerpt from 2nd renku New Millennium’s Day my father has gone too soon to the office Yukiko quietly, peacefully it gets dark the author photo of me in a kimono at the Coming-of-Age Day celebration looks cool and mature Yukiko
In the second renku, her stanzas tend to be better linked to the author’s. With her stanza (2-3), she showed the photo to let the author realize what she was like. 2-9.
at my sister’s age! her birthday present is a PlayStation 2 2-10. Ah! nails beautifully manicured 2-11. the last song. . . Speed brought me a lump in my throat
Yukiko the author
Yukiko
She also expressed her honest opinion and emotions in her stanza (2-9). I responded with the stanza (2-10) with two contexts, a literal one relevant to “age” and a situational one, a reference to her pearly
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pink manicured nails that seemed to be a manifestation of her self-awareness. ‘Speed’ is her favorite group of teenage singers. She felt sad about their last concert and wrote her stanza (2-11). In the course of 13-month renku therapy Yukiko improved significantly in social functioning and decreased negative symptoms. When her mother had a recurrence of a manic disorder with psychotic symptoms under the stress of moving from her house, she helped her mother and showed that her own improvement did not leave her vulnerable.
wants to move with no money
I wrote the second stanza following her haiku, and renku began. She wrote stanzas that were suitable in form, but eccentric and unrealistic in content. It seems that Tomoko tried to fabricate her own fantasy throughout the first renku only with her own stanzas. 3-5.
Case 2
3-6.
Tomoko is a 52-year-old unmarried female with chronic schizophrenia, paranoid type. She was born into a wealthy family. Her mother died of tuberculosis when she was seven. She was brought up by her stepmother, and they did not get along well. Her onset was at the age of 22 when she was a university student. Since then, she had been institutionalized on and off. When she was 25, she was introduced to the composition of haiku in a group therapy at the mental hospital where she was admitted. After being discharged, she voluntarily joined a small society of tanka (a Japanese traditional form of poetry with 5-7-5 and 7-7 syllables) for several years. Her selfhealing activity worked. However, her acute psychotic recurrence interrupted her writing. One and a half years after her tenth admission, I was in charge of her treatment. Her principle clinical feature was vivid auditory hallucinations and delusions of persecution that intruded on her everyday life. She often blubbered and tried to get away from her voices. Two months later, Tomoko showed the author her tanka in a little magazine published about 10 years ago. Many of her tanka, notably the second part (fourth and fifth lines) of them, seemed to be bizarre. So, I asked her to write haiku with three lines.
3-7.
hydrangeas in deep blue. . . the death of a patient
1-1.
1-2. 1-3.
“Skylark”: excerpt from 4th renku the old house being rebuilt with reminiscences the author 4-10. splashed out on a bottle of vintage wine Tomoko 4-9.
One year later, her stanzas showed changes: her stanzas became increasingly based on real experiences; her stanzas became well linked to the author’s, as seen above. Meanwhile, she began to develop double orientation that enabled her clear separation of actual life and delusions.
Tomoko
“Lily of the Valley”: excerpt from 1st renku sweet memories of lily of the valley a little girl set off Tomoko a few swallows flying across the rail the author a snail,
“First Snow”: excerpt from 3rd renku such a brief moment a boy on a swing swinging rain Tomoko his pride, a canister full of iron tops the author early childhood in front of the death-mask spinning spring Tomoko
Nine months later, Tomoko was still involved with her hallucinations that disturbed her routines. A part of her delusion occasionally appeared in her stanza that was still eccentric. The “death-mask” may be a symbol of her death. Her stanza (3-7) is connected by the word “spinning” associated with “iron tops” in the preceding stanza, but the imagery linking between the stanzas is unclear.
6-3.
This is one of Tomoko’s earliest haiku. It is obvious that her delusion is expressed in it. She believed that she would be caught by the police and would be given a death sentence.
Tomoko
6-4. 6-5.
“Christmas”: excerpt from 6th renku the eyes of my mum gone to heaven. . . the winter stars Tomoko her pride Xmas pudding smells sweet the author naughty boys on their best behavior. . . new year’s photo Tomoko
Sixteen months later, her hallucinations and delusions decreased significantly, and she ceased being involved with them. She became better able to express and understand humor in her stanzas as well as in daily conversation.
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“Cicada”: excerpt from 9th renku 9-15. always a five-pound rice pack that the widower buys on his way home the author 9-16. shall I be his second spouse bearing a gift of dried squid Tomoko Two years later, Tomoko mentioned that her delusions and hallucinations almost disappeared. Her verse (9-16) is finely linked to the therapist’s with an acceptable fantasy with humor.
Prototypical therapeutic processes and results Prototypical therapeutic processes and results are based on 30 patients including 2 presented above satisfying DSM-IV criteria for schizophrenia (10 males and 20 females; mean age, 38.3 years; mean duration of observation, 16.8 months) who had been treated using renku therapy by the author at Tokyo Women’s Medical University Hospital, the Tokyo Koˆ sei-nenkin Hospital (general hospital), and the Nakayama Hospital (mental hospital). A patient writes a stanza At the beginning of renku therapy, the therapist asks the patient to write an opening stanza with 7-5-7 syllables (three lines in English) that is the same in form as haiku. Initial responses to renku therapy are varied: some schizophrenics are willing to write a stanza, some are reluctant to do so mainly because they find it difficult, some express no interest, and a few refuse. However, many patients with chronic schizophrenia will be able to join renku therapy if given suitable warm-ups. For instance, when it is spring, the therapist encourages the patient to observe plants and such as plums and cherry blossoms, fresh, new grass, wild flowers and weeds sprouting up, and the events of spring, and the climate such as long day, warm and bright, and whatever our imaginings may come up. After sharing the images to be written, the therapist sometimes helps to write a stanza by putting patient’s utterances into the format (Asano, 1983). Even patients with delusions and hallucinations do not often include them directly in their stanzas. The brief format (Iimori, 1984, 1997) and dialogue form (Tamura & Asano, 1997) in renku may work to exclude pathological thought such as delusions and irrelevant associations from surface language. During the first stage of renku therapy, schizophrenics may practice word-to-object matching with reality. In addition, with the comfortable rhythmical syllable pattern, the patients often enjoy reading their own stanzas and begin to feel something new. In other words,
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stanzas again draw their attention to the words, the images and back to reality. The therapist shares and responds to the patient’s stanza In the next step, the therapist shares a stanza written by the patient. As stanzas composed by schizophrenics are usually not so bizarre as their prose and utterances, the therapist is likely to respond in a natural manner. Therefore, the patient will regain one of the paths to appropriate communication through renku. Whatever the patient’s state is, with or without delusions and hallucinations, the therapist will be able to share in a stanza, in a sound context within a therapeutic context. Even if the therapist finds aspects of delusions in a stanza, it also contains images without pathology. In other words, the therapist is expected to pick up sound images out of the patient’s stanza and develop them while composing the following stanza. The significance of renku is “a sense of balance between link and shift” (Kondo & Higginson, 1994, p. 125) that are relevant to context. In renku, a stanza should be linked to adjacent stanzas and should not be linked to others. A renku does not have a plot as a whole so that one can “shift” a context in the light of an interpretation of the preceding stanza and one’s own experiences and imaginations. In practice, the therapist’s stanza should not be written beyond patient’s understanding. Therefore, the therapist will not write a stanza with highly metaphorical expressions, but write with simple word associations at the early stages of renku therapy sessions. In addition, it might be better for the therapist to avoid writing a stanza with therapeutic suggestions and implications that may harm the communication through poetry. The patient shares a therapist’s stanza The main contextual markers for a patient, at this stage, may be words that have arisen out of simple word associations. The patient comes to express even happy emotions in short utterances or comments when reading the therapist’s stanza, because the patient feels that his/her own stanzas are interpreted appropriately. The patient will also practice extending and relating the semantic field of each word. The patient and the therapist create meanings and reality that are jointly constructed out of words and phrases in two stanzas in succession. After such a rewarding experience with poetry the patient feels connected and in a common world with the therapist. In the course of renku therapy, patients come to understand metaphors in the therapist’s stanzas.
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Table 1 Evolution of linking and treated linguistic components Linking manners of patients
Treated linguistic components
Simple composition (barely linked) Linking with simple word association Linked with contextual development Well-linked with metaphor
Meaning/concept of a word Association Context Metaphor
The patient links a stanza A patient’s stanzas can be categorized according to ways of linking. Evolution of linking manner seems to correspond to the treated linguistic components shown in Table 1. These components are complementary rather than sequential, but distorted meaning/concept of a word and associations are likely to be treated earlier than disordered context and metaphor. To write and link the following stanza responding to the therapist’s is not easy for the patient. There might be a missing link in barely linked stanzas that are hardly noticeable by the therapist in surface language. Some attempt to imitate the preceding therapist’s stanza by putting it into a given format. Then the patients come to write stanzas with close and comprehensible word associations. As renku therapy proceeds, the manner of the patient’s linking is likely to change from simple word associations to contextual developments and to metaphorical extensions. These changes often are related to the process of clinical improvement (Tamura & Asano, 1997).
Discussion Language and reality Language is a device of cognition as well as communication. “Every language articulates reality in its own way, thereby creating its own particular view of reality and establishing its own unique concepts” (Trier, 1934 as cited in Lyons, 1977, p. 259 – 60). The meaning of a word is not precisely the same to any two people, so that people recognize reality in different ways represented through language. We must know that our reality of the world will change when our concept of a word has changed. Neither in concepts, nor in language itself, does anything exist in isolation. But concepts actually acquire associations only if the mind acts in inner
unity, if full subjectivity is directed upon a complete objectivity [his italic] (von Humboldt, 1988, p. 156 – 7).
Semantic linking between words seems to be categorized in two: one is coordinates and collocational links that may be particularly strong, and another is hyponyms and their superordinates, where connections may be weaker (Aitchison, 1994). That is, there are common word associations based on common mental lexicon that are reality-oriented and socially conditioned. Surface language plays an important role in giving context and meaning to each word. Context is also given by situational, cultural, and temporal parameters that are based on common background knowledge of the community. Linguistic metaphor is a fundamental mental capacity that reflects a constrained set of conceptual mappings that structures our thinking, reasoning, and understanding (Gibbs, 1994). Metaphor is also widely accepted as a proper cognitive device of language (Mac Cormac, 1985). The basic power of poetry lies in metaphor and simile that serve to activate archetypal images deeply buried within the psyche (Lerner, 1981). In short, meaning/concept of a word, association, context and metaphor are essential linguistic components by which human beings recognize the reality of their world. Schizophrenics seem to fail to do this because of impairments in these components. Language impairments in schizophrenia Bleuler noted that schizophrenia is a disorder of associations. The association disturbances were conceived of as the primary event from which the majority of secondary symptoms can be derived (Bleuler, 1950). Associationism assumed that language and thought were so closely associated that disturbances of the one necessarily showed up in the other (Berrios, 1995). On associative response tests, compared to normal controls, schizophrenics give fewer responses than are ordinarily given (fewer primary responses, less response commonality), they give unusual responses (larger associative-response domain, more clang responses and more “distant” responses), which are less stable on retest (Cramer, 1968 as cited in Spitzer, 1992). Chapin et al. (1989) suggest that schizophrenics do not lose the continuity of their associations at the initial sensory or perceptual processing stages of information processing and that the process becomes impaired at the level of the controlled attention process. McKenna, Mortimer, and Hodges (1994) demon-
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strate that the chronic, severe schizophrenics performed significantly worse than the normal people in the subsets dependent on semantic memory such as category fluency, naming, sorting, and definitions, but not in word-to-picture matching. Chen et al. (1995) suggest that semantic categories are intact internally, but the category boundaries are expanded in schizophrenia. McKay et al. (1996) show that semantic memory is impaired in schizophrenia. Semantic memory refers to stored information that is impersonal, and includes knowledge of words and their meanings, knowledge about objects and their interrelationships, and also general information about the world. At the level of pragmatics, various forms of thinking disturbance in schizophrenia, including delusions and formal thought disorder, constitute a disorder of “deficient real world knowledge” (Cutting & Murphy, 1988, p. 310). An heuristic model of language impairments in chronic schizophrenia The language system is a cosmos. There are no isolated words in the system. The system is well ordered and highly adaptable. In everyday life, we assume that there will be sufficient overlap between the meaning of words in the minds of different speakers for us to communicate (Aitchison, 1994). According to de Saussure (1983), language is the form of relation between a signal and a concept whose link is arbitrary. Lieberman (1984) says, “The ambiguity and uncertainty of the linguistic system probably matches the richness of our inner, psychological conceptual framework” (p. 82). This lack of precision may, on the other hand, be reflected in the language impairments of schizophrenics. Diachronic linguistics suggests that the acquisition of a new meaning by one word will affect others in the same semantic field, and also the word(s) that previously carried that meaning (McMahon, 1994). These semantic changes seem to occur in schizophrenia in a pathological and drastic way. Distorted semantic structure of words may set off a chain reaction of linguistic dysfunction in terms of association, contextualization, and metaphorical recognition. Wro´ bel (1990) showed a distorted concept of a word among schizophrenics, in which the central meanings of the word were replaced by personal or marginal meanings. Semantic changes in schizophrenic language manifest the dissociation of concept and reality from a sign. Misunderstandings arise not from objective incoherencies and semantic errors but from the existence of a separate, schizophrenic semantic system (Wro´ bel, 1990). Thus, schizophrenics conceive distorted reality by referring to their pathological systems of signs that may fit to understand
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Fig. 1. A vicious cycle of schizophrenic thought.
their unique, psychotic world. Neologisms are seen in extreme cases, but schizophrenics usually use everyday vocabulary with uncommon meanings. Language impairments may lead schizophrenics to misjudge their experience and embrace a distorted world view. Consequently, schizophrenic language impairments constitute a vicious cycle (Fig. 1). Such false beliefs are firmly maintained despite contradiction by social reality, invalidation, or psychotherapy. A linguistic psychotherapeutic model of renku therapy I propose a linguistic psychotherapy model of chronic schizophrenia under the premise that: impaired semantic systems cause disorders of cognition, thought, and communication among chronic schizophrenics, and that a psychotherapy which addresses such language impairments may break the vicious cycle of schizophrenic thought. The linguistic psychotherapy model makes it possible to understand the schizophrenic mind and how schizophrenics are treated with renku therapy. Some basic therapeutic qualities of renku include that it is: (1) reality oriented, (2) uses less conventional syntax, (3) is short, (4) is based on the principle of dialogue, (5) employs ambiguity, (6) depends on association of words and images, (7) requires interpretation and development of context, and (8) carries multiple meanings through metaphor (Tamura, 1998). Nijoˆ Yoshimoto (translated by Ueda, M., as cited in Higginson, 1996, p. 41) says, “The essence of linked verse lies in making everyday things look fresh.” The main topics addressed in renku are nature and everyday life. Season words and everyday vocabulary in poetic use act as suitable stimuli that evoke reality oriented memories and imagination.
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Poetic language thus put into practice treats distorted concepts of a word in schizophrenics by making the connection between a sign, its concept, and its reality tight with well-organized meanings. The poetic devices, such as less conventional syntax, shortness and dialogue in form, and ambiguity, work to draw considerable attention to each word and activate a train of association. In poetry, word order tends to be less conventional than that in common discourse, so that a patient with thought disorders or even with incoherence can write a stanza or quasipoetic lines by putting words into the format. The shortness and form may also be a useful therapeutic framework that prevents a stanza from being contaminated with their pathological thought in surface language. Common meanings for each word will develop common associations. Collins and Loftus (1975) have proposed a network theory model of spreading activation to explain the search for semantic memory. For them, a concept is represented as a node in a network, with properties of the concept interconnected through links with related concept nodes. When a word of a category is activated, activation will spread to other items of the same category, attributes of the exemplar, and the superordinate and subordinate (as cited in Shallice, 1988). Both to write a stanza and to develop “linking” in renku is thus to activate normal semantic memory and association. “Text and context are complementary: each presupposes the other” (Lyons, 1995, p. 258). A specific meaning of a word in a stanza can be defined by a context, which includes situation, time, and culture, among other contextual parameters. The renku process begins with simple associational links, then gradually leads the participant to make more complex constructions in successfully relating the newly created stanza to its predecessor. In the course of renku therapy, schizophrenics learn common meanings and concepts of words, common associations, and common knowledge of the world, so that they come to regain the ability of contextual recognition. Metaphor is accepted as a powerful cognitive device that often suggests new ways of perceiving and conceiving of the world (Mac Cormac, 1985). In a therapeutic setting, metaphor is regarded as a device of communication that leads to the development of rapport and mutual understanding between participants (Ferrara, 1994). Through the use of metaphors, connections between internal and external reality can be facilitated (Mazza, 1999). Metaphor appearing in a patient’s stanza might be a displaced interpretation of less acceptable thoughts. However, the therapist need not make such interpretation. Metaphors may be effective just because their meanings lie beneath the surface and below the defenses (Novalis, Rojcewicz
& Peele, 1993). Successful exchange of metaphor makes schizophrenics communicate at a deeper level with great satisfaction, and empathy with others will also be improved. In renku therapy, schizophrenics practice understanding and using metaphor and learn a common world view, which may be new to them. Pathology at the levels of semantics, cognition, and pragmatics may be the basis of schizophrenic thought and communication disorders. The acquisition of an uncommon meaning by one word will affect others and will change judgment of experience and world view. On the other hand, as Carl Jung (1979) notes, there exist innumerable normal associations in schizophrenics (as cited in Spitzer, 1992). Human mental lexicon contains equipment that enables us to continually extend existing words and coin new ones (Aitchison, 1994). Chronic schizophrenics may still have the equipment by which impaired semantic systems can be reformed. Indeed, renku is a sophisticated therapeutic tool through which schizophrenics may be treated within the domain of language impairment. The improvement in linguistic functioning in schizophrenic patients enables them to have a more appropriate judgment of experience, to recognize a shared world view, and to communicate with others through a common language.
Conclusion Humans employ the poetic dimensions of language in every aspect of life. Discourse is therapeutic when it is jointly constructed; creating a dynamic and vibrant reality through words (Ferrara, 1994). Renku is a poetic form of dialogue in which reality is collaboratively constructed and shared by therapist and patient. Asano (1986) notes that the essence of renku therapy, as well as renku itself, lies in fostering “linkand-share-with of the mind and heart” (p. 45). Thus the structure of renku is inherently suitable for psychotherapy. I have shown that renku therapy works as a way of treating the language impairments of chronic schizophrenia. Through renku therapy, a patient comes to understand or even to express humor, because to understand humor is to recognize meaning, context, and metaphor in utterances and writings (Tamura, 1998). Renku therapy may also work for the rehabilitation of emotional and empathetic functioning among schizophrenics. Ralph Waldo Emerson (1844), an American poet and philosopher, stated that “Language is fossil poetry” (p. 13). The language of chronic schizophrenics seems to be distorted and fossilized. The poetic use of language may activate or resurrect their language so
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that it may be possible for them to reform their impaired semantic systems.
Acknowledgments The author wishes to acknowledge the help and support of Kris Kondo, Dr. Kenneth Gorelick, Professor Tadashi Kondo, Dr. Kathleen Decker, and Dr. German E. Berrios in the writing of this paper.
References Aitchison, J. (1994). Words in the mind: an introduction to the mental lexicon (2nd ed.). Oxford: Blackwell. Asano, K. (1983). A therapy attempt with “Ren-ku”: an experiment concerning the therapeutic value of “Renku.” Japanese Bulletin of Arts Therapy, 14, 7–14. Asano, K. (1986). Psychotherapeutic significance inherent in structure of Renku-poı¨esis. Japanese Bulletin of Arts Therapy, 17, 45–52. Berrios, G. E. (1995). Disorders of thought and language in psychiatry: a conceptual history. In: A. Sims, Speech and language disorders in psychiatry (pp. 15–30). London: Gaskell. Bleuler, E. (1950). Dementia praecox or the group of schizophrenias (J. Zinkin, Trans.). New York: International Universities Press. (Original work published 1911) Chapin, K., Vann, L. E., Lycaki, H., Josef, N., & Meyendorff, E. (1989). Investigation of the associative network in schizophrenia using the semantic priming paradigm. Schizophrenia Research, 2, 355–360. Chen, E., McKenna, P., & Wilkins, A. (1995). Semantic processing and categorisation in schizophrenia. In: A. Sims, Speech and language disorders in psychiatry (pp. 126 –137). London: Gaskell. Collins, A. M., & Loftus, E. F. (1975). A spreading-activation theory of semantic processing. Psychological Review, 82, 407– 428. Cutting, J. (1985). The psychology of schizophrenia. Edinburgh: Churchill Livingstone. Cutting, J., & Murphy, D. (1988). Schizophrenic thought disorder: a psychological and organic interpretation. British Journal of Psychiatry, 152, 310 –319. de Saussure, F. (1983). Course in general linguistics (R. Harris, Trans., C. Bally & A. Sechehaye, Eds., with A. Riedlinger). London: Duckworth. (Original work published 1972) Emerson, R. W. (1983). The Poet. In: J. Slater, A. R. Ferguson & J. F. Carr, The collected works of Ralph Waldo Emerson, essays: second series (pp. 1–24). Cambridge, MA: The Belknap Press of Harvard University Press. (Original work published 1844) Ferrara, K. W. (1994). Therapeutic ways with words. New York: Oxford University Press. Gibbs, R. W., Jr. (1994). The poetics of mind: figurative thought, language, and understanding. Cambridge: Cambridge University Press.
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Gorelick, K. (1987). Greek tragedy and ancient healing: poems as theater and Asclepian temple in miniature. Journal of Poetry Therapy, 1, 38 – 43. Higginson, W. J. (with Harter, P.) (1985). The haiku handbook: how to write, share, and teach haiku. Tokyo: Kodansha International. Higginson, W. J. (1996). The haiku seasons: poetry of the natural world. Tokyo: Kodansha International. Iimori, M. (1984). Poetry therapy as psychotherapy: on its therapeutic mechanism, theory, technique, and application. Journal of Tokyo Medical College, 42(2), 221–237. Iimori, M. (1997). Poetry therapy in Japan: haiku therapy for schizophrenics. In: R. R. Pratt & Y. Tokuda, Arts Medicine (pp. 124 –131). Saint Louis, MO: MMB Music. Imoto, N., & Imaizumi, J. (1982). Renku-tokuhon [Renku readings]. Tokyo: Taishuˆ kan Shoten. ¨ ber die Psychologie der Dermentia Jung, C. G. (1979) U Praecox [The psychology of dementia praecox]. Gesammelte Werke 3, Psychogenese der Geisteskrankheiten (2nd ed.) (pp. 3–170), Olten: Walter. (Original work published 1906). Kindaichi, H. (1978). The Japanese language (U. Hirano, Trans.). Rutland, VT: Charles E. Tuttle. (Original work published 1957) Kondo, T., & Higginson, W. J. (1994). Link and shift: a practical guide to renku composition. Journal of the Faculty of Economics, Seikei University, 24 (2), 116 – 125. Lerner, A. (1981). Poetry therapy. In: R. J. Corsini, Handbook of innovative psychotherapies (pp. 640 – 649). New York: Wiley–Interscience. Lieberman, P. (1984). The biology and evolution of language. Cambridge, MA: Harvard University Press. Lyons, J. (1977). Semantics: vol. 1. Cambridge: Cambridge University Press. Lyons, J. (1995). Linguistic semantics: an introduction. Cambridge: Cambridge University Press. Mac Cormac, E. R. (1985). A cognitive theory of metaphor. Cambridge, MA: MIT Press. Mazza, N. (1999). Poetry therapy: interface of the arts and psychology. Boca Raton, FL: CRC Press. McKay, A. P., McKenna, P. J., Bentham, P., Mortimer, A. M., Holbery, A., & Hodges, J. R. (1996). Semantic memory is impaired in schizophrenia. Biological Psychiatry, 39, 929 –937. McKenna, P. J., Mortimer, A. M., & Hodges, J. R. (1994). Semantic memory and schizophrenia. In: A. S. David & J. C. Cutting, The neuropsychology of schizophrenia (pp. 163–178). Hove, UK: Lawrence Erlbaum Associates. McMahon, A. M. S. (1994). Understanding language change. Cambridge: Cambridge University Press. Novalis, P. N., Rojcewicz, S. J., Jr., & Peele, R. (1993). Clinical manual of supportive psychotherapy. Washington, DC: American Psychiatric Press. Shallice, T. (1988). From neuropsychology to mental structure. Cambridge: Cambridge University Press. Spitzer, M. (1992). Word-associations in experimental psychiatry: a historical perspective. In: M. Spitzer, F. Uehlein, M. A. Schwartz & C. Mundt, Phenomenology,
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language & schizophrenia (pp. 160 –196). New York: Springer–Verlag. Tamura, H. (1998). Therapeutic functions of poetic language in schizophrenia. In: G. Roux & M. Laharie, L’Humour: histoire, culture et psychologie (pp. 386 – 390). Biarritz, France: La Socie´ te´ Internationale de Psychopathologie de l’Expression et d’Art-The´ rapie. Tamura, H., & Asano, K. (1997). Renku as psychotherapy: Japanese traditional poetic forms adapted to poetry ther-
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Poetry therapy for schizophrenia: a linguistic psychotherapeutic model of renku (linked poetry) Hiroshi Tamura, M.D.* Nakayama Hospital and Tokyo Women’s Medical University, 54-23, Wakamiya 2 chome, Nakano-ku, Tokyo, 165-0033, Japan
cussed and a linguistic psychotherapeutic model will be proposed.
Introduction Disturbances of association are suggested to be fundamental characteristics in schizophrenia (Bleuler, 1950). Schizophrenics may have pathological semantic systems that are less socially conditioned. In fact, schizophrenics often fail to understand the meaning of words in context and cannot communicate their intended meaning to others (Cutting, 1985). Language impairments may also precipitate thought disorders, including misjudgment of experience, delusions, and a distorted worldview, because human cognitive ability is enhanced by the linguistic aspects of thought (Lieberman, 1984). The current psycholinguistic approach suggests that chronic schizophrenics have language impairments at the levels of semantics, cognition, and pragmatics. The semantic and cognitive levels can be regarded as deeper structures that operate association and thought, while the pragmatic level is viewed as the study of meaning in context pertinent to communication and the relations between signs and their users. I will present two cases of chronic schizophrenia significantly improved after participating in renku, a Japanese traditional poetic form, used in one-to-one therapeutic sessions. The unique character of renku is its dialogue in form. A series of exchanges of stanzas seem to treat schizophrenic language impairments as well as disordered reality testing. The therapeutic functions of poetic language in renku will be dis-
* E-mail Tamura).
address:
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(H.
Renku, a Japanese traditional poetic form The origins of renku called renga dates back to the 12th century in Japan. The oldest formal linkingrules we have were defined by Nijoˆ Yoshimoto in 1372. Modern renku was founded by Matsuo Bashoˆ in the late 17th century, who also founded haiku (hokku), which was the opening stanza of renku. Renku is written by more than two people as follows: the first person composes an opening stanza, a three-line stanza with onji or Japanese syllables arranged in the pattern 5-7-5. The second person replies with a two-line stanza arranged in 7-7. Then the next responds to the 7-7 with another 5-7-5. This pattern, 5-7-5/7-7/5-7-5/7-7/. . . is repeated until some fixed number will be completed. A kasen form with thirty-six stanzas and a half-kasen containing eighteen stanzas, are the common forms of modern renku. Techniques for linking (tsukeai) changed from era to era. In the Teimon School organized by Matsunaga Teitoku circa 1625, the main idea of linking is word association. The Danrin School led by Nishiyama Soˆin circa 1673 claims that the linking is based on the whole meaning of the previous stanza. The Bashoˆ School developed the linking into subtle and various manners that depended mainly on the images of the immediate stanza, and “on the psychic archetypes and actual situations from life which the images represent” (Higginson, 1985, p. 195). Mukai Kyorai, one of Bashoˆ’s disciples, states in his book Kyoraishoˆ
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(1702–1704) that Bashoˆ exemplified four linking manners: “reflection” (utsuri), “echo” (hibiki), “scent” (nioi), and “rank” (kurai). Bashoˆ also regarded wit and humor as an essential factor in linking (Imoto & Imaizumi, 1982). It is of utmost importance that each stanza be linked in imagery to the one just preceding. There are rather complicated linking guidelines that define things so as to avoid repeating similar topics. For example, there are rules that limit the number of stanzas referring to the same seasons in succession. There are also rules for the positions of the moon and blossom within the whole renku. Nature and seasons are the central framework in renku, as are other topics, such as love, nostalgia, religion, illness, life and death, travel, history, and other human affairs. Such linking guidelines are not meant to obstruct creativity, but to give participants a suitable framework of images and to facilitate the composition of a following stanza. The role of the renku leader (sabaki) is the key to the participants’ peace of mind and willingness to participate. The sabaki takes all responsibility for gently leading and imparting the guidelines. The therapist of course has this role in renku therapy. Prosody, which is the matter of suprasegmental phonological features of language (e.g., rhythm, pause, tempo, stress, and pitch), is also an indispensable element in poetry. Since there is pitch accent but not stress accent in Japanese language, the sound of each syllable or onji is the same in length. Japanese syllables are very short, and there is a tendency for two syllables to form a minimal meaning unit (Kindaichi, 1978). Lines arranged in odd syllables, five or seven, are common in Japanese poetry. Sounds are perceived with rhythmical breaks and silence, producing poetic effects, which may be as familiar and comforting as nursery rhymes in the Western world. Thus, Japanese words arranged in these syllable patterns sound poetic. In addition, there are no rules governing rhyme in renku. As the sound system between Japanese and English is quite different, it is difficult to keep the syllable pattern in an English translation. Renku has been attempted in English, and the long stanza in renku is commonly written in three lines while the short stanza is written in two lines.
Renku as psychotherapy I usually use an 18-stanza format originating from half-kasen for renku therapy because of its suitable length in various clinical settings. Linking rules are simplified to suit each patient. Nature and events relevant to the present season and patients’ everyday life are the main content topics of stanzas, which
serve to promote reality-oriented thinking. Despite linking guidelines mentioned above, I will rarely ask patients to write something about seasons they are not in, because it might be difficult and less therapeutic for them to do so. As sessions proceed, patients will experience the actual change of seasons and they will express seasonal feelings naturally in their stanzas. Patients will be given enough time, normally a few days for in-patients and two weeks for out-patients, to write a stanza, while the therapist writes the stanza during the session. Rules governing season changes can also be used as a collaborative and therapeutic task in a group setting. Gorelick (1987) regards the group poetry therapy as a miniature theater-in-the-round in which the participants take dual roles of protagonist and audience as they reflect and create a here-and-now reality for one another.
Case study Case 1 Yukiko is a 20-year-old single female with chronic schizophrenia. She lives with her mother and younger sister, and her father, who because of his work, is home only at weekends. Her mother has a sixteen-year history of affective disorders and had been hospitalized with psychotic symptoms in her manic episode and participated in group renku therapy organized by the author. She was diagnosed as schizophrenia at the age of 14. She showed an insidious onset and developed symptoms such as social withdrawal, lack of conversation, confusion, underactivity, auditory hallucinations, and delusions of reference. Antipsychotic medication was effective in relieving her hallucinations and delusions. However, negative symptoms did not improve. She had difficulties in getting along with her classmates, and since leaving high school, she became more isolated. It was her routine to watch videos (e.g., animated comics with a teenage heroine), to listen to popular music late at night, and to get up in the afternoon. She also liked to spend time at home by herself without doing anything. Psychotherapeutic treatment by a previous psychiatrist ended without effective contact being achieved. Yukiko was referred to the author when she was 18. During first examination, her mental state was characterized as blunted affect, no eye contact, disturbances of association, and a tendency to prefer fantasy to reality. She looked much younger than she was. She was seen biweekly and her medication, haloperidol, was replaced with mosapramine hydro-
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chloride, which improved her blunted affect somewhat. Three months later, she was asked to write haiku as homework. The instruction went as follows: “Can you write haiku describing your current life and seasonal feeling?” pushing my way through New year’s visit to the shrine my wishes . . .
She tried to describe her New Year with encouragement and assistance from her mother. It was not an easy task for her to write haiku, but she came to recognize seasonal feelings and topics in her everyday life that worked to extend her interests to the real world. However, she often seemed to live in her fantasy world. Setsubun day I couldn’t perform bean-scattering so, scolded my mother
Yukiko
This is her first haiku written by herself. She looked forward to performing Setsubun, one of the Japanese annual events, which involves praying for good health and fortune for the year, but her mother forgot to buy soybeans for the performance. So, she scolded her mother for that. Though a little later, she was able to laugh it away with the above haiku. This event got her more interested in writing haiku. even mustard flowers my mother cooks for dinner
1-2. 1-3.
1-4.
1-11.
1-12. 1-13.
Yukiko
“New Sandals”: excerpt from 1st renku these new sandals I bought make me feel it’s summer now Yukiko looking at the bubbles in an ice-cream soda the author when shopping tires me what makes me better is ice-cream soda Yukiko feeling secure today with my umbrella the author
The form is half-kasen with eighteen stanzas. Her stanzas were not difficult to interpret in general. The second stanza showed how to link stanzas with a simple word association between “summer” and an
a cool sea breeze in the evening the blue sea I wanna swim on Joˆ do-ga-hama beach footprints in the sand soon wiped off pampas grass looks great with full moon
the author
Yukiko the author
Yukiko
She created her images of the “sea”(1-11) from the author’s stanza (1-10) plus her memories of the beach lately visited. “Moon (autumn)” as a given topic and “pampas grass” is collocations (1-13). When she understood the linking between her stanza and the author’s well, she expressed happy feelings. Five months after beginning renku, her paucity of speech began to improve so that she felt like talking to the author about her interests. It became her routine to help her mother in housekeeping.
2-1.
Through 10 sessions of haiku therapy, her emotional responses began to improve. She started to play a small part in kitchen work, and she often wrote haiku about this. Accordingly, I suggested that she started renku. I introduced it as a poetic association game. 1-1
“ice-cream soda” (1-2). She expressed the slightest response to the author’s stanza, however, she tried to describe her images by employing the “ice-cream soda” in the preceding stanza (1-3). This closeness in association is often seen at the early stage as a positive response to renku therapy. 1-10.
Yukiko
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2-2. 2-3.
“New Millennium’s Day”: excerpt from 2nd renku New Millennium’s Day my father has gone too soon to the office Yukiko quietly, peacefully it gets dark the author photo of me in a kimono at the Coming-of-Age Day celebration looks cool and mature Yukiko
In the second renku, her stanzas tend to be better linked to the author’s. With her stanza (2-3), she showed the photo to let the author realize what she was like. 2-9.
at my sister’s age! her birthday present is a PlayStation 2 2-10. Ah! nails beautifully manicured 2-11. the last song. . . Speed brought me a lump in my throat
Yukiko the author
Yukiko
She also expressed her honest opinion and emotions in her stanza (2-9). I responded with the stanza (2-10) with two contexts, a literal one relevant to “age” and a situational one, a reference to her pearly
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pink manicured nails that seemed to be a manifestation of her self-awareness. ‘Speed’ is her favorite group of teenage singers. She felt sad about their last concert and wrote her stanza (2-11). In the course of 13-month renku therapy Yukiko improved significantly in social functioning and decreased negative symptoms. When her mother had a recurrence of a manic disorder with psychotic symptoms under the stress of moving from her house, she helped her mother and showed that her own improvement did not leave her vulnerable.
wants to move with no money
I wrote the second stanza following her haiku, and renku began. She wrote stanzas that were suitable in form, but eccentric and unrealistic in content. It seems that Tomoko tried to fabricate her own fantasy throughout the first renku only with her own stanzas. 3-5.
Case 2
3-6.
Tomoko is a 52-year-old unmarried female with chronic schizophrenia, paranoid type. She was born into a wealthy family. Her mother died of tuberculosis when she was seven. She was brought up by her stepmother, and they did not get along well. Her onset was at the age of 22 when she was a university student. Since then, she had been institutionalized on and off. When she was 25, she was introduced to the composition of haiku in a group therapy at the mental hospital where she was admitted. After being discharged, she voluntarily joined a small society of tanka (a Japanese traditional form of poetry with 5-7-5 and 7-7 syllables) for several years. Her selfhealing activity worked. However, her acute psychotic recurrence interrupted her writing. One and a half years after her tenth admission, I was in charge of her treatment. Her principle clinical feature was vivid auditory hallucinations and delusions of persecution that intruded on her everyday life. She often blubbered and tried to get away from her voices. Two months later, Tomoko showed the author her tanka in a little magazine published about 10 years ago. Many of her tanka, notably the second part (fourth and fifth lines) of them, seemed to be bizarre. So, I asked her to write haiku with three lines.
3-7.
hydrangeas in deep blue. . . the death of a patient
1-1.
1-2. 1-3.
“Skylark”: excerpt from 4th renku the old house being rebuilt with reminiscences the author 4-10. splashed out on a bottle of vintage wine Tomoko 4-9.
One year later, her stanzas showed changes: her stanzas became increasingly based on real experiences; her stanzas became well linked to the author’s, as seen above. Meanwhile, she began to develop double orientation that enabled her clear separation of actual life and delusions.
Tomoko
“Lily of the Valley”: excerpt from 1st renku sweet memories of lily of the valley a little girl set off Tomoko a few swallows flying across the rail the author a snail,
“First Snow”: excerpt from 3rd renku such a brief moment a boy on a swing swinging rain Tomoko his pride, a canister full of iron tops the author early childhood in front of the death-mask spinning spring Tomoko
Nine months later, Tomoko was still involved with her hallucinations that disturbed her routines. A part of her delusion occasionally appeared in her stanza that was still eccentric. The “death-mask” may be a symbol of her death. Her stanza (3-7) is connected by the word “spinning” associated with “iron tops” in the preceding stanza, but the imagery linking between the stanzas is unclear.
6-3.
This is one of Tomoko’s earliest haiku. It is obvious that her delusion is expressed in it. She believed that she would be caught by the police and would be given a death sentence.
Tomoko
6-4. 6-5.
“Christmas”: excerpt from 6th renku the eyes of my mum gone to heaven. . . the winter stars Tomoko her pride Xmas pudding smells sweet the author naughty boys on their best behavior. . . new year’s photo Tomoko
Sixteen months later, her hallucinations and delusions decreased significantly, and she ceased being involved with them. She became better able to express and understand humor in her stanzas as well as in daily conversation.
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“Cicada”: excerpt from 9th renku 9-15. always a five-pound rice pack that the widower buys on his way home the author 9-16. shall I be his second spouse bearing a gift of dried squid Tomoko Two years later, Tomoko mentioned that her delusions and hallucinations almost disappeared. Her verse (9-16) is finely linked to the therapist’s with an acceptable fantasy with humor.
Prototypical therapeutic processes and results Prototypical therapeutic processes and results are based on 30 patients including 2 presented above satisfying DSM-IV criteria for schizophrenia (10 males and 20 females; mean age, 38.3 years; mean duration of observation, 16.8 months) who had been treated using renku therapy by the author at Tokyo Women’s Medical University Hospital, the Tokyo Koˆ sei-nenkin Hospital (general hospital), and the Nakayama Hospital (mental hospital). A patient writes a stanza At the beginning of renku therapy, the therapist asks the patient to write an opening stanza with 7-5-7 syllables (three lines in English) that is the same in form as haiku. Initial responses to renku therapy are varied: some schizophrenics are willing to write a stanza, some are reluctant to do so mainly because they find it difficult, some express no interest, and a few refuse. However, many patients with chronic schizophrenia will be able to join renku therapy if given suitable warm-ups. For instance, when it is spring, the therapist encourages the patient to observe plants and such as plums and cherry blossoms, fresh, new grass, wild flowers and weeds sprouting up, and the events of spring, and the climate such as long day, warm and bright, and whatever our imaginings may come up. After sharing the images to be written, the therapist sometimes helps to write a stanza by putting patient’s utterances into the format (Asano, 1983). Even patients with delusions and hallucinations do not often include them directly in their stanzas. The brief format (Iimori, 1984, 1997) and dialogue form (Tamura & Asano, 1997) in renku may work to exclude pathological thought such as delusions and irrelevant associations from surface language. During the first stage of renku therapy, schizophrenics may practice word-to-object matching with reality. In addition, with the comfortable rhythmical syllable pattern, the patients often enjoy reading their own stanzas and begin to feel something new. In other words,
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stanzas again draw their attention to the words, the images and back to reality. The therapist shares and responds to the patient’s stanza In the next step, the therapist shares a stanza written by the patient. As stanzas composed by schizophrenics are usually not so bizarre as their prose and utterances, the therapist is likely to respond in a natural manner. Therefore, the patient will regain one of the paths to appropriate communication through renku. Whatever the patient’s state is, with or without delusions and hallucinations, the therapist will be able to share in a stanza, in a sound context within a therapeutic context. Even if the therapist finds aspects of delusions in a stanza, it also contains images without pathology. In other words, the therapist is expected to pick up sound images out of the patient’s stanza and develop them while composing the following stanza. The significance of renku is “a sense of balance between link and shift” (Kondo & Higginson, 1994, p. 125) that are relevant to context. In renku, a stanza should be linked to adjacent stanzas and should not be linked to others. A renku does not have a plot as a whole so that one can “shift” a context in the light of an interpretation of the preceding stanza and one’s own experiences and imaginations. In practice, the therapist’s stanza should not be written beyond patient’s understanding. Therefore, the therapist will not write a stanza with highly metaphorical expressions, but write with simple word associations at the early stages of renku therapy sessions. In addition, it might be better for the therapist to avoid writing a stanza with therapeutic suggestions and implications that may harm the communication through poetry. The patient shares a therapist’s stanza The main contextual markers for a patient, at this stage, may be words that have arisen out of simple word associations. The patient comes to express even happy emotions in short utterances or comments when reading the therapist’s stanza, because the patient feels that his/her own stanzas are interpreted appropriately. The patient will also practice extending and relating the semantic field of each word. The patient and the therapist create meanings and reality that are jointly constructed out of words and phrases in two stanzas in succession. After such a rewarding experience with poetry the patient feels connected and in a common world with the therapist. In the course of renku therapy, patients come to understand metaphors in the therapist’s stanzas.
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Table 1 Evolution of linking and treated linguistic components Linking manners of patients
Treated linguistic components
Simple composition (barely linked) Linking with simple word association Linked with contextual development Well-linked with metaphor
Meaning/concept of a word Association Context Metaphor
The patient links a stanza A patient’s stanzas can be categorized according to ways of linking. Evolution of linking manner seems to correspond to the treated linguistic components shown in Table 1. These components are complementary rather than sequential, but distorted meaning/concept of a word and associations are likely to be treated earlier than disordered context and metaphor. To write and link the following stanza responding to the therapist’s is not easy for the patient. There might be a missing link in barely linked stanzas that are hardly noticeable by the therapist in surface language. Some attempt to imitate the preceding therapist’s stanza by putting it into a given format. Then the patients come to write stanzas with close and comprehensible word associations. As renku therapy proceeds, the manner of the patient’s linking is likely to change from simple word associations to contextual developments and to metaphorical extensions. These changes often are related to the process of clinical improvement (Tamura & Asano, 1997).
Discussion Language and reality Language is a device of cognition as well as communication. “Every language articulates reality in its own way, thereby creating its own particular view of reality and establishing its own unique concepts” (Trier, 1934 as cited in Lyons, 1977, p. 259 – 60). The meaning of a word is not precisely the same to any two people, so that people recognize reality in different ways represented through language. We must know that our reality of the world will change when our concept of a word has changed. Neither in concepts, nor in language itself, does anything exist in isolation. But concepts actually acquire associations only if the mind acts in inner
unity, if full subjectivity is directed upon a complete objectivity [his italic] (von Humboldt, 1988, p. 156 – 7).
Semantic linking between words seems to be categorized in two: one is coordinates and collocational links that may be particularly strong, and another is hyponyms and their superordinates, where connections may be weaker (Aitchison, 1994). That is, there are common word associations based on common mental lexicon that are reality-oriented and socially conditioned. Surface language plays an important role in giving context and meaning to each word. Context is also given by situational, cultural, and temporal parameters that are based on common background knowledge of the community. Linguistic metaphor is a fundamental mental capacity that reflects a constrained set of conceptual mappings that structures our thinking, reasoning, and understanding (Gibbs, 1994). Metaphor is also widely accepted as a proper cognitive device of language (Mac Cormac, 1985). The basic power of poetry lies in metaphor and simile that serve to activate archetypal images deeply buried within the psyche (Lerner, 1981). In short, meaning/concept of a word, association, context and metaphor are essential linguistic components by which human beings recognize the reality of their world. Schizophrenics seem to fail to do this because of impairments in these components. Language impairments in schizophrenia Bleuler noted that schizophrenia is a disorder of associations. The association disturbances were conceived of as the primary event from which the majority of secondary symptoms can be derived (Bleuler, 1950). Associationism assumed that language and thought were so closely associated that disturbances of the one necessarily showed up in the other (Berrios, 1995). On associative response tests, compared to normal controls, schizophrenics give fewer responses than are ordinarily given (fewer primary responses, less response commonality), they give unusual responses (larger associative-response domain, more clang responses and more “distant” responses), which are less stable on retest (Cramer, 1968 as cited in Spitzer, 1992). Chapin et al. (1989) suggest that schizophrenics do not lose the continuity of their associations at the initial sensory or perceptual processing stages of information processing and that the process becomes impaired at the level of the controlled attention process. McKenna, Mortimer, and Hodges (1994) demon-
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strate that the chronic, severe schizophrenics performed significantly worse than the normal people in the subsets dependent on semantic memory such as category fluency, naming, sorting, and definitions, but not in word-to-picture matching. Chen et al. (1995) suggest that semantic categories are intact internally, but the category boundaries are expanded in schizophrenia. McKay et al. (1996) show that semantic memory is impaired in schizophrenia. Semantic memory refers to stored information that is impersonal, and includes knowledge of words and their meanings, knowledge about objects and their interrelationships, and also general information about the world. At the level of pragmatics, various forms of thinking disturbance in schizophrenia, including delusions and formal thought disorder, constitute a disorder of “deficient real world knowledge” (Cutting & Murphy, 1988, p. 310). An heuristic model of language impairments in chronic schizophrenia The language system is a cosmos. There are no isolated words in the system. The system is well ordered and highly adaptable. In everyday life, we assume that there will be sufficient overlap between the meaning of words in the minds of different speakers for us to communicate (Aitchison, 1994). According to de Saussure (1983), language is the form of relation between a signal and a concept whose link is arbitrary. Lieberman (1984) says, “The ambiguity and uncertainty of the linguistic system probably matches the richness of our inner, psychological conceptual framework” (p. 82). This lack of precision may, on the other hand, be reflected in the language impairments of schizophrenics. Diachronic linguistics suggests that the acquisition of a new meaning by one word will affect others in the same semantic field, and also the word(s) that previously carried that meaning (McMahon, 1994). These semantic changes seem to occur in schizophrenia in a pathological and drastic way. Distorted semantic structure of words may set off a chain reaction of linguistic dysfunction in terms of association, contextualization, and metaphorical recognition. Wro´ bel (1990) showed a distorted concept of a word among schizophrenics, in which the central meanings of the word were replaced by personal or marginal meanings. Semantic changes in schizophrenic language manifest the dissociation of concept and reality from a sign. Misunderstandings arise not from objective incoherencies and semantic errors but from the existence of a separate, schizophrenic semantic system (Wro´ bel, 1990). Thus, schizophrenics conceive distorted reality by referring to their pathological systems of signs that may fit to understand
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Fig. 1. A vicious cycle of schizophrenic thought.
their unique, psychotic world. Neologisms are seen in extreme cases, but schizophrenics usually use everyday vocabulary with uncommon meanings. Language impairments may lead schizophrenics to misjudge their experience and embrace a distorted world view. Consequently, schizophrenic language impairments constitute a vicious cycle (Fig. 1). Such false beliefs are firmly maintained despite contradiction by social reality, invalidation, or psychotherapy. A linguistic psychotherapeutic model of renku therapy I propose a linguistic psychotherapy model of chronic schizophrenia under the premise that: impaired semantic systems cause disorders of cognition, thought, and communication among chronic schizophrenics, and that a psychotherapy which addresses such language impairments may break the vicious cycle of schizophrenic thought. The linguistic psychotherapy model makes it possible to understand the schizophrenic mind and how schizophrenics are treated with renku therapy. Some basic therapeutic qualities of renku include that it is: (1) reality oriented, (2) uses less conventional syntax, (3) is short, (4) is based on the principle of dialogue, (5) employs ambiguity, (6) depends on association of words and images, (7) requires interpretation and development of context, and (8) carries multiple meanings through metaphor (Tamura, 1998). Nijoˆ Yoshimoto (translated by Ueda, M., as cited in Higginson, 1996, p. 41) says, “The essence of linked verse lies in making everyday things look fresh.” The main topics addressed in renku are nature and everyday life. Season words and everyday vocabulary in poetic use act as suitable stimuli that evoke reality oriented memories and imagination.
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Poetic language thus put into practice treats distorted concepts of a word in schizophrenics by making the connection between a sign, its concept, and its reality tight with well-organized meanings. The poetic devices, such as less conventional syntax, shortness and dialogue in form, and ambiguity, work to draw considerable attention to each word and activate a train of association. In poetry, word order tends to be less conventional than that in common discourse, so that a patient with thought disorders or even with incoherence can write a stanza or quasipoetic lines by putting words into the format. The shortness and form may also be a useful therapeutic framework that prevents a stanza from being contaminated with their pathological thought in surface language. Common meanings for each word will develop common associations. Collins and Loftus (1975) have proposed a network theory model of spreading activation to explain the search for semantic memory. For them, a concept is represented as a node in a network, with properties of the concept interconnected through links with related concept nodes. When a word of a category is activated, activation will spread to other items of the same category, attributes of the exemplar, and the superordinate and subordinate (as cited in Shallice, 1988). Both to write a stanza and to develop “linking” in renku is thus to activate normal semantic memory and association. “Text and context are complementary: each presupposes the other” (Lyons, 1995, p. 258). A specific meaning of a word in a stanza can be defined by a context, which includes situation, time, and culture, among other contextual parameters. The renku process begins with simple associational links, then gradually leads the participant to make more complex constructions in successfully relating the newly created stanza to its predecessor. In the course of renku therapy, schizophrenics learn common meanings and concepts of words, common associations, and common knowledge of the world, so that they come to regain the ability of contextual recognition. Metaphor is accepted as a powerful cognitive device that often suggests new ways of perceiving and conceiving of the world (Mac Cormac, 1985). In a therapeutic setting, metaphor is regarded as a device of communication that leads to the development of rapport and mutual understanding between participants (Ferrara, 1994). Through the use of metaphors, connections between internal and external reality can be facilitated (Mazza, 1999). Metaphor appearing in a patient’s stanza might be a displaced interpretation of less acceptable thoughts. However, the therapist need not make such interpretation. Metaphors may be effective just because their meanings lie beneath the surface and below the defenses (Novalis, Rojcewicz
& Peele, 1993). Successful exchange of metaphor makes schizophrenics communicate at a deeper level with great satisfaction, and empathy with others will also be improved. In renku therapy, schizophrenics practice understanding and using metaphor and learn a common world view, which may be new to them. Pathology at the levels of semantics, cognition, and pragmatics may be the basis of schizophrenic thought and communication disorders. The acquisition of an uncommon meaning by one word will affect others and will change judgment of experience and world view. On the other hand, as Carl Jung (1979) notes, there exist innumerable normal associations in schizophrenics (as cited in Spitzer, 1992). Human mental lexicon contains equipment that enables us to continually extend existing words and coin new ones (Aitchison, 1994). Chronic schizophrenics may still have the equipment by which impaired semantic systems can be reformed. Indeed, renku is a sophisticated therapeutic tool through which schizophrenics may be treated within the domain of language impairment. The improvement in linguistic functioning in schizophrenic patients enables them to have a more appropriate judgment of experience, to recognize a shared world view, and to communicate with others through a common language.
Conclusion Humans employ the poetic dimensions of language in every aspect of life. Discourse is therapeutic when it is jointly constructed; creating a dynamic and vibrant reality through words (Ferrara, 1994). Renku is a poetic form of dialogue in which reality is collaboratively constructed and shared by therapist and patient. Asano (1986) notes that the essence of renku therapy, as well as renku itself, lies in fostering “linkand-share-with of the mind and heart” (p. 45). Thus the structure of renku is inherently suitable for psychotherapy. I have shown that renku therapy works as a way of treating the language impairments of chronic schizophrenia. Through renku therapy, a patient comes to understand or even to express humor, because to understand humor is to recognize meaning, context, and metaphor in utterances and writings (Tamura, 1998). Renku therapy may also work for the rehabilitation of emotional and empathetic functioning among schizophrenics. Ralph Waldo Emerson (1844), an American poet and philosopher, stated that “Language is fossil poetry” (p. 13). The language of chronic schizophrenics seems to be distorted and fossilized. The poetic use of language may activate or resurrect their language so
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that it may be possible for them to reform their impaired semantic systems.
Acknowledgments The author wishes to acknowledge the help and support of Kris Kondo, Dr. Kenneth Gorelick, Professor Tadashi Kondo, Dr. Kathleen Decker, and Dr. German E. Berrios in the writing of this paper.
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