INTERGRATINGMORITATHERAPYANDARTTHERAPY:ANANALYSIS

ADissertation

PresentedtotheFacultyofAntiochUniversitySeattle

Seattle,WA

InPartialFulfillmentoftheRequirementsoftheDegreeDoctoralofPsychology

By

AyakoSato

January2011

COMBININGMORITATHERAPYANDARTTHERAPY:ANANALYSIS

Thisdissertation,byAyakoSato,hasbeenapprovedbythecommitteememberssignedbelowwhorecommendthatitbeacceptedbythefacultyof

AntiochUniversitySeattleinSeattle,WAinpartialfulfillmentofrequirementsforthedegreeof 

DOCTOROFPSYCHOLOGY

DissertationCommittee:________________________LiangTien,Psy.D.Chairperson________________________MinoruOishi,M.D.________________________JaneHarmonJacobs,Ph.D.________________________Date

ii

©CopyrightbyAyakoSato,2011

AllRightsReserved

iii

ABSTRACT

INTEGRATINGMORITATHERAPYANDARTTHERAPY:AnAnalysis

AyakoSato

AntiochUniversitySeattle

Seattle,WA ThisstudypresentstherapeuticinterventionscombiningMoritaTherapywithart

therapytechniques.Theauthorpresentsliteraturereviewsofarttherapyaswellasthe

originalMoritaTherapyformulatedbyShomaMorita,M.D.Anewarttherapy

techniquebasedontheworkofKenjiKitanishi,M.D.(2008)foroutpatienttreatmentis

alsopresented.Acaseillustrationofaneleven‐year‐oldVietnamese‐Americanboywho

presentedwithhighanxietyandschoolrefusalisusedasanexampleoftheeffective

integrationofMoritaTherapywitharttherapytechniquesformulatedbytheauthor.

EventhoughtheboywasnotfamiliarwithMoritaTherapyprinciples,thecreative

processhelpedtheclientmaketherapeuticprogress.Thecombinedtreatmentof

MoritaTherapyprinciplesandarttherapytechniquesresultedinaneffectiveoutcome

fortheclient.Asacentralconcept,MoritaTherapyfocusesonlearningtoacceptone’s

emotionsandtherealityofone’slife.Thisanalysisconcludesthatarttherapy

techniquescanbeeffectivelyintegratedwithMoritaTherapyasatreatmentmethod

aimedatimprovementinfunctioning.Thenumberofclientsthatcanpotentially

benefitfromMoritaTherapyincreaseswiththeuseofarttherapy.

1

GiventhatMoritaTherapyisbasedonBuddhistphilosophy,itmaybeparticularlyuseful

Buddhistbasedcultures.

2

DEDICATION

Iwouldliketodedicatethisdissertationwithmywholeheartandlovetomy

parentsandmychildren.Mymotherinstilledinmetheimportanceofwomenpursuing

highereducationandindependence,breakingwithtraditionalJapaneseculture.

Throughmyfather’scompassion,perseveranceandpositiveworkethicsofnevergiving

up,Ilearnedtobediligentandaffectionate.Mychildren,YukoandYusuke,enriched

mylifebytheirwillingnesstofollowmeinlivinginthetotallydifferentcultureofthe

UnitedStatesfortheelevenyearsofmyprofessionaljourney.Iwillneverforgettosay

thankstoDr.IkuoTakahashiforbeingmymentorandmajorsupportformyacademic

journey.

iv

ACKNOWLEDGEMENTS

Iwouldliketoexpressthedeepestappreciationtomydissertationcommittee

chair,Dr.LiangTien,whohadastrongpassionandtheskilltoeducatemeasa

psychologistthroughthisdissertationprocess.Asarespectfulprofessor,personal

mentor,andintelligentAsian‐Americanwoman,sheprovidedapowerfulrolemodel.I

wouldalsoliketothankmycommitteemembers,MinoruOishi,MD.andJaneHarmon

Jacobs,Ph.D.IappreciateDr.Oishi’swillingnesstoparticipatefromJapan.Asa

medicaldoctor,hisknowledgeandclearopinionshelpedmythinkinginthisdifficult

project.Dr.Jacobs’continuingencouragement,professionalperspective,andfaithin

myabilityhelpedmepersevereinthiscourseofstudy.

Inaddition,IappreciateMarkYamada,Ph.D.,whoismyclinicalsupervisor,and

AndyBenjamin,Ph.D.IrespectDr.Yamada’swisdom,knowledge,andtenacious

commitmenttoeducationandclinicalsupport.Iwouldhavebeenunabletocomplete

mystudieswithoutDr.Benjamin.Hiswisdomandprofessionalattitudegavemea

modelofhowtolivemyprofessionallifeinthefuture.

IwouldalsoliketoexpressmygratitudetoPatriciaLinn,Ph.D.,JudithA.Rubin,

Ph.D.,andthefacultyofAntiochUniversitySeattlefortheirtime,encouragement,and

love.

v

Ofcourse,manythankstomystrongsupporters:Mr.MisaoandMs.Masako

Yazaki,andtomymanyfriendsandprofessorsintheU.S.andJapan.Especially,I

appreciateMs.Yuko,Mr.HitoshiChiba,Mr.ShojiOshio,Ms.RyokoNabetani,and

Ms.ChiekoKimurawhohavegivenmesupporttopursuemyeducation.

IalsothankmyEnglishtutorMr.JohnNewmanandeditorDr.ResaRaven,who

nevercomplainedaboutmypersistentquestions.

Lastbutnotleast,Iappreciatemyex‐husband,Mr.TakahiroAkita.IfIhadnot

marriedhim,IwouldnotbewhereIamtoday.Thankyoutoallofmypeople.Arigatou. 

vi

TABLEofCONTENTSPageDEDICATION…….……………………………………………………………………………………ivACKNOWLEDGMENT…………………………………………………………………………….vListofTables……………………………………...........…………………………………………ixListofFigures……………………………………….………………………………………………xI.WHATISARTTHERAPY?..............................................................................1

Definitions…………………………………………………………………………………………….....…2WhatIsArtTherapy?………………………………………………………………………….….......6UsefulnessofArtTherapy……………………………………………………………………….....12ThePlaceofPsychologicalTheoryinTherapy………………………………………….....15ArtTherapyandTheory………………………………………………………………………….…..16ArtTherapyasAssessment………………………………………………………………………….17ArtandCulture………………………………………………………………………………………..….20ZenArtUsedinHealing………………………………………………………………………….......22

II.THEORETICALHISTORYOFARTTHERAPY…………………………………………..………..26 ArtTherapyandTheories……………………………………………………………………….…….26

TheoreticalHistoryofArtTherapy………………………………………………………….…….26ChoiceofTheory………………………………………………………………………………….….……30AdvantageofIntegratingArtTherapywithTheory…………………………………..…..31 PossibleIntegrationofMoritaTherapyandArtTherapy……………………………...31

III.MORITATHERAPY…………………………………………………………….……………….....33ConceptofMoritaTherapy……………………………………………………..…………………...33 HistoryofMoritaTherapy…………………………………………………….……..……….………35Morita’sChildhoodExperiences………………………………………….…………..…..……….36BirthofMoritaTherapy…………………………………………………….………………..………..37HowMoritaTherapyViewsPathology……………………………………………………..…..39TheCoreofMoritaTherapyPathology:ViciousCircleofConflictingThoughts……………………………….…………...40AnxietyandDesire…………………………………………………………………….…………..……...45NatureTheory……………………………………………………………………………..…………….....46CorePrinciplesofMoritaTherapy…………………………………….……………….……….....47

vii

Psychopathology………………………………………………….…………………………….………....52MoritaTherapyandBuddhism………………………………………………………….…………...56MoritaTherapyandWesternPsychology………………………………………….…………..57Modalities………………………………………………………………………………………….…….......58Treatments………………………………………………………………………………….…….………....59PossibilitiesofMoritaTherapyinWesternCulture…………………………..……………64MoritaTherapyPastandPresent…………………………………………………….……..…....66

IV.ANALYTICALPERSPECTIVEOFMORITATHERAPY.…………………………………………..……….68

BackgroundConsiderationsRegardingMoritaTherapy………………………………….68MoritaTherapyandMedication…………………………………………………………………....69AnalyticalIssuesoftheOriginalMoritaTherapy…………………………………………....69EnvironmentofMoritaTherapy……………………………………………………………………...69IssuesRegardingtheInpatientUnitatMorita’sHome…………………………………...71RelationshipBetweenClientsandClinicians…………………………………………………..73

DifficultyUnderstandingMoritaTherapy……………………………………………………….76AfterMorita…………………………………………………………………………………………………...83MoritaTherapyToday………………………………………………………………………………….…84Conclusion………………………………………………………………………………………………........84

V.THEINTEGRATIONOFMORITATHERAPYWITHARTTHERAPY………………………………..87 ExampleofArtTherapyInterventionTechnique…………………………………………….89

CaseSummary…………………………………………………………………………………………….…106

VI.Conclusions…………………………………….…………………………………………………………..……….109References………………………………………………………………….…………………………..…………………112

viii

ListofTables

1. ContextandHistoryMoritaTherapy.........................................................................86

ix

ListofFigures

PageFigure1:ViciousCircleofConflictingThoughts………………………………………….……..…….41Figure2:DiscrepancyBetweenImaginaryandRealSelf…………………………….……...…….43Figure3:SummaryoftheViciousCircleofConflictingThoughts……………………..….…..45Figure4:TheConnectionBetweenAnxietyandDesire……………………………….….…....…46Figure5:DifferencesBetweenBuddhismandWesternPhilosophy……………..….……...58Figure6:ChangingImpactofExternalEvaluation………………………………..……….……….….64Figure7:DistinguishingBetweenICanDoItandICan’tDoIt…………………..………….....89Figure8:AdmittingVersusFightingEmotions……………………………………….…...…………….90Figure9:HoldingtheEmotions……………………………………………..……….……….….…….………91Figure10:HoldingtheEmotions‐2………………………………….….………….……….….…….………91Figure11:ObservingDynamicEmotions……………………………….……………….…...…………….92Figure12:RecognizingDynamicEmotions…………………………….…….……….…………………...92Figure13:ObservingtheBehavior……………………………….…………….…….…………….………….93Figure14:TakingActionandHavingExperiences…………….………..……………………………...93Figure15:MakingDecisions………………………………………………….…….…………….……….……...94Figure16:AvoidingPerfectionism………………………………….………….………….…………….……..95Figure17:ActionsChangeEmotions……………………………….………….………….………….……….95Figure18:FeelingEnoughEnergytoLive……………………….……………………………….….……….96

x

Figure19:IdentifyingExternalJudgments……………………………………………………….………….96Figure20:RecognizingtheImpactofExternalJudgments.............................................97

Figure21:ChangingtheImpactofExternalJudgments.................................................98Figure22:Alex’sFamily.................................................................................................101

Figure23:Alex’sPictureofSelf.....................................................................................102

Figure24:Mother’sPictureofSelf...............................................................................102

Figure25:AnxietyTemperatureIndicators1...............................................................103

Figure26:MyUncle......................................................................................................104

Figure27:Alex’sActions...............................................................................................105

Figure28:AnxietyTemperatureIndicators2...............................................................107

xi

1

I.WHATISARTTHERAPY?

ShomaMoritawhoformulatedMoritaTherapyin1917,focusedonaccepting

life,resolvingconflictingthoughts,andbecomingfreefromobsession(France,Cadieax,

&Allen,1995).Moritabelievedthatitismucheasierforpeopletochangetheir

behavior/actionthantochangetheirsymptoms(Kitanishi,2007).MoritaTherapy

stemsfromZenBuddhism.MoritaTherapymaybeagoodfitformanyclients,

particularlythosefromBuddhist‐basedcultures.WithinterestinZenpracticegrowing

beyondAsia,MoritaTherapymayalsobehelpfulforindividualsfromWesterncultures.

ArttherapyintheUnitedStateshasbeeninfluencedbyanarrayofWestern

theories,buthasnotbenefitedfromBuddhist‐basedculturalinfluences.Western

influenceshaveincludedFreudianpsychology,theeducationalmovement,andart

education(Jung,1994).Anarttherapyapproachisfrequentlyusedtoclarifyand

expressanindividualpatient’semotionsandtofacilitatethefindingofsolutionstotheir

problems(Rubin,1998,2001,2005).Throughtheprocessofmakingart,atherapeutic

dialoguebetweenpatientandarttherapistiscreated.Arttherapythenbecomesa

guidetoleadapersontohisorhergoals.

Asadiscipline,arttherapydoesnothaveonecompellingtheorysupportingits

techniques.Rather,arttherapyisoneoftheapproachesthatcanbeusedtosupport

treatmentgoalsinalargercontext.Thisrequiresthearttherapisttointegrateart

therapytechniqueswiththetheoreticalorientationthatguidesthetherapist’sthinking.

IntegratingMoritaTherapyandarttherapymaybeaneffectivetherapeuticmethodto

2

helpanindividualpatientunderstandtheiremotionsandgaininsightintotheir

functioning.ThispaperexploresthepossibleintegrationofarttherapywithMorita

Therapy.

TherearenostudiesordiscussionsofintegratingMoritaTherapyandarttherapy

inWesternpsychologicalliterature.TheintegrationofMoritaTherapyandarttherapy

byAmericanarttherapistshasyettobepursued.Thisdoctoralpaperwillexplorethat

possibility.Insectiononeandtwo,Iwillreviewthecurrentstateoftheliterature

regardingarttherapyandtheoreticalhistoryofarttherapyintheUnitedStates.In

sectionthree,IwilloutlineMoritaTherapyasoriginallypromulgatedbyDr.Shoma

Morita.Insectionfour,IwilldiscusstheanalyticalperspectiveofMoritaTherapy.In

sectionfive,IwillillustrateamethodofintegratingMoritaTherapyforoutpatient

treatmentwhichisbasedonKitanishi’sidea(2008)ofarttherapy.Acasestudyexample

willbepresentedtodemonstrateconcretelyhowarttherapytechniquescanbe

integratedwithMoritaTherapy.

Definitions

Art

Manyofusenjoyartbygoingtoplaceswhereitisactivelypursued,suchasart

museums,concerthalls,andtheaters.Butartisasignificantpartofoureverydaylife.

Artcanbefoundinthefoodsthatweselectandpresenttothetable,beautifulpictures

weenjoyinthemedia,dishesandpotteryweuseinourhomes,etc.Arttakesmany

differentformsthatinvolveothersensesinadditiontosightandsound(Rubin,2005).

3

Sinceancienttimes,humanbeingshaveexpressedthemselvesthroughart.Art

isapowerfulandeffectivemeansfortheartisttoexpressfeelings.Peoplehavealso

usedarttoexpressideasandtofacilitatehealing.Arteducationhasassistedchildrenin

theirdevelopment(Eckhoff,2007).Educationintheartsisconsideredbymanytobea

corecurriculum.Viewingartandattendingartisticperformancesareincludedin

nationaleducationalstandardsandincurriculumrequirementsforchildreninthe

UnitedStates(Eckhoff,2007).

Psychotherapy

Psychotherapyis“thetreatmentofmentalandemotionaldisordersthroughthe

useofpsychologicaltechniquesdesignedtoencouragecommunicationofconflictsand

insightintoproblems,withthegoalbeingreliefofsymptoms,changesinbehavior

leadingtoimprovedsocialandvocationalfunctioning,andpersonalitygrowth”

(AmericanHeritageDictionaryoftheEnglishLanguage,2009).Psychotherapyisa

treatmentapproachthatfocusesonoralcommunication.Thepsychotherapistasksthe

patienttoexploreandrecognizeanxietyandconflicts(Thyme,Sundin,Stahlberg,

Lindstrom,Eklof&Wiberg,2007,p.252).Thyme,etal.(2007)statedthatresearch

showedthatanypsychotherapywasmoreeffectiveforpsychiatricdisordersthanno

treatment.Patientssufferingfromdepressionwhoreceivedbriefpsychotherapy

showedsignificantimprovementwhencomparedtopatientswithoutpsychotherapy.

Andersen(2005)arguedthatitwasdifficulttomeasurescientificallytowhatdegree

symptomsimproved,becauseclients’symptomsweredifferentandtheresultsmightbe

4

verysubjective.Andersenconcludedthatsuccessfulpsychotherapyoftenresultedin

mindfulawareness,acognitivestatecentraltoBuddhistphilosophy(2005).

Historically,psychotherapyemergedfromthescientificobservationofhuman

behavior(Hayes,2002).CarlRogers(1957)statedthatsuccessfulpsychotherapyhas

threeimportantelements:therapistempathy,unconditionalpositiveregard,and

congruenceinrelationtotheclient.

Aspartoftheirprofessionaltraining,psychotherapistsstudyawiderangeof

psychologicaltopicssuchasdevelopmentalpsychology,psychopathology,ethics,

psychopharmacology,etc.Inordertoobtainprofessionalcompetence,theymust

understandboththetheoriesandtechniquesofpsychotherapy.Whenartisusedina

clinicalsetting,itisimperativetounderstandhowtocombinearttechniqueswith

psychotherapy.Psychotherapistswhodothiswell,provideeffectivetreatmentsfor

theirclients.Itisimportantforarttherapiststobewellversedinpsychotherapy.

ArtTherapyintheUnitedStates

AccordingtoRubin(1998),arttherapyis“art+therapy.”Shecontends

thattwokindsoftheoriesaboutarttherapyexist.Thefirsttheoryisfocusedonthe

clientengaginginthecreativeprocessofanarttherapysession.Thisencouragesthe

clienttoconnecttothetreatmentprocess(Rubin,1998).Thesecondtheoretical

positionconsidersthattheartworkofclientsilluminatestheirinnerconflictsand

unconsciousprocesses.Accordingtothistheory,artisusedinpsychotherapytoassist

indevelopingmeaningthroughananalysisofthesymbolismoftheart.Rubinsaidthat

5

therearedifferentnamesforarttherapy,including"expressiveanalysis,""clinicalart

therapy,""psychoaesthetics"and"expressivetherapy"(Rubin,1998,p.61).

AmericanArtTherapyAssociation’sDefinitionofArtTherapy

TheAmericanArtTherapyAssociationdefinesarttherapyas:

Thetherapeuticuseofartmaking,withinaprofessionalrelationship,by

peoplewhoexperienceillness,traumaorchallengesinliving,andby

peoplewhoseekpersonaldevelopment.Throughcreatingartand

reflectingontheartproductsandprocesses,peoplecanincrease

awarenessofselfandothers;copewithsymptoms,stressandtraumatic

experiences;enhancecognitiveabilities;andenjoythelife‐affirming

pleasuresofmakingart(AmericanArtTherapyAssociation,2010).

TheAssociationstatesthatarttherapyisamentalhealthprofession.Also,the

Associationdefinesarttherapistsas:

…professionalstrainedinbothartandtherapy.Theyareknowledgeable

abouthumandevelopment,psychologicaltheories,clinicalpractice,

spiritual,multiculturalandartistictraditions,andthehealingpotentialof

art.Theyuseartintreatment,assessmentandresearch,andprovide

consultationstoalliedprofessionals(AmericanArtTherapyAssociation,

2010).

IntheUnitedStates,theAmericanArtTherapyAssociationhassupportedthe

establishmentofarttherapyasaprofessionandtheeducationofarttherapists.

6

WhatisArtTherapy?

“Arttherapy’srootsextendasfarbackasprehistorywhenpeopledrewimages

incavesinattemptstoexpressandmastertheirworld”(Jung,1994,P.1).Sinceancient

times,humanbeingshaveexpressedthemselvesthroughart.Amongotherapproaches,

artisatooltoexpressfeelings.Peoplehavealsousedartforhealingandexpression.

JudithA.Rubin,apioneerofarttherapy,stated“Artisanaturalwaytocommunicate”

(2005,p.21).Arttherapyisaclinicalwayforpeopletoexpresstheirinnerthoughts.Art

isausefulmodalityinwhichtoexpressnon‐verbalthoughtsandimages.Malchiodi

(1998)wrotethatclientsdonotneedtoworryabouttheirartisticabilitiesbecauseall

artgeneratedinanarttherapysessionisautomaticallyacceptable.

Arttherapytechniquescanbeaneffectivetoolforbothassessmentand

treatment(Rubin,1998,2001).Arttherapydevelopedasawaytotreatpatients.

Becausearttherapyusesarttotreatpatients,mentalhealthprofessionalswhouseart

therapytechniquesmustbetrainednotjustintheuseofart,butalsointheclinicaluse

ofarttotreatdifferentkindsofsymptomsthatafflictpeople(Rubin,2005).Accurate

diagnosticskillsandeffectiveinterventionskillsinclinicalsettingsarealsocritical

necessities(2005).

Arttherapistsfocusontwoaspectsoffunctioning:psychologicaland

physiologicalfunctioning.Psychologicalfunctionsincludemood,self‐awareness,and

self‐esteem.Physiologicalfunctionsincludedecreaseinheartrate,bloodpressure,and

respirationrate(www.wholehealthmd.com.June4th,2010).McMurray(2000)

7

describedarttherapyasbeingcomprisedoftwomaintechniques:structuralandthe

freecreativeapproaches.Thestructuralapproachoccurswhenthearttherapistgives

concreteartdirectionsandspecificartmaterialstotheclient(McMurray,2000).The

freeapproachiswhenaclientspontaneouslycreatesimagesofhisorherimpulsesand

fantasies(McMurray,2000).Throughthesearttherapyexperiences,clientsareableto

recognizeandexpressimpulsesandfantasiesthatarenotintheirconsciousawareness.

Arttherapyisexperientialtherapyandassuch,isdifferentfromother

therapeuticapproaches(Wadeson,1995).Arttherapistsdonotleadclientswith

language.Clientsareabletodiscovertheirownstrengthsandreachtheirgoalsthough

theirownexperiences(Rubin,2005).Peopleprocesstheirownexperiencesviscerallyin

theirbodiesandminds(Rubin,2005).Forexample,childrentypicallydemonstrate

happinesswhentheybuildamodelcarforthefirsttime.Frequentlytheywilltryto

buildamoredifficultmodelthenexttime.Theyexperienceachievementandgrowthin

confidencethroughtheseexperiences.Clientsalsocanself‐discoverandgain

confidencethroughdrawingpicturesorcreatingobjects.Arttherapistssupportand

encourageaclient’sinternalprocesses,andfacilitatetheclientreachinghisorherown

goals.Experiencesduringarttherapysessionscanresultinstrongtherapeutic

movementfortheclient(Rubin,2005).

Duringarttherapy,challengesandsolutionsforproblemsareaddressedinthe

process.Atthesametime,clientsexploreandexpressinnerconflictanddifficulties

(Clements,1996).Supportingclientsintheirprocessincludesengagingindialoguewith

8

them,preparingtoolsthattheycanusetoextendtheirreflectionsthroughart,and

providingasafeenvironmentforgrowthandlearning.

Arttherapycangivetheclientapositiveexperienceofcreativityasexpressed

throughart.Creativitycanleadtodevelopinggreatermeaninginaperson’slife.People

canfreetheirmindsbyexpressingthemselves.Fun,creativeexperiencesareimportant

forhumanbeings.

AccordingtoRosen(2009)arttherapyissimilartomeditationorreflection.For

example,peoplecanobtainpeaceofmindinanarttherapysessionwhichissimilarto

thestateofmindoneexperienceslookingatagardenataZentemple,orengagingin

anyothermeditationpractice.Aclinically‐trainedtherapistcanlinkrelaxationwith

clinicaltreatmentgoals.Arttherapyhelpsclientsidentifyissuesandconsiderwaysto

overcomedifficulties.Suchanapproachcanleadtoeffectivestrategies.

Theroleofthetherapistisnotjusttotreatclientskindly,buttodesignand

implementtreatmentinterventionssothattheclient’spsychologicalsymptomsare

relieved(Rubin,1998,2005).Trainedarttherapistsprovidetherapeuticinterventionsin

amannerindividuallysuitedtoeachclient(Rubin,2005).Forexample,arttherapycan

teachclientsabouttheimpactofillegaldrugsonthecerebralcortex,orthemechanisms

ofviolenceandangerandhowtodiffusetriggersleadingtomaladaptiveaffective

states.Arttherapistscanbehighlyspecializedinprovidingthistypeof

psychoeducationaltraining(Jung,1994;Rubin,2005).

9

Choosingartmaterialsisacriticalpartofprovidingeffectivetreatment(Rubin,

2001,2005).Itisaveryimportantjobtoselectartmaterialsmatchedtoanindividual

client’spsychologicalstate,developmentallevel,andphysicalcondition.Arttherapists

providemanykindsofmaterialsandmethodstofittheclient’sneedtodevelopinsight

andexpressfeelings.Itisnecessaryforarttherapiststoalwaysconsiderwhetherthe

artisticmediumissuitableornot,whetheritreallyshouldbethoseparticularmaterials.

Forexample,atherapistmightprepareclippingsfrommagazinesformakingacollage

forthosewhoarenotgoodatdrawing.Whenchoosingthematerialsfor

psychologicallyunstableclients,anarttherapistneedstoavoidmaterialsthathave

sharpedgesorcanbeusedtoinflictwoundsandwhichcanleadtoself‐destructive

behaviororviolence.Theskilledarttherapistconsidersthosepossibilitiesatalltimes.

Itisalsoimportanttoorganizematerials.Oneneedstoknowwhichtoolstoprepare

andhowmanyofthem,beforethesessioncommences.Whenworkingwithclientsin

aninpatientsetting,forexample,itisimportanttoconfirmthenumberofpairsof

scissors.

Arttherapymethodspermitassessmentandtreatmentapproachestobe

identified.Arttherapycanintegrateknowledgeaboutpsychologicaldevelopmental

stageswithknowledgeobtainedthroughassessment.Anarttherapistmustbesensitive

totheuseofcertainarttherapytechniques.Forexample,someclientsmightbeafraid

ofdrawingpicturesbecausesometimeintheirhistory,theyhaveassociateddrawing

withcriticism.Arttherapistsshouldbuildtrustingrelationshipswithclientsandshow

10

themthatthearttherapysessionisasafeenvironment,ratherthanaplaceofcriticism

andharshjudgment.Also,arttherapymightnotbeusefulforcertainindividualswho

havephysicaldisabilitiesorvisualimpairments.However,theseindividualsmaybeable

tobenefitfromarttherapyifarttherapistsareabletoworkwiththemindividuallyand

adaptartmaterialsanddirectionstothatwhichwouldpermitexpression.

Rubin(1998)distinguishedbetweenwhatarttherapyisandwhatitisnot.She

saidthatiftheartactivityisforfunorrecreation‐‐evenifitoccursinapsychiatric

hospital‐‐itisnotarttherapy.Arttherapyisnotactivitiesforthesolepurposeof

engaginginfun.Further,sheclarifiedthat,“Eventhemostsensitiveartistorartteacher

isnotatherapist,”(Rubin,1998,p.63).Arteducatorsmayindeedengageinactive

influenceofclients,butarttherapistsfocusonthetherapeuticprocessandprovide

quietmomentsofselfreflectionanddialoguewiththeirclients(Naumburg,2001).

Educationalactivitiesinartcanpromotesocialandemotionalgrowth,butarttherapy

includeseducationtohelpclientsexpressthemselves(Rubin,1998).Forexample,anart

therapistmayuseartmaterialstohelpaclienttoexpressfeelings,toencouragehealthy

sublimation,andtobuildasenseofself‐esteem.Arttherapistsfocusonhowart

processesandartisticmaterialscanactivatecertainpsychologicalprocesses.Teaching

artistictechniqueisnottheprimarygoal.

Furtherdifferencesexistbetweenanartactivityandanarttherapysession.An

arttherapistisabletoobserveandassesstheclients’psychologicaldynamics.Even

thoughanarttherapistandartteacherusethesamematerials,theirmethodologyand

11

usageofthosematerialscanvarygreatly.Anarttherapistobservespsychological

dynamicsthroughoutthetherapysessions(Rubin,1998).Oneexampleofthisistheuse

ofprojectivedrawingasameansofassessment.Projectivedrawingwasoriginally

developedasanassessmenttoolbyclinicalpsychologistsbuthasbeenwidelyusedby

arttherapistsaswell.Socialworkersandpsychotherapists,aswellaspsychologists,

havefounditusefultoemployartinsessionsbecauseimagescanshowthepatient’s

unconscious(Rubin,1998).

Arttherapyinvolvesnotonlyexpressingandenjoyingoneselfthroughart,but

alsoengagingintherapythroughthemediumofart(Wadeson,1987).Wadesonfurther

clarifiedthat,“Creativityisatthecoreofarttherapy’’(2000,p.xiii).Arttherapyis

usefulforhealingandcanleadtocatharsis,areleasingofemotions(Malchiodi,1998).

Inaddition,arttherapistshelpclientstoexperiencetransformationandtofindpersonal

meaningandhealingthroughart(Malchiodi,1998).

Arttherapyvalidatesnotonlyperspectivesthatarepositiveinnature,butalso

morenegativeperspectivesthataresometimeshardforclientstoaccept,suchas

ugliness,strangeness,andsoon.Arttherapycanprovideunderstanding,non‐

judgmentalsupport,andatrustedrelationshipwithanother‐‐thearttherapist.Many

clientshaveneverbeenabletoexpressthemselvesinthiswaybefore(Wadeson,1987).

Self‐expressionandexplorationwithanarttherapistcansupportaclient'spositive

personaldevelopment(Wadeson,1987).Wadesonstatedthatarttherapycanproduce

12

asynergisticeffectbyusingartandhelpingpeoplediscoveranddeveloptheirinner

selveswhichcannotbeobtainedintherapiesthatdependonverballanguagealone.

UsefulnessofArtTherapy

Artisnonverballanguage.Creativityandnonverbalimageryareusefulwithall

kindsofpeople(Hoshino,2003).Malchiodi(1998)wrotethatvisualartspeaksinways

thatwordscannot.Gladding&Henderson(1998)statedthatthecreativeartsare

universallanguage(p.187).Peoplecantransformtheiremotionsintodrawingand

expressaffectandcognitionsnoteasilyputintolanguage(Kearney&Hyle,2004).Art

canleadtodisclosuresthatarehardertoexpressthroughverballanguage.Artprovides

visualdata(McNiff,2009).Becausearttherapyrisesaboveculturalbackgrounds,itis

usefulforclientsandclinicianswhoaremoreverballylimited(McNiff,2009).Artcan

serveasacommunicationtoolthathelpstomediatedevelopmentalandmulticultural

differences.Ifthereisnocommonlanguagebetweenarttherapistandclient,amethod

ofcommunicatingwitheachothercanoccurthroughart.Malchiodi(1998)statedthat

expressioninartdoesnotdependontherulesoflanguage,suchasgrammarand

correctspelling.Inaddition,arttherapyisusefulforthosewhohavelittlelanguage

ability,suchasthosewhoareimpairedbyemotionalorcognitivedisorders.

Artcannaturallyexpresssensationsandemotions,unconsciousthoughts,and

underlyingbehavior(Kearney,&Hyle,2004).Forexample,aclientcanfreelyexpress

themselveswithoutsummarizingtheirthoughtsormakinganefforttobeverbally

understoodbyothers.Throughart,aclientcanexpressemotions,ideas,and

13

unconsciousprocesseswithfewerconstraintsandinalessthreateningmanner

(Malchiodi,1998).Arttherapytreatmentisusefulforclientswhohavedifficulty

expressingtheirinternalexperiencesasaresultofinflexibledefensemechanisms

(McMurray,2000).

Arttherapyprovidesasafeenvironmentforclients’innerfeelings.Clientscan

describethemselvesthroughartwithoutanyrejectionorcriticism(Naumberg,2001).

Whenpeoplewanttoexposewhatisatthebottomoftheirhearts,itusuallyisonly

possibleinfrontofthosetheytrust.Arttherapistsbuildclienttrust,accepttheirclients,

avoidjudgmentandassistclientsintheirpsychologicaljourney.Malchiodi(1998)stated

thatvisualthinkinghelpstoorganizeanddescribeourthoughts.Arttherapyis

nonverballanguageandcommunicationthatdisplaysvalues(Malchiodi,1998).Art

therapyisafirst‐handexperience(Malchiodi,1998)thatcanleadtoaricher

understandingabouttheself.

Thearttherapyprocessofcreativeexpressionhealspeople(Gladding&

Henderson,1998).Artactivitiesreducestress(Malchiodi,1997).Kramer(1972)opined

thatarttherapyisusefulforaggressiveclientswhorequireexpressionandenergy

reduction.Writingdailyaboutdistressfuleventshelpspeopleheal,incontrastto

peoplethatdonotwrite(Gladding&Henderson,1998).Theexperienceofjournal

writingissimilartothearttherapyprocess.Malchiodi(1998)statedthatvisualthinking

helpspeopletoorganizeanddescribetheirthoughts.

Arttherapyisespeciallyusefulforchildren.Engaginginartactivitiesisbeneficial

14

inthatitimproveschildren’sself‐esteem(Ozimo&Ozimo,1989,citedinGladding&

Henderson,1998).Artcanbealessthreateningwayforchildrentoaddressgriefthan

tospeakaboutit(CummingandVisser,2009).Otherresearchhasshownthatthrough

artactivities,childrendiscovernewinterests,ideas,abilities,andstrengths(Appleton&

Dykeman,1996,citedinGladding&Henderson,1998).Arttherapycanbeusefulfor

childreninpartbecausechildrendonothavelargevocabularies.Takahashi(1986)

wrotethatartallowsustoexploreboththeunconsciousandconsciousrealms,and

accessissuesthatcanbedifficulttodescribeverbally(p.30).

Gussak(2009)showedthatarttherapyresultedinpositivechangesofmoodand

behaviorinbothmaleandfemaleinmates.Whilehisresearchfindingsindicatedthat

arttherapywasmoreeffectiveforfemaleinmates,therewereclearfindingsthatart

therapywaseffectivefortreatingmaleinmatesaswell.Arttherapyismorefocusedon

innerexperiences.Duringasessionofarttherapy,clientsworkonexploringtheirinner

selvesand/orconflicts.Paintingsorobjectscreatedduringsuchsessionsarevery

personal.Theprocesssupportstheclient’sbehavior,motivation,andself‐esteem

throughdevelopingskillsandsharingartwithpeers(Cumming,&Visser,2009).

Becauseclientstalkaboutverypersonalandprivatefactsorfeelings,itis

necessarytokeepconfidentialityabouttheartworkandconversationsthattakeplace

duringthesessions.Buildingatherapeuticalliancerequiresthetherapisttovalidatethe

meaningfortheclientthatemergesfromarttherapy,andkeepsecretthatmeaning

fromothersoutsideofthesession.Supportingclientsalsomeansbuildingasenseof

15

personalsafetywiththem.Withouttrustinthetherapeuticrelationship,cliniciansare

unabletoprovideeffectivetreatments.

Arttherapycanbeeffectivefortreatingclientswhohavesufferedsevere

trauma.Researchshowstraumaticexperiencesareencodedintheimagesformedinthe

mind(Malchiodi,1998).Itcanbeverydifficulttorememberorverbalizeatraumatic

experience.Arttherapycanassistinintegratingwhatisdifficulttoverbalize.

Fromaneuro‐scientificperspective,arttherapyprovidesdistinctbenefits.For

example,usingbothhandsduringthecreationofartengagesbothrightandleftbrain

(McMamee,2005,p.544‐545).Alsoarttherapyhasbeenshowntobeeffectivefor

cancerpatientstodecreasetheirdepressivesymptomsandincreasetheirattentiveness

(Thyme,Sundin,Stahlberg,Lindstrom,EklofandWiberg,2007).Ithasbeenusedin

inpatientandoutpatientsettings;withseverementalillness;withthosewhosuffer

depression,anxietydisorder,andaddictions;andwithautisticchildren,prisoninmates,

andpeoplewhohaveproblemswithverbalexpression(Rustin,2008).

ThePlaceofPsychologicalTheoryinTherapy

Therearemanykindsoftheoreticalorientationsinpsychology,suchas

psychodynamic,cognitive‐behavioral,person‐centered,objectrelations,existential,and

familysystemstheory.Theoriesareimportantframeworkstohelptherapists

understandtheirpatients.Theycanindicatehowtoleadpatientstoreachtheirgoals,

stepbystep.Itisimportantforarttherapiststostudyandunderstandtheoriesof

humanpsychologicalfunctioningandpsychopathologyinordertoeffectivelyintegrate

16

arttherapymethodswiththetreatmentorientation.AsRubinstates,“Iamquite

convincedthatonlyiftheapproachiscomfortableforatherapistisitatallusefulinhis

andherhands”(2001,p.3).Therapistsneedtofindtheoriesthattheyunderstandand

withwhichtheyfeelcomfortablewhileworkingwithpatients.Rubin(2001)saweach

theoreticalorientationasproviding“differentsetsoflenses,(which)illuminatesslightly

differentaspectsofhumanpersonalityandgrowth”(p.1).Eachtheoryprovidesa

differentperspectivetouseinanalyzingpeople.Hefurtherclarifiedthat“[I]fart

therapistsaretofunctionassophisticatedmembersofaclinical,educational,medical,

orsocialteam,ourcomprehensionofanytheoreticalstanceneedstobeasdeepand

clearasthatofothers”(Rubin,2001,p.2).

Sometheoriesmaynotfitfortherapistsfromdifferentculturalbackgroundsand

withdifferingculturalvalues.Forexample,forAsiantherapists,itmaybedifficultto

understandWesterntheories.AsiantherapistsmaymoreeasilyunderstandanEastern

worldvieworphilosophysuchasBuddhism.Religionisnotpsychotherapy,but

therapistscanintegrateaspectsofareligiousbeliefsystemintopsychotherapy,suchas

thepracticesofmeditationandmindfulness.Iftherapistsdonotunderstandand

consciouslyapplyastructuredtheoreticalorientation,theymaybelesseffectivein

helpingpatients.

ArttherapyandTheory

Arttherapydoesnothaveoneunifyingtheoryuponwhichitisbased.Because

arttherapylacksasinglefoundationalframework,arttherapistsarefreetostudymany

17

theoriesduringtheirtrainingasclinicians(Rubin,2001).Arttherapistshavetochoose

psychologicaltheorieswhicharecomfortableforthemtousewiththeirclientsand

integratetheseviewpointswitharttherapymethodology.

Allpsychotherapistssometimesneedtochangetheapplicationofthethchniqueto

meetaclient’sindividualneeds.Ifononeday,aclientneedseducationorbehavior‐

changingskills,thearttherapistmightchoosetechniquebasedonCBT‐arttherapy,

whichisacombinationofcognitivebehaviortherapyandart.Anotherday,whena

clientstruggleswithher/hisdivorcedparents,thearttherapistcanasktheclientto

drawafamilytree/genogram.Throughsuchanimage,arttherapistsareableto

observetheclient’sperspectiveoffamilyhistoryandculturalheritage.Asaresultof

suchportraiture,thearttherapistmightselectfamilysystemtechniqueasan

appropriateinvitationfortreatment.Onstillanotherday,iftheclienthasfamily

problems,thearttherapistmightasktheclient’sfamilytobeapartofaconjointsession

andaskthemtoworktogetherusinganarttherapytechnique.Suchsessionscreatean

opportunityforthearttherapisttoassessfamilydynamicsdirectly,leadingtoamore

clearunderstandingoftheclient’stherapeuticneeds.

ArtTherapyasAssessment

Artisknowntoencapsulatehumanexperiences,whichiswhyartassessments

havebeendescribedas“artbasedresearch”(Nissimov‐Nahum,2009).Drawingsare

usedasapartofdatacollectionbecausetheyshowtheclient’sthoughts,emotions,and

18

fantasies(Kearney&Hyle,2004;Silver,2009).Drawingcanbeatoolforunstructured

interviews,aswellasincreasingtheclient’srateofresponse(Kearney&Hyle,2004).

However,artinterviewsmustbecarefullyconductedinordertonotinvalidatetheclient

(Naumverg,2001).Cliniciansneedspecifictrainingonhowtouseartasassessment.

Whenaclinicianadministersartaspartoftheassessment,itisimportantforthemtobe

clearaboutwhatkindsofinformationcanhelptodirecttreatment.

Arttherapyassessmentsareusefulforfamilytherapy.Arttherapycanbeused

toassessfamilyfunctioninganddynamics,includingpointsofviewofthevariousfamily

members,relationshipsamongfamilymembers,thefamily’scommunication

mechanisms,family‐heldemotions,values,andbeliefs,etc.Itmaybepossibleto

determinewhohasthemostpowerinafamilywhentheyworktogetheronanart

activity.Forexample,drawingthefamilydinnertablemayrevealfamilynutrition,daily

lifestyle,andcommunicationstyle.Rubin(1984)statedthatthroughfamilydrawing,

arttherapistsareabletoobservefamilydynamicsandinteractionssuchaswhositsnext

towhomandwhointeractswithwhom(p.138).Clinicianscanaskaboutthefamilyand

relationshipswithinitbyusingthefamilypictures.Drawingapictureoffamilyalsois

usefultoanalyzefamilyfunctioning(Rubin,1984).

Cliniciansmustunderstandthemeaningofsymbolswhenartisusedfor

assessment(McNiff,2009).Symbolswillbeaffectedbytheclient’sculture,religion,and

philosophytowardsart(McNiff,2009).Forinstance,artcanbeusedtolearnmore

abouttheclient’sexperienceofdeathandgrief,aswellashowcognitiveand

developmentallevelsaffecttheprocessofdealingwithdeathorgrief(Nagy,1948;

19

Singer,1984,citedinGraham&Sontag,2001).Sometimesitisdifficultforclientsto

discloseandexpresstheirpainfulexperiencesoftheseeventsthroughlanguage.Art

canbeagreatwaytofeelsafeenoughtoallowexpressionofthesetroublingaffective

states.

Clinicianscanobserveclientsastheirclientsexpressfeelingsbyusingcertainart

materials.Sometheoriessuggestthatcolorshavecertainmeanings.However,itseems

unlikelythataparticularcolorhasaparticularmeaninginallcases.Forexample,using

alotofblackcrayondoesnotnecessarilymeanthattheclientisdepressedorthatthey

arethinkingaboutdeath.Culturalvaluesaffectthemeaningofcolors.Thus,itmaybe

inaccuratetointerpretclients’pictureswithoutconsideringculturalcontextfactors.

Whenclientstalkanddescribetheirexperiences,thoughtsandfeelings,diligent

clinicianswillalsotakenoteofsuchnonverbalexpressionsastensioninthefaceand

body.Carefulobservationcanleadtounderstandingwhenaclientisself‐regulatingin

aneffectivemanner.

Mostarttherapistsalsorecognizethataclient’sartworkmayshowaspectsof

theclient’sunconscious.Jungsaidthatarthasthepowertoworkwiththeunconscious

(Brooke,2004).Oneapproachtoaccessingtheunconsciousistodirectclientsinthe

firstsessiontoscribbledraw.Rubin(1984)suggestedthatbyusingthisapproach,art

therapistsareabletogetamaximumamountofinformationwithminimalstress.Such

anapproachcanalsoserveasapowerfuldiagnostictool(Rubin,1984).Drawingcan

highlighttheclient’scurrentleveloffunctioning(Wadeson,1980;Cohen,1986;Gantt,

2001aandb,citedinBrooke,2004).

20

Becausedrawingiseasierthantalkingforchildren,especiallyyoungerchildren,

drawingisusefultoassessthecourseoftheirlivesandprocesspainfulexperiences

(Graham&Sontag,2001).Drawingsareinitialassessmentsinarttherapysessions

(Brook,2004).Arttherapistsareabletoobservetheclient’smotorskills,movement,

personality,andcognitiveskills.White,Wallace,andHuffman(2004)wroteaboutthe

benefitsofarttherapyassessmentforchildren:

Artassessmentsoffer(a)anuncensoredviewofachild’sthoughtsand

feelings(Neale&Rosal,1993),(b)anonverbalmethodofassessmentfor

childrenwhoarestilldevelopinglanguageskillsorwhoareunwillingto

verbalizefeelingsemotions(Arrington,2001),and(c)anonintimidating

meansofassessmentinwhichchildrenarelikelytoparticipate(Peterson

&Hardin,1997).Tobemostuseful,artassessmentsshouldbe“non‐

threatening,easytoadminister,nortootime‐consumingtocomplete,

andeasyanalyzed”(Anderson,2001a,p.210).

ArtandCulture

Cultureimpactspeople’sfunctioningbecauseofitsstrongtraditions(Hoshino,

2003).Itisimportantforclinicianstounderstandtheculturalcontextofeachclientso

thattreatmentdoesnotinvalidateaspectsoftheirheritage.Ifcliniciansdonot

understandtheclient’svalues,andwheretheirthoughtscomefrom,theycannot

understandtheirclients’behaviors.Increasingly,cliniciansarestudyingcrosscultural

psychotherapypractice(Tanaka‐Matsumi,1979).Thesedays,whenAmerican

psychologistsdiagnosetheirclients,thepsychologisttypicallyasksabouttheclient’s

21

religion,values,ethnicities,andfamilytraditions,mentalissuesamongfamilymembers,

developmentalhistory,socioeconomicstatus,andeducationalhistory.Sharingworld

viewsbetweencliniciansandclientscanbeaneffectiveintervention(Tanaka‐Matsumi,

1979).Culturecreatesanimportantcontextwhichmustbetakenintoconsideration.

Forexample,ifparentssleepwiththeirtwelve‐year‐oldchild,throughtheAmerican

perspective,theymightneedtobereportedaspossiblechildabusers.However,ifthe

familyiscomprisedofrefugeesandhasnotsleptseparatelyduringtheirlongjourneyto

theUnitedStates,theirbehaviormaynotberelatedtoabuse.

Inthesameway,cliniciansneedtounderstandclients’cultureswhenartisused

withinsessions.Forexample,drawingachimneymightbenormalforpeoplein

Westerncultures.However,itmightbenotbenormalforpeopleinEasterncultures

becausetheymightnotusechimneys.Artitselfisacentralaspectofculturethatalso

playsanimportantpartinpsychologicalfunctioning.Forinstance,inJapan,eachfamily

ownsafamilycrest.Itisaconcretesymbolofone’sfamilyandencapsulatesthefamily

history.Symbolsintheworkofclientsoftenspontaneouslyemergeduringarttherapy

sessions.Themeaningsofthesymbolscanleadtoadeeperunderstandingaboutthe

client’sissues.

Recently,culturalpracticeshavebeguntobemorewidelydisseminatedaround

theworld.Forinstance,Japanesepeoplearenottheonlyindividualstositandlookat

theZenJapanesetraditionalgarden,andreflectontheirlife.Manypeopleinother

partsoftheworldnowenjoythispracticeaswell.Thesetypesofreflectionshelp

peoplerealizenewaspectsaboutthemselves.Theefficacyofformalperiodsof

22

reflectionmaybeonereasonwhymanyAmericansareinterestedinlearningaboutZen

andotherJapaneseculturaltraditions.

Culturesareaffectedbyenvironment,lifestyles,andvalues.Forexample,

peoplewholiveincloserelationshipsinacommunityaredifferentfrompeoplewholive

inanindividualisticsociety.Theformergroupmightbelievethatharmonyismore

importantthanthelattergroup,whereasthelattermayvalueautonomytoagreater

degreethantheformer.Cultureisaverysensitiveaspectofpsychologythatdeeply

influencesone’sworldview.

ZenArtUsedinHealing

TodaymanypeopleintheworldarefascinatedbyZenphilosophyandZenarts.

ItisclearthatJapaneseZenculturecanhealpeoplepsychologically.Itisimportantfor

clinicianstoknowhowZencultureandBuddhistphilosophyhaveinfluencedpeople’s

psychologicalwell‐being.ArthasbeenusedinthepracticeofZenandcanplayan

importantpartinhealing(Yanagida,1982).ZenandBuddhistculturehaveincorporated

artasahealingtool.However,BuddhistandZenarthasnotbeenusedasaclinicaltool

inmedicineorpsychologybecausetheirreligiousoriginshavedeterredscientific

acceptance.TheperspectiveofAmericanarttherapistsaboutarttherapyandwhatart

therapyiscanbeincorporatedinMoritaassessmentandtreatmentapproaches.Itis

importantforJapaneseclinicianstoknowhowZencultureandAsianphilosophy

influencepeople’smentalhealth.Forinstance,Zenpromotessimpleliving,meditation,

andthearts.

23

JapaneseZenhasdevelopedprimarilysincethethirteencentury.Itcamefrom

China(Yanagida,1982).BuddhismwasfirstestablishedinIndia.However,eachcountry

hasdevelopedBuddhismindifferentwaysandadjustedittotheircultures(Yoshida,

1985).ZendevelopedinmanywaysthroughoutJapaneseculture.WhenZenBuddhism

andJapaneseculturemelded,JapaneseclimateshapedJapaneseBuddhism,whichis

differentfromthestrainofBuddhismthatdevelopedinotherAsiancontinental

countries(Yoshida,1985).Forinstance,climateaspectssuchashighhumidity,

mountainousislands,manyrivers,andtheever‐presentoceanhaveaffectedthe

philosophyofJapaneseZen(Yoshida,1996).Zensaystolookattruth,notattheoutside

surfaces.Itvaluestheinside,anddoesnotvaluetheoutside(Yoshida,1985).Amajor

teachingofZenphilosophyistolivelikeariver.Thatmeanshavingnoresistanceand

followingyourdestiny.Anothercoreprincipleisthatallvisiblethingsarevain;allis

vanity(Yoshida,1985).Zenpromotesmeditationformindfulness(Yoshida,1985).Ona

practicallevel,theclimatealsoinfluencedartistictechniques.Highhumidityinfluenced

theuseofsimplecolorsforZenart.EventhoughJapaneseBuddhistsculptors

decoratedwoodstatueswithmanycolorslongago,highhumiditycorrodedthepaintof

thesestatues.ThatiswhyJapaneseBuddhistsculpturesarepaintedwithresinsfroma

lacquertreeandthecolorsareverysimple.

Zenoffersaphilosophyforhealing,andZenarthasbeenusedforhealing.Using

blackinkforZenartmeanstobesimpleandavoidcolor,infinityandvanity(Yoshida,

1985).Zenartusesaminimumoflinesandshapes(Suzuki,1940).Itdoesnot

24

distinguishbetweenbeautyandugliness(Yanagi,1949,p.95).Yanagi(1949)wrotethat

beautyanduglinessareoppositesonthesameline(p.90).Zenphilosophysuggests

makingacircleofthelinethatisbeautyandugliness.AccordingtoZenphilosophy,the

circleharmonizesorunitesasoneworld(Yanagi,1949,p.90).Thereisalinewhichhas

oppositefeelings(internalconflicts).Zensaysthatwhenyouusethelineandmakea

circle,thecircleisyourmind.ManyWesternarttherapistsuseacirclepicturefor

treatment.Theyasktheirclientstodrawinsideofthecircle,whichiscalledamandala.

Thetheoryisthatcreatingamandalaishealingbecausethecircleisabletocontainand

holdtheclient’sfeelingsandthoughts(Rubin,2001).

Also,Zenrockgardenshavecontributedmanywaystohealpeopleintheworld.

RockgardensdemonstrateZenphilosophy.Thegardenoftendoesnotuserealwater

andtrees;itusesonlyrockstoshownature(Yanagida,1982).Therocksaresymbolsof

death,andthegardenismadetobeimperfect.Zenart'sgoalis“beforeperfect”or

“imperfection”(Yanagida,1982,p.19).TheJapanesesenseofbeautyisobtained

throughimbalanceandimperfection.Forexample,Japaneseculturevaluesodd

numbers,notevennumbers(Yanagida,1982).Zenphilosophyiscontradictorytosome

Westernvalues.Forexample,manyAmericansbelievethathavingalotofthingsisa

sourceofhappiness.Bycontrast,Zenphilosophysaysthatmaterialisticdesiresand

externalbeautifulobjectsdonotmakepeoplehappy.Zenemphasizescompassion

towardpeople.ArthasbeenusedinthepracticeofZenandcanplayanimportantpart

inhealing.

25

Zenphilosophyandhealingmethodshaveanimportantroletoplayinmental

health.Asianculture,includingJapaneseZenandBuddhistcultureandphilosophy,have

muchtoteachusabouthealthypsychologicalfunctioning.

26

II.THEORETICALHISTORYOFARTTHERAPY

ArtTherapyandTheories

InordertoexaminetheintegrationofMoritatherapyandarttherapy,itis

importanttostudytheotherkindsoftheoriesuponwhicharttherapistshavedrawn

historically.Arttherapistsaredrawntopsychologicalmodelstousewitharttherapy

thatarecomfortableforthempersonallyandthatofferdeeperunderstandingforthem

(Rubin,2001).Theoriesarechosenasaframeworkforarttherapyasaresultofother

reasonsaswell,reasonssuchasculture,psychologicalhistory,andsocialsituations.

Cultureaffectsdiagnosesandtreatments.Newtheorieshavebeendeveloped

throughoutthehistoryofthefieldofpsychology,inresponsetochangingtimesand

historicalevents.Evolvingsocialsituationshaveresultedinnewkindsofmentalillness.

Infact,mentalillnessesandtreatmentsdonotexistwithoutculturalinfluence(Frank&

Frank,1993).Mentalillnessesoccurincombinationwithone’sphysicalandsocial

relationshipproblems,profoundlyaffectedbyculturalnormsinregardsto

communicationstyles,thoughts,behaviors,andfeelings(Frank,&Frank,1993).One

exampleoftheinfluenceofcultureondiagnosisisShinkeisitsu‐showhichwasseenonly

inJapan,asclassifiedbyMorita.Anotherexampleofculturalinfluenceisthatduring

WorldWarII,Russiansoldierswereneverdiagnosedwithpsychoneurosesbecausethe

RussianArmydidnotrecognizetheseasillnesses(Frank,&Frank,1993).

TheoreticalHistoryofArtTherapy

Inthe1910s,Naumburg,whoiscalledthemotherofarttherapy,choseCarl

Jung’sanalyticalpsychology,whichwascloselyalignedwithpsychoanalysis,asthe

27

theoreticalframeworkforherworkinarttherapy.Atthattime,FreudandJungwere

verypopularintheUnitedStates.AfterWorldWarI,peopleintheUnitedStateswere

sufferingagreatdealofanxietyandstrugglingwithpoverty.ManyvictimsofNazi

GermanyhadimmigratedtotheUnitedStatesandweredealingwiththetraumatic

aftermathofthewar.Naumburgwasanartteacherforchildrenwhosufferedfrom

mentalillness.Inworkingwiththemartistically,shefoundthattheirpictureswere

symbolic.SheappliedJung’stheorytoanalyzeandunderstandherstudents.

NaumburgbelievedthatJung’spsychologicalmodelwasusefulforherstudentswithits

strongvalidationthatartexpressestheunconscious.Later,shebecameapsychologist

andusedthetheorywithartwithherclients.

Inshort,therearemanylikelyreasonswhyNaumburgchoseJung’stheoretical

modelforherwork.Forone,psychoanalysiswasapopularandmajortheoretical

orientationinWesterncultureatthattimeinhistory.Psychologywasarelativelynew

fieldandthenumbersofavailabletheorieswerelimited.Additionally,Jung’sanalysis

aboutimagesinspiredherthinkingandresonatedwithherwork.Shewantedtohelp

andunderstandherstudentsdeeply.ShebecameanardentadmirerofJung.Forthe

firsttimeinAmericanhistory,apsychologicaltheorybecametheframeworkfortheuse

ofartintreatment.

Duringthesametimeperiod,artwasusedasahealingmethodinZenculture.In

theearly1920sinJapan,MoritastudiedFreudbutbelievedthatFreud’stheoretical

orientationwasnotusefulbecausepeopledidnotneedtogetintouchwiththeir

unconsciousinordertobehelped.Instead,heformulatedhisowntheoretical

28

orientation,whichhecalledMoritaTherapyandfoundedaninpatientunitusingthis

approach.

Inthe1920s,behaviorismbecameapopularpartoftheworldofpsychology.In

theUnitedStates,EdwardLeeThomdike(1874‐1949)conductedaseriesofexperiments

withratsandpuzzles.InRussia,IvanPavlovbeganhisfamousexperimentswithdogs,

tones,andmeatpowder.Behaviorismstudiedhumanbehaviorthroughanimal

experiments.However,thereisnorecordthatpsychologists,psychiatrists,ortherapists

usedthetheorybehindbehaviorismwithartatthattime.Americanarttherapistsdid

notappeartobefamiliarwithbehaviorism,butrather,werefocusedonpsychoanalytic

models.Interestingly,thetheorybehindMoritaTherapyhassomesimilaritieswith

behaviorismbecauseclientsaretaughthowtothinkandbehave.

IntheUnitedStates,manyhospitalswerebuiltfollowingtheendofWorldWarI

inordertoaddressmedicalproblemsexperiencedbyveterans.IntheStateofKansas,

theMenningerClinicopenedupwithJeanettaLyleandRuthFasionShawproviding

treatmentbyusingartwithlong‐termin‐patientswhosufferedfromPostTraumatic

StressSyndrome(PTSD),especiallychildren(Jung,1994).SimilartowhatNaumburg

wasdoingelsewhere,attheMenningerClinicartwasusedinthetreatmentof

children’smentalillnessundertherubricofpsychoanalyticaltheory.

Inthe1930s,EdithKramer,whowasanartteacherandfineartist,usedartwith

childrenwhohadescapedfromtheNaziconcentrationcamps.Theartallowedthemto

expressangerwithHitler,fear,andunsolvedconflict.Shefoundthatthosechildren

becamemoreresilientthroughtheart‐makingprocessandfoundhopefortheirfuture

29

lives(Kramer,1972b).LikeNaumburg,KramerhasusedJung’sanalyticalpsychologyto

interpretsymbolicmeaningandalsousedFreud’stheoryoftheunconscious.

Essentially,NaumburgandKramerchoseanexistingpsychologicaltheoryuponwhichto

basetheirclinicalwork.Moritadidnotfindanavailabletheorythatwassuitableforhis

work,andtherefore,turnedtocreatinganewone.

Duringthe1960s,withtheinfluenceofFreudandJunghavingdiminished

somewhat,manyarttherapistsintegratedavarietyofotherpsychologicalorientations

withtheirclinicalwork.Forexample,ElkinsandStovall(2000)foundthat28.2%of

1,846membersoftheArtTherapyAssociationin1998‐1999usedmorethanone

theory.20.8%oftheassociationmembersinthestudydeclaredthemselvesaseclectic,

meaningtheychoosefromavarietyoftheoreticalorientations,dependingonthecase.

10.1%ofthemwerepsychodynamicpractitioners,ofwhichtheJungianswere5.4%and

4.6%employedobjectrelationstheory.CognitiveBehavioralTheorywasusedby2.2%

ofthemembers.Between1.0%and1.9%ofthesearttherapistsascribedtoclient

centeredtheory,Cognitive,Gestalt,Developmental,Existential,orFamilySystems

theory.Allothertheoreticalorientationswerelessthan1%oftheresponses(Elkins,&

Stovall,2000).

Theabovesurveyshowedwhatkindsoftheoriesarttherapistschose.However,

itdidnotshowthereasonswhytheychosethetheories.80%ofthemembershipchose

aparticulartheory.Nonetheless,alltheoriesdonotfitwithallkindsofmentalillness.

Certaintheoriesaremorehelpfulinexplainingortreatingcertainillnesses.Onemodel

maynotbeeffectiveforallkindsofpsychiatricdisorders.Forexample,itmightbe

30

bettertouseCognitiveBehaviorTherapyorExistentialTherapyforPTSDclientsrather

thanpsychoanalysis.Thepsychoanalyticmethodtakestimeandiscostly.Theclient

mightneedacutetreatmentorneedtofocusonthepresentandfutureratherthanthe

past.FortherapistswhoidentifiedtheirtheoreticalorientationasEclectic,thereare

reasonstochooseparticulartheoriesforparticularclients.Itisnotunreasonableto

assumethataclinicianwoulddrawondifferenttheoriesthroughthecourseof

treatment.UsingWesterntheorymaynotfitculturallyforAsianclientswhereasusing

MoritaTherapymaybemoreappropriateforthem.Futurestudiesarewarrantedto

studythereasonswhyarttherapistschoseparticularpsychologicaltheoriesandhow

effectivetheyareinusingthem.

ChoiceofTheory

Therearetwotendenciesthatinfluencehowarttherapistschoosethetheories

underwhichtheyoperate.Firstofall,manyclinicianschooseatheorytofitclient

conditions.Secondofall,cliniciansmaychooseatheorywithwhichtheypersonallyare

morecomfortable,onethatmakessenseforthem(Rubin,2001).Arttherapistswho

usedEclecticmethodsintheAmericanArtTherapyAssociationsurveysubscribedtothe

firsttendency.Thosewhousedaparticulartheorysubscribedtothesecondtendency.

Fortheirpart,clientsoftenchosetheirtherapistbasedonwhattheyunderstandto

bethatperson’stheoreticalorientation.However,theymightnotunderstandeach

theoryverywell.Itisimportantforclinicianstobeawareofthetheorytowhichthey

subscribe,aswellasthereasonsforit.

31

AdvantageofIntegratingArtTherapywithTheory

Inthepast,arttherapyhasbeenusedwithavarietyofpsychologicaltheories.

Usingartisefficaciousformanyclinicaltreatmentapproaches.Itcanfacilitate

communicationbetweentheclientandtheouterworld.Anarttherapistisabletobe

withtheclient’spsychologicalprocessatits’mostvulnerable.Duringtheprocessof

makingart,clientsareabletofindtheirtrueself,andbymakingart,clientsexperience

achievement.Ontheotherhand,itisimportanttoconsideriftherearepsychological

modelswhichshouldnotuseart.Currently,thereisnopublishedinformationabout

this.However,inthefuturethisissueneedstobeexaminedbecauseitisvery

importanttofindthemosteffectiveintegrationoftheorywithart.

PossibleIntegrationofMoritaTherapyandArtTherapy

TherearereasonsarttherapymaybeabletobeintegratedwithMoritaTherapy.

First,historicallyarttherapyhasbeenabletointegratewithanytheoreticalorientation

totreatment.SoitshouldbepossibletointegrateMoritaTherapyandarttherapy.

Typically,MoritaTherapyhasusedartinitssecondstage,whichislabeledLight

OccupationalWork,aswellasinthethirdstage,IntensiveOccupationalWork.For

example,thecliniciansasktheirclientstowritedailyjournalsandtomakewood

sculptures.UsingartisanaturalmatterforMoritaTherapy.Second,MoritaTherapy

mightworkwellwithsomepopulationssuchaswithAsianclientswhoarefamiliarwith

Buddhism.Asiancliniciansandthepeopletheytreattypicallyarecomfortablewiththe

philosophybehindit.ItmaybeeasyforAsianstounderstandaboutBuddhist

philosophyandhealingmethods.Otherpeople,whoareinterestedinAsianphilosophy,

32

whoarenotinclinedtoexploretheirunconscious,wholiketomeditate,orwholiketo

makeagardenorsandtraymaywanttouseMoritaTherapy.

33

III:MORITATHERAPY

ConceptofMoritaTherapy

In1917,ShomaMorita,M.D.(1874‐1937),whowasaJapanesepsychiatristin

Japan,formulatedMoritaTherapy.Thistherapyfocusedonacceptingandholdingall

emotions,resolvingconflictingthoughts,andbecomingfreefromobsession(France,M.,

Cadieax,J.&Allen,E.,1995).Moritabelievedthatmentalillnessoccurredbecauseof

conflictbetweenone’sdesireandone’sattempttocontrolanxiety(Morita,1929/1960/

2004;andNakamoto,2009).MoritaTherapydevelopedasatreatmentfor

ShinkeishitsushoorNervosity,whichincludedproblemswithobsessiveshyness,

oversensitivityandfeelingsofinferiority(Ishiyama,1986;Sansone,2005).Morita

(1929/1960)statedthatclientswithShinkeishitsushoorNervosityhadlonghistoriesof

innerconflictsandbehavioralproblemswithsocialadjustment,anxietyandneuroses,

includingobsessiveshyness,oversensitivity,andfeelingsofinferiority(Sansone,2005).

ClientswithShinkeisitsushotendtopersistinunrealistic,dogmaticthinking(Ishiyama,

1990).Inparticular,theseJapaneseneuroticclientstendedtofeelguiltybecauseof

lazinessorself‐centerednessandlackofsociallyresponsiblebehaviorsintheabsenceof

physicalsickness(Reynolds,1969).PossiblybecauseMoritastrictlyselectedclientsfor

hisMoritaTherapytreatment,hisratesofsuccessfultreatmentwerehigh(Ishiyama,

1986).CurrentlyMoritaTherapyisalsousedforavarietyofdisorderssuchas

depression,schizophrenia,borderlinepersonalitydisorder,andalcoholdependence

(Maeda&Nathen,1999).However,MoritaTherapyisnotconsideredsuitableforthe

34

treatmentofacuteschizophrenia,borderlinepersonalitydisorder,oraggressive

behavior(Nakamura,2008).

MoritaTherapyisaholisticapproach,whichmeansthatitisbasedonthe

premisethataperson’smind,body,andenvironmentareconnected.Itiscalledholistic

humannature(Nakamoto,2009).Theholisticphilosophythatnatureandspiritcannot

beseparated,isaconceptthatisendorsedbybothTaoismandZen(Nakamoto,2009).

Accordingtothisbeliefsystem,becausethemindandbodyarerelated,maintaininga

healthybodyleadstohavingahealthymind(Morita,1928/1998).Bothpsychological

andphysicalwell‐beingismaintainedbybalancinginternalandexternalfunctioning

(Morita,2004).MoritastatedthatMoritaTherapyiscognitive,transpersonal,and

experientialpsychotherapy(Morita,1928/1998).

MoritaTherapyisreality‐basedandfocusesmoreon“thehereandthenow”of

theclient’severydaylife.Lessemphasisisgiventopastevents,asthepastcannotbe

changed(Sansone,2005;Nakamoto,2009).Ishsiyama(1986,1990)hasarguedthat

MoritaTherapyisaJapaneseversionofCognitiveBehaviorTherapyaspracticedin

Westerncountries.BothMoritaTherapyandBehaviorTherapytreatmentsshowed

improvementratesof75%to95%forindividualswithobsessive‐compulsivedisorder

withanxietyneuroses(Reynolds,1969).ReynoldssaidthatAcceptanceand

CommitmentTherapy(ACT)intheWestissimilartoMoritaTherapybecauseit

encouragesclientstofocusonpracticingmindfulnesstechniques,ratherthanchanging

theirenvironment(Hofman,2008).Japanesecognitivetherapyisinfluencedby

BuddhismandEasternphilosophy.Westerntherapiestendtofocusonself‐reflection,

35

insight,controlofsymptoms,andsupportofself‐esteem(Ishiyama,2003).However,

thegoalofMoritaTherapyistohelpclientschangetheirmood‐basedandpurpose‐

orientedlifestyles(Ishiyama,1986).MoritaTherapyisconcernedwithchangingthe

client’sdysfunctionalcognitiveandbehavioralpatternsanddoesnotfocusonreducing

symptomsastheprimarygoal(Ishiyama,1986).Itisdifficultforpeopletochangetheir

livingsituationsandespeciallytochangetheirfamilydynamics,evenifthosefactors

affecttheirpsychologicalproblems.Inthecaseofabuse,thevictimsmustberemoved

fromtheiroriginalfamily.Insomesituations,changingenvironmentsisthemost

reasonableaction.However,inmanysituations,ifthechildrenliveindysfunctional

familyenvironments,eveniftheyexperiencepsychologicaldistress,theycannotchange

theirenvironmentsorcaregivers.Itmightbedifficultorimpossibleforthemtomove

fromtheenvironment.

HistoryofMoritaTherapy

Asamedicaldoctor,Morita’sbasictreatmentbeliefswerebasedonZen

Buddhism.Heaskedhispatientstoobeyhisdirection(Fumo/不問),tobecomeinvolved

ininpatienttreatment,andtolearnfromtheirexperiences(Morita,2004;Kitanishi,

2008).Afteratime,hisinitialinpatientprogramranintodifficultiesandwaschanged

intoanoutpatientprogrambecauseofthefinancialproblemsassociatedwithfinding

clinicianswhowereabletoworktwentyfourhoursaday,sevendaysaweek.Today,

outpatienttreatmentisthemainstayofMoritaTherapy.Inaddition,inJapanthereare

nowmanykindsofsupportgroupsinthecommunitysuchas“Seikatsunohakken”and“

Ikigairyohojissenkai”whichcarryoutthegoalsofMoritaTherapy.Thegroupof

36

“Seikatsunohakken”isasupportgroupthatcountsmorethan3,000membersamong

theJapanese.Eachprefecturehasitsowngroup.Seikatsumeansdailylife.Hakkenis

discovery.TheHakkenhavemeetingswithtrainerswhoareeducatedattheMorita

TherapyAssociationandlearntosupporteachotherinregardstotheirmentalhealth

issues.The“Ikigairyohojissenkai”aresupportgroupsforcancerpatientsinJapan.

“Ikigai”meansthatfindingthereasonsforourlife.“Ryoho”meanstreatment.“Jissen”

meanspractice.“Kai”meansagroup.Thesegroupsarededicatedtosupportingcancer

patients,andhelpingthemlearnhowtolivestronglivesdespitetheirillness.Morita

Therapy’stheoreticalframeworkisusefulforthem.MoritaTherapyisabout

holding/acceptingallemotionsandlivingwiththem.Bycontrast,Westerntheories

stresscontrolling/suppressingemotionandfindingit’scauses(Morita,2004;Kitanishi,

2008;Nakamura,Iwaki&Kubota,2007).

Morita’sChildhoodExperiences

Morita’schildhoodaffectedthedevelopmentofMoritaTherapy.He

experiencedfearofdeathduringhischildhood.Moritawasexposedtoapictureofhell

ataBuddhisttemplethathefounddisturbing.Followingtheexposure,hehadrepeated

thoughtsaboutdeath.TheepisodegreatlyaffectedthetheoryunderlyingMorita

Therapy.“Fearofdeath”isoneofthemostimportantelementsofMoritaTherapy

theory.Moritabelievedthatbecausehumanbeingshavefearofdeath,theyalsohave

desiretolive,asthesetendenciesareliketwosidesofonecoin(Morita,2004).Morita

continuedtohavefeelingsof“fearofdeath”duringhisadolescence.Hebecame

anxiousandcontinuedtofeardeath.Heagonizedwithhisfatheraboutit.Hischronic

37

anxietymeantthatheneededanextrayearbeforehewasabletograduatefromschool.

Italsowasafactorinhisrunningawayfromhishome.Later,Moritawrotethateven

whileheexperiencedpanic,healsofeltastrongdesiretolive.

AfterMoritabecameacollegestudenthefoundhimselfinconflictwithhis

father.Inresponse,hedevelopeda“who‐gives‐a‐damn”attitude.Thoughhehadbeen

treatedforhisanxietybyhisdoctor,hequittakinghismedicationanddevotedhimself

tostudyingforhisnextexaminationathiscollege.Theresultofthisdefiancewas

surprising.Hegotgoodgradeswhichhehadneverhadbefore.Throughthese

experiences,hedevelopedanotherprincipleofMoritaTherapy:ifpeoplewantto

removeanxietyandfear,theyhavetoconfrontit.Hestatedthatthereisnowayto

resolvefearexcepttoaddressitdirectly.

Afterhegraduatedfromtheuniversityin1903,Moritabecameapsychiatrist.

HeusedhypnotismandmedicaltreatmentsforhispatientswhohadShinkeishitsushoor

nervosityproblems.However,heconcludedthattheusefulnessofhypnotismwas

temporary,makingthisformoftreatmentnotessential(Morita,2004).Duringthistime

periodMoritastudiedWesternandEasternphilosophiesandpsychology(Morita,

1928/1998).MoritastudiedFreud’stheories(Ishiyama,1986),Montessorimethods,

abdominalbreathing,Shintorituals,andZenmeditation(Nakamoto,2009).

BirthofMoritaTherapy

Moritabelievedthatallhumanbeingshaveafearofliving,aging,gettingsick,

anddeath.ThesearebasictenetsofBuddhism.HecalledthisbeliefSeirobyoshi,生老

38

病死.Sei,生,meansliveandlife.Ro,老,meansaging.Byo,病,meanssickness.Shi,死,

meansdeath.

In1915,beforehestartedhisinpatienttreatmentprogram,Moritahada

significantexperienceinwhichhetreatedapatientwhohadpanicdisorder.Moritawas

abletohelptheindividualinonesession.Thissuccessfuloutcomeledhimtothe

developanoutpatienttreatmentprogramcalledMoritaTherapy.Inaddition,Morita

createdthe“viciouscircleofconflictingthoughts,”afoundationalconceptinhisnew

theory.In1925,Moritaproposedthatemotionsleadtocognitionsandthatthose

determinebehavior(Morita,1995).ThisisrelatedtoanotherbasicBuddhistbelief:

thatthebodyfirstexperiencesandthenchangesfeelings,thenchangesthoughts,and

nextitchangesconsciousness,whicheventuallychangesvolition.Hewrotethatifthe

experiencesofemotionswerenegative,thenabadcircleofthinkingwasinitiatedand

sufferinggrew,whichmeantthatthereweremorechancesthatthepersonwould

becomementallyill.BeforeCognitiveBehaviorTherapywasformulated,Moritahad

taughtthatemotion,cognition,andbehaviorrelatepowerfullytoeachother.

WhenMoritastartedinpatienttreatmentathishomein1919,hisbasicapproach

wastoprovidetreatmentinterventionswiththeexpectationthattheywouldnotbe

questioned.ObeyingMorita’stherapeuticdirection(Fumo/不問)wasconsistentwith

thefirststepinBuddhistmonktraining.Patientswereexpectedtowritedailyjournals

asameanstoenhancetheircognitions.In1926,MoritaTherapyevolvedtoaprogram

thatprovidedtreatmentthroughthemailforpatientswhowereunabletostayinthe

39

hospitalforalongtimeandwholivedfaraway.In1929,Moritaprovidedtherapyin

bothinandoutpatientsettings.

DuringthisperiodwhenMoritawasdevelopingMoritaTherapy,hehospitalized

patientsinhishome,turningitintoaresidentialclinic.TheoriginaltreatmentofMorita

Therapywas40daysintheresidentialclinicofMorita’shome(Maeda,&Nathan,1999).

Moritabelievedthatin‐patienttreatmentwasinevitable,(Morita,1928/1974).The

durationoftreatmentcouldtakeuptoseveralmonths.Moritaobservedhisclients

closely.Duringtheirfirstphaseoftreatment,hepreventedthemfromdoinganything,

andthengraduallyallowedthemtoengageinactivitiesonlyiftheyeagerlyfelttheir

ownSeinoYokuboor“desireoflife.”SeinoYokuboissimilartoFreud’s“lifeprinciple”

orRoger’sstateof“self‐actualization”(Reynolds,1969).Inotherwords,Moritatook

totalcontrolofhisclientsinordertobreakdowntheirhabitofover‐controlling

themselves.MoritaTherapycausestheirself‐defeatingbehaviorandcycleofthoughts

tochangeinapositivedirection(Ishiyama,1990).Thistreatmentmethodiscalled“Re‐

educationalTreatment”orthe“HomelikeEnvironmentTreatment”(Nakamoto,2009).

HowMoritaTherapyViewsPathology

AmostimportantgoalofMoritaTherapyistheeliminationofthe“viciouscircle

ofconflictingthoughts”(Morita,1995,p.112).Moritastatedthatsufferingisnotthe

naturalresultofmentalillness.Rather,sufferingoccurredasaresultofthe“vicious

circleofconflictingthoughts”(Morita,1995).Moreover,hebelievedthatmostpatients

whohadamentalillnesswerecaughtupintheviciouscircle.Thepatientsbelievedthat

theywerepowerlesstoovercometheirillness,butthatwasincorrect.Theyjustneeded

40

tounderstandhowthecircleworked,andhowtocutitoutoftheirlives(Morita,1995;

Kitanishi,2008;andNakamura,Iwaki,&Kubota,2007).

BothCognitiveBehaviorTherapyandMoritaTherapybelievethatavoiding,

controlling,suppressing,andendlesslysearchingforthecauseofemotionscreatesa

viciouscycleandadownwardspiral(Nakamura,Iwaki,&Kubota,2007).Thedifference

betweenthetwotheoreticalorientationshastodowithhoweachunderstandsthe

circleandwhateachproposestodotoaddressit.MoritaTherapytheorizesthat

anxietyistheoppositeofdesire.Itisimportantforapatienttoacceptandlivewith

anxietyandfearbecausetheseaffectivestateswillnotdisappear.CognitiveBehavior

Therapy(CBT)believesthatifpeoplechangetheirthoughts,theirbehaviorswillchange.

CBTteachesthatanxietyandfeararelearnedreactionsthatcomefromwrongthoughts.

TheemphasisinCBTisonchangingone’scognitions.Bycontrast,MoritaTherapy

focusesonaction.ThisisconsistentwiththeBuddhistbeliefthatnothingisrealexcept

foractions.

TheCoreofMoritaTherapyPathology:ViciousCircleofConflictingThoughts

(Akujyunkan/悪環)

Pathology,accordingtoMoritaTherapy,comesfromthe“viciouscircleof

conflictingthoughts,”(Morita,1995),MoritaTherapytreatmentstrivestocutthrough

thecycleandtofocusonaction(Morita,2004;Nakamura,Iwaki,&Kubota,2007;

Kitanishi,2008;andNakamura,2008).Moritatherapistsanalyzewheretheirpatients

areinthecycleofissuesthatstemfromthe“viciouscircleofconflictingthoughts”

(Kitanishi,2008).

41

Kitanishi(2008)believedthattheviciouscircleofconflictingthoughts

(Akujyunka悪循環)wasaffectedbytherelationshipsamongemotion,cognition,and

behavior.Nakamurasaidthatthecyclehappenedasaresultoftherelationshipamong

attention,clingingbehavior,andnarrowthinking.Thesetwotheoristsuseddifferent

wordsforexplainingtheviciouscircle,butMoritausedbothsetsofwords.

Figure1.ViciousCircleofConflictingThoughts(Akujyunkan悪循環)

Agoodexampleoftheviciouscircleofconflictingthoughtscanbefoundinthe

experienceoftraumavictims.Whenclientsremember,focuson,andattendtotheir

traumaticmemories,theysuffer.Theiremotionsbecomeheightenedandtheyoften

experienceacuteanxiety.Themoretheyremember,recallandthinkaboutthose

memoriesagainandagain,themoretheyexperiencesuffering.Thepainfulemotions

increaseinstrengthbecausethefeelingsbecomeincreasinglysensitive.Negative

cognitionandclingresult.Eventually,clientsbecomedysfunctionalbecausethose

Cognition Clinging Behavior

Narrow thinking

Emotion Attention

42

experiencesaffecttheirbehaviorandnarrowtheircognitivefocusincreasinglytowards

thetrauma.Finally,theybecomeslavestotheviciouscycleandthecyclebecomesa

downwardspiral.Theycannotbearthosepainfulexperiencesandbecomementallyill.

AHypotheticalCaseoftheViciousCircle

TheTraumaticEvent

WhenMs.AusedaMetrobustogotohospitalforherappointment,shecouldnotget

offtherightplace.Shemissedthebusstopwhereshewantedtogetoff.Shewasupset

andwaslateherappointment.

AttentiontoNegativeEmotionalExperiences

Atthenextappointmentday,sherememberedthatshehadgottenupsetandmissed

herappointment.Thosememoriescreatedinherthesamefeelingsthatshehad

undergoneduringthetraumaticevent.Shewasupsetandfeltbadagain.Shereadily

focusedonhavingmissedthebusstopandhavingbeenlatetoherappointment.She

gaveattentiontothesethoughtsandemotions.

NegativeCognitionandClingtotheNegativeEmotions

Ms.Awasafraidoftakingabus,butshedidnothaveacar.Sheclungtothenegative

thoughtsagainandagain.Sheimaginedthatifshetookthebus,shewouldstillnot

likelygetthereontime.Shethoughtherdoctormightbedisgustedwithher.Those

negativethoughtsandpainsrolledoverherlikewaves,attachingthemselvestoher.

Shesuffered.

43

BehaviorandNarrowThoughts

Ms.A.believedthatsheshouldbeontimefortheappointmentinordertobeaperfect

andgoodpatientforherdoctor.Shedidnotwanttomakemistakes.Shebelievedif

shecouldnotmakeit,itwasshameful.Itmeantthatshecouldnotdoanythingright.

AViciousCircle

Ms.A.rememberedandrecalledthefirstevent,andthenshethoughtthatshehadto

bethereontime.Ontheotherhand,shewasafraidofmakingthesamemistakeand

arrivingtoolate.Shebelievedthatsheshouldnotbethatkindofperson.Shewas

afraidoftakingabusandgoingout.

Thesufferingcamefromthegapintheclient’sthoughtsbetweenherimagined

ordreamideaofselfandherrealself.Shebelievedthatsheshouldbeherimaginedor

dreamedperfecthumanbeings.Ifthegapbetweenidealandrealisverylarge,people

becomementallyill.

*PathologicalormentallyillImageisbiggerthanreal

*Healthyfunction

Figure2.DiscrepancyBetweenImaginaryandRealSelf

RealFigureEmotion:Anxiety

Can’tdoit.Afraidofit.

Theexample:Imightbelateandmightmissthebusstop.Emotion:Iamafraidofbeinglate.IhaveanxietythatIwillmakethesamemistake.

ImaginaryFigureDesire

Shouldbedoneperfectly.Theexample:Ishouldbeontimetotheappointmentandshouldnotmissthebusstop.

44

MoritaTherapystrivestocutthroughtheviciouscircle.Theviciouscircle

happenswhentheimaginaryself(desire)isbiggerthanrealself(reality).Clientswho

havethetendencytobelievethattheyhavetobebetterthantheyreallyare,Morita

namedas“ShisounoMujun/Incongruentideas”(Morita,2004).Incongruentideas

takeplacewhenpeoplehaveconflictingideasbetweendesiresandrealities.

HumanRelationshipsWithintheViciousCircle

TheviciouscircleandShisounoMujun/Incongruentideashappennotonlyin

regardstoanindividual’spsychologicalorphysicalstate,butalsowithinhuman

relationships.Anexampleofindividualpsychologicalandphysicalpainisasfollows.Ifa

persongetsinacaraccident,theyfeelpainbecauseoftheevent.Whentheyfeelpain,

theyremembertheaccident.Atthetimetheyhavememoriesoftheaccident,andthey

experiencepainpsychologicallyandphysically.Theybelievethattheaccidentisthe

causeforalltheirpain.Whentheyseeorthinkaboutacar,theviciouscirclehappens

andtheydonotgooutside.

Anexampleofhowtheviciouscircleoperateswithinarelationshipisasfollows.If

parentsfocusontheironlychild,theirparentingstylebecomesoverprotective.The

childisunabletothinkandmakedecisionsbyherself.Thechildmightfinditdifficultto

communicatewithfriendsatschool.Themoredifficultythechildhasatschool,the

moredistresstheparentsexperienced,leadingthemtoprotecttheirchildtoagreater

extent.Thisexampleshowstheviciouscircleofrelationships.MoritaTherapyhasa

uniqueapproachtosolvingtheseissues.

45

Figure3.SummaryoftheViciousCircleofConflictingThoughts

AnxietyandDesire恐怖と欲望

Morita(2004)believedthatbasictoallhumanbeingsareanxietyanddesire.

Allhumanbeingshavedesire.Consequently,allhumanbeingshaveanxiety.For

example,acoupleownsahouseandtheyhavetopaythemortgage.Iftheyreallywant

togetthehouse(desire),theyhavetohaveajobandworkforthemoneytopaythe

mortgage.Theyworryaboutlosingtheirjob(anxiety).Iftheyjustclingtoathoughtof

havingthehousebutlosingtheirjob,theymightpanicbecauseoftheanxietyoflosing

thehouse.Theyworryandmightbecomedepressedandbecomeunabletoeat.

Becausetheybecomephysicallyill,theycannotfindajob.Moritasaidthatanxietyand

desirearetwosidesofonecoin.Itisimpossibletotakeanxietyaway.However,this

alsomeansthatnobodycantakedesireaway.

TheViciousCircleofConflictingThoughts

Desirevs.Reality MoritaTherapyTreatments

SELF

ImageReal

Leaveallfactsandemotion.Trytochangetheirbehaviorbychangingactions.

CognitionClinging

BehaviorNarrowthinking

EmotionAttention

46

HumanBeings

AnxietyDesire

Figure4.TheConnectionBetweenAnxietyandDesire

Morita(2004)statedthatifhumanbeingsareunabletoeliminateeitheranxiety

desire,theyhavetoacceptandholdtheseasnaturalphenomenon.Additionally,he

statedthathumanbeingshavetofindsomethingthatwecandoafteracceptingand

holdinganxietyanddesire.Otherwise,humansengageinself‐negation.

NatureTheory自然論

NatureTheoryisonewayofunderstandinginMoritaTherapy.Morita(2004)

statedthatitwasnaturalforhumanbeingstohavealotofkindsofemotions.He

believedthatanger,jealousy,anddesirewerenormalhumanreactions.Forhim,these

arenotpathologicalreactions.Normalhumanreactionsbecomementalillnessonly

whenthereactionsaresuppressedbyourcognitions.Ifanaturalphenomenonsuchas

anger,jealousy,desire,andotheremotionisaccepted,itwillreachitspeakand

eventuallydisappear,likeanormaldistributionfunctionline.Evenwhentheemotions

47

taketimetopeak,itisimportanttoholdallofthemuntiltheydisappear(Morita,2004;

Kitanishi,2008).

CorePrinciplesofMoritaTherapy

ShisounoMujun/IncongruentIdeas

Incongruentideasmeanthatpeoplehaveconflictingideasbetweentheirdesires

andreality.Often,realitydoesnotallowadesiretobeobtained.Forexample,ifone

thinksthatitisnecessarytogotothegymeverydayat6a.m.beforeworkbutcannot

wakeupandgoatthattime,onemightfeelalotofstress.Thus,thereareincongruent

ideasbetweenone’sdesireandreality.Moritasaidthatifpeopleareobsessiveor

attachedtooneidea,theirthoughtswillbelimited.Theywillbeunabletoentertain

otherideas.Hesaidthatclientsdonotneedtothinkintermsof“shouldand

shouldn’t.”Evenifonecannotgotothegymat6a.m.beforework,onewillbefineand

canchangeone’splanstofitwithreallife.

SyukanandKyakkan/SubjectiveandObjective

Moritasaidthatiftheclientsfocusontheirsymptomsorfeelingsstrongly,theywill

havedifficultythinkingaboutothermatters,suchastheirreallifewithitsdailyroutines.

Theymaypersistinthinkingabouttheirsymptomsandfeelingssubjectively.Ifaclient

feelsthatway,theclinician’sobjectiveadvicewillnotwork.

KanjyoandChishiki/EmotionandKnowledge

Peoplehaveemotions,buttheymaytrytocontroltheiremotionswiththeir

intellect.However,havingandfeelingemotionsarenaturalforhumanbeings.Morita

48

advocatedthatwetrynottocontrolouremotions.Itisfinetofeelemotions.Ifpeople

trytocontrolemotions,theywillfocusonthemunconsciously.Bycontrast,ifthey

leaveemotionstoruntheirnaturalcourse,andsimplyholdthem,theemotionswill

calmdownanddisappear.Shinkeisitsushoclientstrytocontroltheiremotions,which

makestheemotionsworsebecauseofobsessing.

TaitokuandRikai/LearningfromExperiencesandDeepUnderstanding

Taitokumeansthatpeoplelearnfromtheirexperiences.Rikaimeansthatpeople

understandwisdomthroughknowledgeandimagination,andabstractideas.Morita

statedthatdeepunderstandingcomesfromlearningexperiences.Learningexperiences

stronglyencouragesthedevelopmentofwisdom.ThatmaybewhyMoritaprovided

learningexperiencestohisclientsinaresidentialtreatmentsetting.

ShinnenandHandan/BeliefandDecision

BehaviorscomefromShinnen,beliefswhicharesubjectiveperspectives,

emotions,andexperiences.Thesesamefactorsshapepersonality.Ontheotherhand,

knowledgeandunderstandingaffectbehaviorindirectlyaselementsofdecision‐making.

Thatmeansthatknowledgeandunderstandingarejustsurfaceaffectations.Clinicians

needtoknowtheirclient’spersonality.However,ifpeoplearemotivatedtoobtain

knowledgeandwisdomandfindthesebythemselves,thoselearningexperiences

stronglyaffectpersonality.

RonrinoSakugo/LogicalAnachronism

Itisveryimportantforclinicianstounderstandtheclient’ssubjectiveand

objectiveperspectivesandtherelationshipbetweentheiremotionandtheir

49

intelligence.Understandingtheclient’sbasicemotionalfunctioningisespecially

significantbecausethosefactorsareveryimportantelementsforunderstandingthe

client’spersonality.Ifcliniciansignoretheirclient’semotionsorperspectivesontheir

illness,andjustgiveclinicaladviceordirections,treatmentwillnotwork.Theclient’s

perspectivesandbeliefsaretheirrealworld.Cliniciansneedtounderstandhowthese

foundationsareconstructed.

ShizenandJini,MokutekiandSyudan/NatureandArtifice,GoalandSteps

Moritawrotethatphysical,mental,andpsychologicalphenomenaarenatural

matters.Nobodycanchangethem.However,mostpeoplebelievethattheycan.

Peopleshouldliveinharmonywithnatureandbenatural.Ifpeoplelackmotivation,

theyneedtowaitfortheirmotivationtochange.However,MoritaTherapyand

Buddhistphilosophybelievethatchangingbehavior/actionsareanaturalpathwayto

change.

KannennnoKyatukanntekiTouei/ConceptofObjectiveProjection

Acquiringself‐confidenceandcouragearedifficult.Similarity,itisdifficulttoleave

orgetridoffeelingsofagonyoranguish.Moritataughtthatthereweretwowaysto

leaveandholdfeelingsofagonyandanguish.Oneistoallowoneselftofeelandbein

thosefeelings(Arugamama/beinnature).Anotherwayistofocusonandtoobserve

andcriticizeone’sfeelings,observingthefeelingsobjectively.

Shizenfukujyu/ObeytheLawsofNature

Whenpeoplesuffer,theyfeelpainandanxiety.Thosearenaturalfeelings.When

itiswinter,peoplefeelcold.Thatisnaturaltoo.Shinkeisitsushopatientstendtothink

50

thattheyshouldnotthinkorfeelthattheyarecold.Iftheythinkthattheyshould

changethemselves,therewillbeconflictbetweentheirideasandtheirrealities.

SeishinnoKikkouSayo/PsychologicalConflicts

Peoplehavetwoactionsthatinteractwithintheirmind.Whenonefeelsanxiety

(firstaction),onetriestogetridofthefeelingorfindasolutiontoreduceanxiety

(secondaction).Ifthefirstfeelingisstrong,thesecondactionalsobecomesstrong.If

thefirststimulationisstrong,thefollowingsecondactiontendstobestrong.Ifthefirst

reactionisnotstrong,onedoesnotneedtotakestrongactiontoreducethereaction.

Theseinterplaysarenaturalmatters.Shinkeisitsushopatientsoftenhavestrong

reactionsofwhichtheystronglydesiretoridthemselves.Whenpeoplehavestrong

psychologicalconflicts,theyhaveagony,andproblems.

KyogunoSentaku/ChoiceofSituation

Whenpeoplefeelagonyandanxiety,itisimportantforthemtoholdthose

feelingsbecausethefeelingsarenaturalandreal.Onedoesnotbenefitfromchoosinga

differentsituationinordertoavoidfeelinganxious.Itisbetterforustofeelanxietyand

beinreality.

SyukanToiukotonoImi/MeaningofSubjectivity

Whenonedrinkswaternaturallywithoutanythoughts,thatbehaviorissubjective.

Onedoesnotexperiencefeelingsasaresultofsubjectivebehavior.Thepurely

subjectiveisnotalinguisticexperience.Whenoneuseslanguageorthinksabout

behavior,itisobjective.Objectivityincludesotherpeople’sperspectiveandthoughts.

51

Chui/Attention

Peopledonotneedtofocusonaspecificmatter.Weareabletolivewithout

focusingonorgivingattentiontoourdailylivesandbodilyfunctions.Shinkeisitsusho

clientsfocusonorgiveattentiontospecificmatters.

ChuitoIshikinoKankei/RelationshipbetweenAttentionandConsciousness

Moritaallowedpatientstofullyfocusontheiragonyinsteadofavoidthinking

aboutit.Sinceitisalreadyanaturalsituationforpatientstothinkabouttheiragony,it

isbetterforthemtofeelenoughpainuntilthepainlessensandgoesaway.

SeishinnoChowa/BalanceofMinds

Ifpeoplearehypersensitivetostimulation,theymightbeobsessiveaboutor

irritatedbynoiseandotherstimulation.Theyfeeluneasyandtrytodismissthenoise

fromtheirminds.Ontheotherhand,ifpeoplearenotawareofthesenoises,theyare

notuncomfortablewiththematall.Moritabelievedthatitisimportantforpeopleto

beabletofindbalancebetweentheirmindsandoutsidestimulation.Shinkeishitsusho

patientstendtobehypersensitive.

Mushojuusin/DailyFunctioning

Itisimportantforhealthymindstobeactive,butitisnotgoodformindsifthey

arefocusedonjustonepoint.BecauseShinkeisitsushopatientstendtofocusonone

area,theirmindsandresultingbehaviorsintheirdailylifearedysfunctional.

KannjyounoHousoku/RulesAboutEmotions

Moritasaidthattherearefiverulesaboutintenseemotions.

52

1.Emotionswillcalmdownanddisappearlikethecurveofamountain,i.e.,intensify

andthengraduallydecrease.

2.Iftheimpulsesatisfies,thefeelingswilldisappear.

3.Peoplewillnotfeelstronglyabouttheiremotionsiftheydonotstimulatethemtoan

obsessivelevelorrejectthemaltogether.

4.Whenemotionsarestimulatedconstantlyandfocusedon,theybecomestrongerand

stronger.

5.Emotionsarederivedfromnewexperiences.Emotionsarestimulatedbyrepetition.

Morita’sideaswerebasedontheconceptofdependentoriginationinBuddhism,

whichissimilartoSatipathanaSutra,thesutraformeditationonthebody.

Psychopathology

CharacteristicsofPatientswhohavetheViciousCycleofConflictingThoughts

Typically,apersoncaughtinthiscycletendstobeintroverted,perfectionist,self‐

centered,analarmist,andeasilyworried.Thegapbetweentheiridealselfandrealityis

large.Theperson‘srealityisnotacceptedbythemselves.Thepersoncompares

themselvestotheidealandlooksforfault.Thepersontriestodothethingthatcannot

bedone.Thepersonisanxiousandworriesaboutotherpeople'sevaluation.The

personishighlyinfluencedbythejudgmentofothersandchangestheirspeech,

behavior,andeventheirvaluestomatchtheopinionofothers.Theyhaveanobstinate

andunyieldingspirit.

TreatmentGoalsinMoritaTherapy

53

Moritatherapistsencouragepatientstolookatandaccepttheirrealselves.

Clientsaretaughtthattheyarenotperfectpeople.Thatmeansthattheyneedto

acceptandholdtheirfeelingsandlearntolivestrongandwell.

Clientsneedtochangetheiremotionally‐basedthinkingandlearntofocuson

action.Forexample,oneclientcouldnotbuyashirtheneededduetosevereanxiety

aboutconversationsthatmighttakeplacewiththepeoplewhoworkedatthestore.In

thiscase,Moritatherapistshelpedtheclientfocusonthespecificgoalofbuyingashirt.

Whentheclientcouldgotoastoretobuyashirtwithouttheworryandanxiety

stoppinghim,thepersonreachedoneofhisgoals.Whenclientshavesuccessful

experienceslikethis,theyareabletocutthroughthe“viciouscircleofconflicting

thoughts.”

AnothergoalinMoritaTherapyistoreachthestateofArugamama‐‐acceptance

ofrealityasitis(Hofman,p.282,2008).Ishiyama(1986)clarifiedthatMoritaTherapy

encouragesacceptanceofaclient’stendencytowardnervoussensitivityand

anxiousness,butdoesnotencouragefocusingonpersonalweakness.MoritaTherapy

considersanxietytobeanacceptableemotionthatonedoesnotneedtobattle

(Ishiyama,1986).Obeyingnaturebyacceptingunwantedthoughtsandfeelingsis

betterthantryingtochangeanunchangeablesituation(Hofman,2008).Ultimately,

acceptanceincludesacceptingaginganddeathbecausethesearenatural(Kitanishi,

2007).

54

TargetSymptomsAddressedbyMoritaTherapy

MoritatargetedShinkeishitsushoornervousproblemsbecausemanyofhis

patientshadthosesymptoms.Inaddition,hehadexperiencedsimilarsymptomsinhis

ownlife.Inhisera,JapanesesocietyfacedstrongsocialstressorsasaresultofWorld

WarI.Afterthewar,theJapaneseeconomydevelopedrapidly,andpeoplehadtowork

harderthanbefore.Eventhoughtheyworkedhard,theydidnotachieveprosperity

becauseoframpantinflation.Manypeoplehadanxietyabouttheirsituation.Morita

hadmanypatientswhohadShinkeishitsushoornervousproblemswhichincludedno

motivationtolive.Ishiyama(1990)describedthesituationbynotingthat“theMorita

therapisthelpsclientstofocusontheirneglectedself‐actualizingdesiresandabilityto

chooseactionandhelpsthemtoleavetheescalatedemotionalsymptomtoanatural

healingprocess”(p.556).

MoritafoundthatevenShinkeishitsushoclientshadthedesiretohavegood

health,solidrelationshipswithothers,andmeaningfullifegoals.Theirproblemswere

connectedwithtryingtobemoreperfectthanothers(Morita,1929/1960/2004).

MoritaTherapyinterventionschangetheclient’slifestyle(Ishiyama,1986).

OnereasonwhyMoritawasinterestedinpatientswhohadShinkeishitsushoand

nervosityproblemswasthathehadfacedsimilarsymptomsinhislife.Heexhibited

clingingbehavioratsomepointsinhislife.Heexperienceddebilitatingfearsofdeath

andahighdegreeofanxiety(Morita,2004).Hewantedtobeperfect.Hisanxiety

primarilycamefromhisrelationshipwithhisfather.Inhiswritingheacknowledged

thatconflictwithhisfatheraffectedhissymptoms.Forinstance,whenhewasastudent

55

atTokyoNationalUniversityMedicalSchool,hisfatherdidnotsendmoneytohim.

Moritawasdepressedandanxiousandexperiencedpanicattacks.Herecoveredby

changinghislifestyleatthattime.Helearnedfirsthandthatifpeoplewhohaveanxiety

changetheirlifestyles,theirsymptomscandisappear.

Moritasoughtfromhispatients,theirvoluntarywilltochange(GikeiMedical

SchoolofMoritaTherapyCenter,2007).Moritabelievedthatifpatientswerenot

motivatedregardingtheirtreatment,theywouldnotimprove.Clinicianscannotforce

theirclientstochangetheirbehaviorbecausetheclientssometimesresist(Ishiyama,

1990).Itisimportantforbothclientsandclinicianstofeelanaturalandspontaneous

motivationtowardengaginginanyactivities(Morita,2004).Moritastatedthatthisidea

wassimilartoMontessoriteachingmethods(Morita,2004).

TargetGoalsofMoritaTherapyToday

Nakamuta(2008)statedthatthesedays,Moritatherapistschooseclientswho

possessgoodjudgmentbecauseitisimportantforclientstounderstandaboutthebasic

theoryofMoritaTherapy.Clientsneedtheabilitytounderstandthattheyhave

responsibilityfortheirproblemsandtheyneedtohavesomeegostrength.Clientsmust

beabletorealizethattheysufferasaresultofthediscrepancybetweentheiridealand

realselves.MoritaTherapyiseffectiveforcancerpatientsandmostofthementallyill

withtheexceptionofpatientssufferingfrombipolardisorderoracuteschizophrenia

(Nakamuta,2008).

56

MoritaTherapyandBuddhism

ThephilosophyofMoritaTherapyissimilartoZenBuddhism,whichwasthe

religionpracticedbyMorita’sfamily.Morita(1934)statedthatafterheformulated

MoritaTherapy,hefoundsimilaritiesbetweenhisnewsystemoftherapyandZen

Buddhism.MoritaTherapywasinfluencedbyJapaneseandEasternculturewhichare

Buddhist(Suzuki,1989).Zen,MoritaTherapyandJapanesecultureasawhole,allplace

importanceonacceptingone’sphenomenologicalreality(Suzuki,1989).Thisis

reflectedinMorita’sprimaryprincipal,“Acceptance.”Whenclientshaveapositiveview

ofacceptance,theyareabletobenefitfrompracticalactivities(Ishiyama,1986).

MoritadidnotformhistherapybasedentirelyonZen.However,hehadadeep

understandingofthebasicphilosophyofZen(Suzuki,1989)andusedmanyZenwords

andillustrationsasexamplestosupporthisstatements.TheJapanesearealmost

entirelyBuddhist.ZenhashadanimportantplaceinJapanesesocietyforsome2,000

years.Naturally,JapanesepeoplehavebeenheavilyinfluencedbyBuddhism,even

Japanesepeoplewhoareapartofadifferentreligion.Oneexampleofthefundamental

principlesofBuddhismthathaveinfluencedMoritaTherapyistherenouncementofall

possessionsandattachmentstomaterialthings.InMoritaTherapy,thisprinciplehas

beenextendedtomeangettingridofmentalobsessionsaswellasotheradherencesor

attachments,eveniftheyaregenerallyregardedasvirtues.

AnotherBuddhistprinciplethathashaditseffectonMoritaTherapyis“donot

thinkyouhavetodosomething,andifyouthinkthatyoucannotdosomething,donot

doit”(Kitanishi,2007).ThesimilarMoritaTherapyprincipleistonotthinkaboutwhat

57

youhavetodo,buttoacceptyouremotionsandlimitations.Ifanactionistoohardto

achieve,youdonothavetoforceyourselftoattemptit(Kitanishi,2007).Nakamoto

(2009)taughtthatmindandbodyshouldbebalancedbynature.Ifpeoplehave

emotionalconflictsanddisharmoniesintheirmindsandlives,theseproblemswillbe

solvednaturallybytime.Humanshavestrongsurvivalabilitiesthatarenaturalsystems

becausewearepartofnature(Nakamoto,2009).Ourmindsandemotionsalways

changebecauseweareinfluencedbymanypeople(Nakamoto,2009).Itisimportantin

MoritaTherapyforclientstoacceptthemselvesandtolearnhowtolivewiththeir

emotions(Nakamoto,2009).

MoritaTherapyandWesternPsychology

MoritaTherapyandBuddhismbothteachthatthebodygeneratesfeelingsthat

leadtothoughts/cognition,whichleadstobehavior.ThatiswhyMoritaaskedhis

clientstodosomeactionswithoutanyquestions.Zenmonkswereoftenaskedtodo

workwithoutanyconversationsorquestionsoftheirteachers.However,mostWestern

psychologiesbelievethatcognitionleadsbehavior.Inaddition,Westernpsychology

looksforthecausesofsymptomsinlightofthebeliefthatourthoughtsareableto

controlemotionsandsituations(Kitanishi,2007).Easternpsychologydoesnotfocuson

thecauseofsymptomsbecauseitbelievesthatpeoplecannotanddonotneedto

changetheirsituation.MoritaTherapyfocusesuponacceptingallkindsofemotions

andenvironments.MoritaTherapyisanexperientiallearningsystem,anapproachthat

isdifferentfromWesterntherapy(Ishiyama,1987).MoritaTherapyholdsthatall

psychologicalproblemsstemfromanxiety(Kitanishi,2007).AccordingtoMorita

58

Therapy,acceptingaging,otherlifeeventsandevendeaththroughtheprocessingof

emotionsisournaturalheritage.MoritaTherapyhelpsrestoreaperson’sabilityto

engageinsuchhealthyprocesses.Ifonetriestochangethoseemotionsandfeelings

throughthoughtalone,thoseemotionsandfeelingsmaybecomestronger.Morita

Therapyholdsthatitisdifficultforustodecreaseanxietybyusingthoughts.Instead,

MoritaTherapyfocusesonchangesinbehaviorbecauseanxietydecreasesafterchanges

inbehavior(Kitanishi,2007).Clientswhohavementalillnesstendtobepreoccupied

withtheirsymptomsandneglecttheirphysicalwell‐being(Nakamoto,2009).

BuddhismBehaviorchangesFeelingschangeThoughtschangeWesternphilosophyCognitionschangeBehaviorchanges

Figure5.DifferencesBetweenBuddhismandWesternPhilosophy

Modalities

MoritaTherapyhasvariousmodalitiesnowavailable,includingprogramsfor

residentialpatients,outpatients,groups,andotherprogramsthatcombineseveral

methodsoftreatment(Ishiyama,1986).MoritaTherapyiswell‐knownintheWestern

world(Reynolds,1969)andhasbeenusedthereformanykindsofmentalillness

(Kitanishi,2007).MoritaTherapydoesnotfocusontheunconscioususing

psychoanalysis(Reynolds,1969).WesternclinicianspointoutthatMoritaTherapyisa

viableandusefultherapyfornotonlyJapanese,butalsoforotherAsianandWestern

clients(Ishiyama,2003).SomecliniciansareconcernedthatMoritaTherapymightbe

59

difficulttoacceptforWesternclientsbecauseofculturaldifferences(Ishiyama,1987).

However,thesedaysmanypeopleareinterestedinBuddhismandhaveusedpractices

suchasZengardenandmeditation.Ifinthefuture,MoritaTherapygarnersscientific

evidenceastoitseffectiveness,MoritaTherapywillbeusedmoreprominently

throughouttheworld.MoritaTherapyhasdevelopedovertimeinJapan.Theoriginal

MoritaTherapyhasnotperseveredintheexactsameform.ThisprovesthatMorita

Therapycanevolvetofitintodifferentenvironments.MoritaTherapyshouldbe

developedtomeettheneedsofdifferentculturesindifferentcountries.

Treatments

OriginalStagesofMoritaTherapyTreatmentAsPracticedbyMoritaandPossibilitiesfor

GreaterIntegrationwithArtTherapy

Moritaemphasizedthateffortdoesnotalwaysleadtoresults.Hestatedthat

mosttreatmentswerenoteffectiveifclientswereobsessive,inotherwords,attached

toonethought.Whatismostimportantisforclientstoleavetreatmentandfirst

decreasetheirattachmentbeforetheycaneffectivelyreentertherapy.Moritastated

thatclinicianshavetoassessanddiagnosepatients.Withoutassessmentanddiagnosis,

theycannotlocatethecoreissuesbehindthesymptomsandpsychopathology.Morita

likenedtheprovidingoftreatmentwiththelackofproperassessmentanddiagnosisto

committingafelony(Morita,2004).WhenheformulatedMoritaTherapy,heutilized

strictselectioncriteriaandonlyworkedwithclientswithShinkeishitsushowhohad

hypochondriasis,anxietyneurosis,phobic‐obsessiveneurosis,orpsychogenicphysio‐

60

motormalfunctions(Ishiyama,1986).Oncepatientswereidentified,diagnosedand

readyfortreatment,theyweretakenthroughfourstagesoftherapy,asfollows.

TheFirstStageofIsolationandRest

Duringthisstage,clientsareisolatedfromhumancontactandrestrictedfrom

anyactivitieswiththeexceptionofusingthetoilet,eatingandbathing.Thepurposeof

thisstageisforclientstorestphysicallyandmentally.Clientshavetocalmdownand

lookattheirinnerthoughtsandrecouptheirstrength(Nakamoto,2009)beforethey

canengageinmoreactivetreatment.BecauseWesternclientsneedmoreverbal

communicationfortheirtherapysessions,Westerntherapiesencourageclientstotalk

andexpresstheiremotions,toanalyzeandcontroltheirsymptoms(Ishiyama,2003).

However,Moritahadhisclientsisolatedfromanybody,anyactivities,andany

interaction.Moritabelievedthatclientsneededtoreflectwiththemselveswithout

interference.Whenclientsareabletoaccepttheiremotions,theymayexperience

inconvenient,painfulorstressfulfeelings.However,throughthisprocess,clientscan

recoverfromtheirfatigueandbegintochangebehaviors(Ishiyama,1990).Morita

(1998)statedthatthegoalofthistherapyistofundamentallybreakloosetheclient’s

mentalsufferingandpain.Itallowsthemtoexperiencethementalstatehereferredto

asimmediateliberationthroughconfrontationwithone’ssuffering(Morita,1998).

Duringthisstageartisnotbeneficialbecausethepatientshavetoliedownandarenot

allowedtoengageinactivities.

61

TheSecondStageofLightOccupationalWork

Duringthisstage,clientsarestillprohibitedfromengaginginconversations,

amusements,andactivemovementsbecausethoseactivitiesdiverttheirconcentration

fromreflectionanddevelopinginsight.Inthisstage,therapistsdonotgivetasksto

clients.Therapistshavetowaitfortheclient’smotivationtoincrease.Itisimportantin

thistreatmentthattheclientresumesfeelingnaturalandspontaneousmotivation

towardengaginginactivities.Smallactivitiessuchasjournalwritingandartactivities

afterdinnerareallowed(Morita,1998).Theclient’slifestylewascontrolledbya

structuredschedule.ThisisconsistentwiththefocusinMoritaTherapyonlifestyles

ratherthansymptoms.

Duringthisstage,arttherapycouldbeapartofthetherapeuticprocess.Art

therapistsmightbeabletochooseartmaterialsforeachclient.Forexample,some

clientsmightnotliketowrite,butmightliketodrawormakeacollage.Drawingand

scribblingmightbeagoodartdirectionforclientsduringthisslowandquietperiod.

TheThirdStageofIntensiveOccupationalWork

Duringthisperiod,clientsareencouragedtoengageinanylargemotorskill

activitiessuchassawing,choppingwood,anddiggingholesinthefields.Through

intensivework,clientsexperiencethereemergenceofpatience,cultivateself‐

confidence,accomplishsmallsuccesses,andappreciatethevalueoflabor.Such

experienceshelpclientsovercometheirpainanddifficulties(Morita,1998).Thisstage

focusesonsupportingthenaturalinterestsofclients.Certainlytherearemany

possibilitiesregardingtheintegrationofarttherapywiththisstageoftreatment.Some

62

clientsdonotwanttomakewoodsculpturesbecausewoodishardandusingaknifeto

cutincanbedifficult.Someclientsmighthaveaphysicalprobleminmakingthese

typesofsculptures,suchasclientswitharthritichands.Becausesomeclientsmayfind

intensiveactivitiesdifficulttoaccomplish,arttherapistsmightbeabletoprovidemany

artactivities,directionandmaterialsthatengagelargermusclegroupsinanoutside

context.Clientsmaypreferartworkratherthanmeniallabor.

TheFourthStageofPreparationforDailyLiving

Thisstageoftreatmentfocusesonpreparingtheclienttogobacktotheir

naturallife.Clientsslowlystarttoadjusttotheworldoutsideoftherapy.Theyare

allowedtoreadsimplebooksandwalkoutsidealone.Duringsuchmoments,clientsare

encouragedtoexaminetheirfeelingsandthoughtsaboutthefuture.Clientsdelineate

whatkindsoffearsandobsessivethoughtstheyhadbeforesothatwhensuchfeelings

orthoughtsreemerge,theclientcanfindthemeanstoacceptthefeelingorthought.

Arttherapymaybeusefulforhelpingclientstofindthemselvesbecausedrawingand

visualizingareofteneasierwaystofindacceptance.Therearemanywaystouseartto

teachclientshowtoimprovetheirdailyliving.Forexample,artpicturescanbeusedto

assistclientsinpracticinghowtoconductbasicsocialgreetings.

ContemporaryOutpatientTreatmentStrategies

AccordingtoKitanishi(2008),thefollowinginterventions:canbedonewithclients:

1.Experiencehowtoacceptandholdwithemotions.

a.Distinguishbetweenwhatyoucandoandwhatyoucannotdo.

63

b.Trynottocontrolorsuppresstheemotions.

c.Holdandacceptyouremotions.

d. Waituntilhighemotionsbecomelessintense.

e. Observeyouremotions.Writedaily.

f. Recognizethedynamicnatureofemotions.

2.Reviewtheprinciplesofaction.

a.Realizethepurposeofyouraction.

b. Takeaction.

c. Focusontheactionandhaveasuccessfulexperienceofit.

d. Donotallowyourselftoneedtobeperfect.

e. Understandandfindoutabouthowyouractionchangedyouremotions.

f. Feelyourdesireforlife.

3.Reviewtheprinciplesofrelationships. a.Realizehowyoufeelotherpeople’sevaluations,opinions,andjudgmentsaboutyou.

b.Consideryouremotionsandbehaviorandhowthejudgmentofothersaffectsyou.

c. Findouthowyoutrytofitthem.

d. Findyourbehaviorandemotionafteryouchangetofitthem.

Haveyoueatentoomuch?Areyoudepressed?Haveyoudrunkexcessively?

e. Trytofocusonandrealizeyourpurposeofaction.

f. Changeyourbehaviorasaresultofsomeone’sjudgmentastoyourownpurpose.

64

purpose/role<otherperson’sevaluation

purpose/role>otherperson’sevaluation

Figure6.ChangingtheImpactofExternalEvaluations

PossibilitiesofMoritaTherapyinWesternCulture

MoritaTherapyisbasedonEasternphilosophyandculture,andseemstobe

differentfromwhatisfoundintheWest.However,thesedays,itmaybeeasierfor

WesternsocietiestoacceptMoritaTherapy.First,Buddhismismorefamiliarinthe

West.Forexample,thereisalonghistoryofZenintheUnitedStates.Inthe1950s,Dr.

TaisetsuSuzuki,aJapaneseZenmonk,beganteachingZeninNewYork(Morgan,2001).

Inthe1960sand1970s,manyWesternpsychologistsandpsychiatristsbecame

interestedinEasternphilosophyandpracticessuchasmeditationandyoga(Morgan,

2001).AcceptanceandCommitmenttherapistsbelievethatBuddhistphilosophyrelates

welltoBehavioralandCognitiveTherapy(Hays,2002).Hays(2002)saidthatBuddhism

teachesustoacceptrealities.Buddhismencouragesustonothaveastrongfeelingof

attachment.Also,Buddhismshowsushowtocreateagoodbalancebetweenthe

65

insightsofnatureandmentalfunctioning(Teneatto,2002).Thelatterconceptis

relevanttoMoritaTherapy.

Westernsciencehasinvestigatedtheeffectivenessofmeditation.Meditation

practicehelpstopromotecalmness,awareness,open‐mindedness,andbeing

nonjudgmental(Anderson,2005).Itchangesthebrain.Meditationleadstothepower

ofhealingandtolookingatthenatureofthemind(Toneatto,2002).Meditationhas

longbeenassociatedwithBuddhism.TheBuddhistprincipleofnonjudgmental

awarenessisconsistentwiththeMoritaTherapyconceptof“Acceptance.”

Buddhismisnotscience.However,someofitspracticeshaveascientificbasis.

CombiningBuddhistpracticesandpsychotherapymaybevaluableformanypeople,

includingnon‐Buddhists(Hays,2002).ZenhasbecomeabridgebetweenEasternand

Westernpsychology(Kwee&Ellis,1998).MoritaTherapycouldbeaneffective

theoreticalorientationformanypopulations.

Itisimportantfortherapiststobeabletotreatpatientsusingatheoretical

foundation.ForJapanesetherapists,itmaybedifficulttounderstandWestern

psychologicaltheoriesbecausetheoriesareinfluencedbythecultures,values,and

philosophiesoftheplacesfromwhichtheyoriginate(Kitanishi,2007).Asiantherapists

maymoreeasilyunderstandEasternphilosophiessuchasZenandBuddhism.The

client’scultureimpactstheirfamilyfunctioningbecauseeachculturehasitsownstrong

heritage(Hoshino,2003).Peoplecannotignoretheirowncultureandheritage.Clear,

logical,andsystematicunderstandingofthetheoriesthatunderliethepracticesthatare

usedwithpatientsisanecessity.Understandingtheoriesisimportantinknowinghow

66

toapplyinterventionswithpatientsinastep‐by‐stepmanner.Inshort,therapists

shouldchoosetheoriesthattheyunderstandandcanusesuccessfully.Iftherapistsuse

theoriestheydonotunderstand,theycannothelppatients.

WesterntheoriesmakelesssensetopeoplewhoareraisedinBuddhistcultures.

However,MoritaTherapyisbasedonZenBuddhism.Asiantherapistsandclientsmight

finditeasiertounderstandit’sphilosophyandprinciples.However,MoritaTherapy

maybeusefulnotonlyforAsianclients,butalsoforsomeWesternclients.For

example,ifaWesterntheorydoesnotworkwellforaWesternclient,MoritaTherapy

mightworkwellbecausenewperspectivessometimesworkwell.MoritaTherapy

shouldbedevelopedtoapplytoallkindsofpopulations.Clientsdonotneedto

understandthephilosophicalunderpinningsofthetherapywithwhichtheyare

engaged,butclinicianshavetounderstanditclearly.

MoritaTherapyPastandPresent

Morita(2004)wroteaboutpsychopathologyofShinkeisitsusyoinhisbook,

ShinkeishitsunoHontaitoRyoho.Thisbookwaswrittentoexplainthecausesof

symptomsandhowtotreatclientswhohaveShinkeishitsusho.EventhoughMorita

formulateditin1919,thosetreatmentprinciplesarestillusedbytoday’sMorita

therapistsformanykindsofmentaldisorders.ThroughMorita’sbooksandarticles,itis

clearthatMoritaunderstoodBuddhismwellandwasinfluencedbyBuddhism.

Buddhismteachesphysicaltraining.MoritaTherapytaughtphysicaltrainingtoo.

Monksneveraskedquestionswhentheirmastersaskedthemtoworkduringtheir

67

training.MoritadidnotallowhisclientstoaskquestionsorarguewithMorita’s

treatmentorders.Thosemethodsstillexistintoday’sMoritaTherapy.

EventhoughMoritaformulatedMoritaTherapyin1917,over100yearsago,his

theoryandphilosophyareeasyforJapanesepeopletounderstandbecausetheyare

basedonBuddhism.MoritaTherapycanbeagoodfitforJapaneseandAsianclients

becausetheyareinfluencedbyBuddhism.Theseinfluencesarestrongandever‐present

intheirlivesandtheirphilosophytowardslife.Forexample,inJapaneseculture,itis

veryimportanttocleanone’shouseandgardeninthemorning.Childrenhavetoclean

theirschoolsafterschool,includingtherestrooms.Sixthgradestudentscleanthe

restroomsofthefirstgradestudents.ThispracticeisfromBuddhismwhichteaches

thatcleaningtheenvironmentmeanscleaningone’smind,thought,andlife.Buddhism

teachesthatpeoplefindwisdomthroughservice.ThatiswhyMoritaTherapyasks

clientstodowork.

68

IV:ANALYTICALPERSPECTIVEOFMORITATHERAPY

BackgroundConsiderationsRegardingMoritaTherapy

Today,manyJapanesepsychiatristsandpsychologistshavedevelopednew

applicationsofMoritaTherapy.TherearehistoricalreasonswhyMoritaTherapy

changedanddeveloped.ThetimelinebelowshowsthedevelopmentofMoritaTherapy

inthecontextofthehistoryofJapan,theworld,andmedication.Understandingthe

historicalcontextofdevelopmentofMoritaTherapyleadsustounderstandhowithas

evolvedandwhychangeswereneeded.Thehistorydemonstratesthatsocialsituations

suchascultural,economic,andphilosophicvariablesaffectmedicaltechnologyand

development.Forexample,afterbothWorldWars,theeconomicandsocialsituation

affectedpeople’snutritionandmentalconditions.Itisimportanttounderstandthis

historicalbackground.EspeciallyinregardstoMoritaTherapy,itisimportantto

understandhistoryandculturebecausebothaffectedwhichclientsweretreatedin

whatmanner.CultureisaparticularlyimportantcontexthereinthatMoritaTherapy

wasformulatedbyaJapanesepsychiatristinJapanandwasinfluencedbyBuddhismas

wellasJapaneseculture.Indeed,MoritaTherapy’sconceptofShinkeisitsu‐shodoesnot

existinDSM‐IVandcouldbeconsideredaculture‐boundsyndrome.Historically,itis

alsoimportanttounderstandaboutthedevelopmentofmedicationaswellsince

medicationhasgreatlyaffectedclients’conditions.

69

MoritaTherapyandMedication

Thereisabigdifferencebetweenthecurrentandthepastmedicalsituation

becauseofthemoderndevelopmentofpsychiatricmedication.Nakamura(2007)

statedthatinthelasttwentytothirtyyears,medicationforanxietyhasbecome

available.Hesaidthatinthepast,whentherewerenomedicationsforanxiety,

psychotherapywastheonlychoicefortreatment(2007).Today,medicationhas

becomeabigpartofthetreatmentregime.However,Nakamura(2007)pointedthat

evenwhenmedicationisprescribed,itdoesnotworkforabout50%ofclients.

Therefore,therapyisstillimportant.Inthefuture,thetheoryandpracticeofMorita

Therapyneedstotakeintoaccountmodernmedications.

AnalyticalIssuesoftheOriginalMoritaTherapy

ThischapteranalyzestheoriginalMoritaTherapy.Therearethreeissuestobe

considered:1)theenvironmentofMoritaTherapy,2)therelationshipbetweenclients

andclinicians,and3)thedifficultyofunderstandingMoritaTherapy.Itisimportantto

analyzetheseissuesfromamanydimensionalperspectivethatincludesthehistoryof

MoritaTherapyandJapan,medications,andJapaneseculturalperspectivesinregards

tothefuturedevelopmentofMoritaTherapy.

EnvironmentofMoritaTherapy

In1917whenMoritaformulatedMoritaTherapy,itwasjustafterWorldWarI,

theRussianCivilWar,andJapanwaspreparingtoenterWorldWarII.Japanwasinan

economicdepression.Inthatsituation,MoritaformulatedMoritaTherapyafterhisown

experienceofovercomingShinkeishitsu‐shoathishome(Kondo,1966.,Suzuki,1967.,&

70

Kitanish,1989).Moritatriedtoprovidethefamilyatmosphereforhispatientsbyusing

hishomebecausehebelievedthatenvironmentwasimportantfortreatment.

Atthattime,theJapanesefamilystylewasthepatriarchalsystem.Theheadofa

familywasaman‐‐afatherorgrandfather‐‐whohadabsolutepoweroverfamily

members.Inthisculturalsituation,MoritaTherapywasfoundedbyMorita.Hewasa

psychiatristplayingafather‐likeroleattheinpatientunitestablishedinhishome.His

wifebecameaveryimportanttreatmentmember,playingoutfortheclientstheroleof

theirmother.ThemotherrolewasimportantforMoritaTherapy(Uchimura,1970).

Moritaandhiswifehadaheavyworkload.Thereweremanyresponsibilitiesinvolved

withprovidingtreatmentattheirownhouse(Ohara,1970).Itwasahardshipforthem

tousetheirownhouseforthepatients.Therewaslittleornoprivatetime.Morita

sometimesworked24hourshifts,sevenweeksatatimeforseveralmonths.Whatwas

hismotivationtoworksohard?Perhapshefeltagreatdealofresponsibilitytothenew

programofMoritaTherapy.Perhapshisstatusasapsychiatristledhimtoworkhard

andtomakemanypersonalsacrifices.Itispossiblethatherecruitedhiswifetobecome

atreatmentproviderbecauseheneededthehelpwiththeextensiveclinicaland

administrativeworkload.Itwouldhavebeenanaturalmatterforhiswifetoobeyhis

requesttofollowhimintotreatment.TheJapanesesocialnormwasthathewasin

chargeofhisfamilyaswellasthepatients.Havingabsolutepoweroverfamily

memberswasnormalatthattimeinJapan.AfterMoritadied,AizawaandMaruyama

inheritedthisstyleofprovidinginpatienttreatmentwithinafamilyatmosphere

(Kitanishi,1989).Butinlateryears,MoritaTherapybecamesimpler,includingproviding

71

inpatientandoutpatienttreatmentinhospitalssettings(Kitanishi,1989).Asnotedby

Kitanishi(1987),itisnecessaryforMoritatherapiststohavelimitsplacedinregardsto

theirworkloadandtime.

IssuesRegardingtheInpatientUnitatMorita’sHome

QuestionsaboutplacingtheinpatientunitatMorita’shomeincludeethical

considerations,effectivenessofthetreatment,andboundarybetweenclientsand

clinicians.

EthicalConsiderations

OneofthestatedreasonsMoritaopenedaninpatientunitinhisownhomewas

thathebelievedthatprovidingafamilyatmospherewasimportantforthetreatment.

MoritahadhiswifejointheMoritaTherapyprogramastreatmentmembereventhough

shedidnothaveanymedicaltraining.Atalatertime,Aizawa,aphysicianwhowasalso

aMoritatherapistsimilarlywouldappointawomanwhodidnothaveanymedical

trainingasmanagerofaninpatientunitpracticingMoritaTherapyatJikeiHospital.Her

positionwasasmanagerandherrolewaslikeamotherforthepatients(Kitanishi,

1989).

Usingcontemporarystandardsofpractice,wewouldconsidertheseappointments

unethical.AlthoughMorita’swifeandtheunitmanagerdidnothaveanymedical

training,theyworkedastreatmentproviders.Eveniftheclientshaddetailedschedules

duringtheday,whileMoritaworkedwithoutpatientsinahospital,hiswifewouldhave

hadmanyclinicalresponsibilities.Evenifshehadclinicalsupervision,shewouldhave

workedwithclientsalldayandnightintheabsenceofprofessionalstaff.Itisnot

72

ethicalforpeoplewithnoclinicaltrainingtoprovidetreatment.Hiswifeneededtobe

trainedhowtocommunicatewithclients,forexample,sincecommunicationwith

clientswhohaveamentalillnessisadelicatematterandaveryimportantpartof

treatment.InMorita’sbooks,therearenodescriptionsabouttrainingforhiswife.We

willneverknowhowmuchhereffort,behavior,andconversationaffectedtheclients.It

wasMorita’sresponsibilitytowriteabouthertrainingandeducationalbackgroundand

impactontreatment.Didhethinkthathispatientsneededamotherfigure?Didhe

supervisehiswife?Didhegivedirectionaboutdietorothermatterstohiswife?

EffectivenessofTreatment

Clinicianshavearesponsibilitytotakecareofthemselvesphysicallyandmentally

aspartofprovidingeffectivetreatmenttoclients.Moritaprovided24hourandseven

dayaweektreatmentathishome.Suchaworkloadcallstheeffectivenessofthe

treatmentseriouslyintoquestionbecausethecliniciansdidnothavetimetotakecare

ofthemselves.InJapanese,thisprofessionalworkstyleiscalledShyuchiryou‐sei(主治

療制);adoctortakescareofallclientsoftheunitwhereheworks.Moritatookcareof

allhisclientsbyhimself.Suchanexcessiveworkloadcouldeasilyleadtosubjectiveand

narrowtreatment.

BoundaryBetweenClientsandClinicians

Cliniciansmustputboundariesbetweenthemselvesandtheirclients.Using

one’shouseasaninpatienthospitalmakestherelationshipbetweenclientandclinician

ambiguousatbest.Withnoseparationbetweentheclinician’sprivateandpubliclife,

therewasboundtobeconfusionandethicallyquestionabledecisions.EvenifMorita

73

intentionallywantedtheunittorecreateafamilyenvironment,itwasstillahospitalfor

clients.Theplacemightfeellikeasafetreatmentunitforclientsbecausethe

atmospherewaslikeahome.However,theplacemightnotbesafeforclinicians.The

stafftherehadnochoicebuttosharetheirpersonalliveswiththeclients.Becausethe

clinicianswereavailable24hoursadayandsevendaysaweek,clientscouldeasily

developpsychologicalandphysicaldependenciestowardthetreatmentstaff.Wasthis

usefulfortheclients’recovery?Theyhadtobeindependentaftertheywere

discharged.

OneargumentisthatitmighthavebeeneffectiveforMoritaTherapytohavea

fatherfiguretocontroltheclientsbecausethecontrolmadetheclientsworryless

(Kondo,1966;Ohara,1970;Doi,1963).Forexample,ifpeopledonotworryabout

money,theirschedule,orobtainingfoodonadailybasis,peoplearerelievedof

importantsourcesofanxiety.However,usingMorita’sownhomemightnothavebeen

thebestwaytoprovideafatherfigure.Asurrogatefatherfigurewasoftenprovidedat

out‐patientunitsinlocalhospitals.Morita’sfollowers,includingmedicaldoctorsatthe

JikeiMedicalSchool,havecontinuedMoritaTherapywithsomechanges.

RelationshipsbetweenClientsandClinicians:FumonnoKankei(DoNotQuestion,Just

Obey)

TherelationshipbetweenclientsandcliniciansinMoritaTherapyhashadmany

issues that should be examined including power issues, ambiguity, and the unclear

meaningofgrouptreatment.

PowerIssues

74

MoritaTherapyhashadastricthierarchicalorderthatisestablishedbetween

clientsandclinicians.WhenMoritaprovidedtherapy,hewieldedabsolutepowerover

hispatients,likeanold‐styleJapanesefather.Hispatientsdidnothaverighttoexpress

theiropinionsorquestionhisdecisions.ThisiscalledFumon(不問).Moritabelieved

thatsuchanenvironmentdecreasedanxietyinhispatients(Aizawa,1967;Kondo,1966;

Ohara,1970;Doi,1963).“Justobey!Don’taskanything”wasanold‐styleJapanese

familysystemphilosophy.Itwasverymale‐centered.Thefatherhadallthefamily

power.MoritaTherapystrivedtocontrolthepatients’dailyliving.Itwaseasierfor

clinicianstocontrolthepatientswhentheclinicianswerewiththem24hours(Kitanishi,

1989).MoritaTherapytaughtthatyoudonotlookatthepastorthinkaboutthe

unconsciouscausesofproblems.Youjustacceptyoureveryemotion.However,Fumon

(justobeyanddonotquestion)mightnotbeaneffectivewaytodevelopone’scognitive

andpsychologicalgrowth.AsTatematsu(1986)stated,theclient’sownissueswerean

importantpartoftheprocessinvolvedingrowingpsychologicallyandspiritually.Each

developmentalstagecanproducepsychologicalpainorevencrisisattimes.Itis

importantforpatientstolearntoresolvetheseperiodicproblems.Thoseprocesses

shouldbeapartoftreatment.

Thequestionswemustaskourselvesarewhethercontrollingtheclients’thoughts

andbehaviorsisaneffectivetreatmentandwhetheritisethicaltoprovidetreatment

withouttheclient’sparticipationinthetreatmentplan.Therearealreadyexisting

powerissuesbetweenclientsandclinicians.Ifaclinicianusedtheirownhouseasan

75

inpatientunit,theirpowerisenhanced.Itmightbedifficultforclientstosay“No!”toa

treatmentproviderwhoalsoownsandcontrolstheveryresidencewheretheylive.

Morita’streatmentcouldhavepossiblybeenmoreeffectiveifheactively

supportedhiswifeinassumingaroleaskindandwarmmother.Thewife’srolecould

softenthepowerdynamicsbetweenMoritaandhispatients.Moritaplayedoutarole

asaverystrictandstrongleaderandclinician.Ifhiswifewasallowedtobeakindand

warmmother‐likefigurethatencouragedthepatients’feelings,thismighthaveadded

someneededbalance.Forexample,whenMoritawasangrywithhispatient’sbehavior,

perhapshiswifegaveencouragementandunderstandingthathelpedemotionally

supporttheclients.Moritadidnotwriteabouttheseissuessoatthispointweprimarily

havequestions,notanswers.

UnclearRoleRelationships

Moritawasastrictandstrongleaderwhofunctionedlikeafatherfigureforthe

clientsattheunit.Theirrelationshiplookedlikefatherandachildormasteranddisciple

(Ohara,1970).MoritaTherapywasconsideredthemosteffectiveiftherelationship

betweenclinicianandclientduringinpatienttreatmentwaslikeamasterandadisciple

(Uchimura,1970,Niifuku,1980,andFujita,1977).MoritaTherapyispsycho‐educational

innature.Thereareconcretestepsforestablishingtheclient’sdailylife.Itmusthave

beendifficulttokeeptheclinicalrelationshipinthesamecondition.Forexample,one

dayclientsareabletoobeytheirclinician’sadvice,butanotherdaytheymightbe

unabletoobeytheirclinicianbecauseoftheirpsychologicalorphysicalconditions.The

relationshipbetweenclientandclinicianwasnotstable.Ifthetreatmentdependedon

76

therelationship,it’seffectivenessalsodependedontherelationship.Therelationship

wasnotstablesoitseffectivenessfortheclientswasprobablynotconsistent.In

addition,iftheclientdependedontherelationshiptoomuch,itmighthavebeen

difficultforthemtobeindependentwhendischarged.

AcontemporaryissueforMoritaTherapyisthislackofclarityregardingtheclinical

relationshipbasedontheoldrolesoffatherandchildormasteranddisciple.Afather

role,motherrole,familyenvironment,ormasteranddiscipleareverydifferent

constructsindifferentculturesandcountries.Theimplicitrulesgoverningtheseroles

changedependingontheindividual’shistory,andacrosstime.Usingthoseambiguous

wordsandculture‐boundrolesmakesitdifficulttounderstandMoritaTherapyfornot

onlyJapanesepeople,butalsopeoplewhowanttostudyitaroundtheworld.

UnclearMeaningofGroupTreatment

MoritaprovidedMoritaTherapythroughaninpatientsetting.Thepatients

spenttheirdaywithotherpatientsexceptwhentheywererequiredtobealone.

Essentially,theywereinvolvedwithakindofgrouptherapyinthetherapeuticmilieu.

Moritadidnotwriteabouthowtotakecareofthegroupdynamicorinteractionamong

thepatients.Weknowthatthistypeofgrouptherapyaffectedtreatmentpositively

(Kitanishi,1987)butweknowverylittleaboutit.

DifficultyUnderstandingMoritaTherapy

ItisimportantforclinicianswhouseMoritaTherapytobeabletounderstandit

clearlyasaclinicaltreatment.Ifpeopleareunabletounderstandit,itisdifficulttouse,

evaluate,anddevelop.Moritatherapistshaveamissiontoprovideeffectivetreatment

77

aswellastosupportandtoteachMoritaTherapytoyoungerclinicians.Today,Morita

Therapyisdevelopingaroundtheworld,especiallyinChina.ItisimportantforMorita

Therapytodemonstratescientificevidenceforitseffectiveness.Someissuesof

importantfortheuseofMoritaTherapyareits’scientificbasis,dimensionalclinical

support,andclinicaltrainingneeds.

ScientificBasis

In1938theJapaneseSocietyofPsychiatryandNeurologyconductedresearch

thatstatisticallyvalidatedtheeffectivenessofMoritaTherapy.Theresearchproject

studiedhoweffectiveMoritaTherapywasfor541nervousnessclientsfrom1929to

1937.Theresultsshowedthat58%ofthemexperiencedcompleterecoveryand36%of

themexperiencedsomerecoveryinapositivedirection.Inshort,94%ofthemshowed

improvements(Ichikawa,2008).Afterthatpivotalstudy,KitanishandotherMorita

therapistshavecontinuedtoresearchtheeffectivenessofthisformoftreatment

(Kitanishi,1989).KitanishthinksthatMoritaTherapyisdifficulttounderstand.

Consequently,KitanishihastriedtobetterdescribeMoritaTherapybydevelopingand

usingnewvocabulary.

Today,however,itisdifficulttofindmanyscholarlyresearchpapersabout

MoritaTherapyinprofessionalresearchdatabasessuchasCINI(Cochranlibrary),

PsycINFO,andPubMed.Sincetherearefewscholarlyresearchpapersdevotedto

MoritaTherapy,ithasbeendifficulttosaywhetherornotMoritaTherapyenjoysa

scientificbasis.IfMoritaTherapyisgoingtodevelopintheworld,itwillneedtobe

morewidepublishedandevidenceeffectivenesstoscientistsaroundtheworld.

78

Conductingresearchthatiscross‐culturallyvalidmayposesomeinteresting

challenges.Forexample,MoritastatedthatthetreatmentenvironmentforMorita

Therapyhadtobelikeafamilyhome(Hashimoto,1985).However,thisraisesbig

questionaboutwhatthatmeans.Peoplecanhaveverydifferentdefinitionsoffamily.

Familymeanssomethingquitevaried,dependingonculture,individualhistory,andtime

period.Morita’swordsmakeitdifficultforpeopleinotherpartsoftheworldto

understandMoritaTherapy.Thislackofunderstandablelanguagehasaffectedits

development.

Hashimoto(1985)acknowledgedthattheatmosphereofaninpatientunitwas

animportantfactorfortreatment.Hisopinionwasbasedonhisexperiencewhenhe

andhiscolleaguescreatedaninpatientunitattheJikeiMedicalSchoolHospitalafter

Moritadied.Iftheatmosphereaffectstreatmenteffectivenesssodramatically,it

shouldbearesearchprioritytodeterminewhatelementsofatmosphereareneededfor

theeffectiveuseofMoritaTherapy.

DimensionalClinicalSupports

Today,mentalhealthprofessionalsincludemanykindsofclinicians.Notonly

psychiatrists,butalsopsychologists,psychotherapists,socialworkers,occupational

therapists,dieticians,nursesandthelikeareapartoftreatmentservicestopatients.

Theyoftenprovidetreatmentasateamforaclient.Moritadidnottalkabout

medicationsanddietinhiswritings.Thesedays,manymentalhealthclientsare

prescribedmedicationbutthisprobablywasnotthecaseinMorita’stime.Ifclients

79

takemedication,clinicianshavetomonitortheeffectivenessofmedications.Thereis

noevidencewhetherornotMoritaprescribedmedicationtohisclients.

AfterWorldWarII,psychiatricdisorderswereontherisearoundintheworld

whenthefirstpsychotropicmedicationsweredeveloped(Kazamaturi,1980).There

were520,000patientsinstatepublichospitalsin1955intheUnitedStatesofAmerica.

Thatnumberaccountedfor50%ofallinpatientadmissionsintheUnitedStates.Inthe

sameyearinFrance,patientswhoneededpsychiatrictreatmentatthepublichospitals

numberedabout100,000.Thatwas30%ofinpatientsadmissionsinthatcountry.

However,afterchlorpromazinewasdiscovered,thenumbersofpatientsdecreased

significantlyincountriesthathadthemedicationresourcesforpatients.IntheUnited

StatesofAmericain1975,inpatientadmissionstopsychiatrichospitalsdecreasedto

200,000people(30%).Thisdramaticchangecanbeattributednotonlytodevelopinga

nationalsupportsystemforpsychiatricpatients,butalsoimportantly,accesstonew

effectivepsychotropicmedications(Kazamaturi,1980).

Moritaandhisfollowersdidnotwriteaboutmedication.Sincethe1960s,well

afterMorita’sdeath,Benzodiazepinecompoundmedicationshavebeenavailableand

beenprescribedforanxietyinJapan(Ichikawa,2008;Kazamatsuri,1980).However,

therehasbeenlittlewrittenabouttheuseofthesemedicationsinconjunctionwith

MoritaTherapy.Ichikawa(2008)statedthatMoritaTherapywasnotpharmacotherapy.

IfMoritaTherapyremainsprimarilyapsychologicaltheoreticalorientation,medication

mighttakeanancillaryrole.Thisremainstobeseen.

80

Today,nutritionaleducationisanimportantpartofMoritaTherapytreatment.

InJapaneseculture,especiallyinZenBuddhism,itisimportanttoeatwithgoodtable

manners.Moritaandhiswifemighthaveemphasizedgoodmannerswiththeirclients.

Surely,Moritacaredaboutmannerssincehisbasicphilosophywassointricatelytiedto

ZenBuddhismwhereeatingmannersisoneofthemostimportantelementsingood

living.

Furthermore,ZenBuddhismvaluesSamu(work).Working(Samu)isonepartof

treatmentsmodalitiesinMoritaTherapy.Thetreatmentstartswithlightworkand

increasesgraduallytoheavierworkassignments.Heavyworkwasusedtopreparethe

clientfordischarge.Theworkincludedthedetailedandcomplexworkofdailylife.The

workprogramsboreacloseresemblancetothedailyneedsoftheclient(Hashimoto,

1985).

Moritawroteaboutsomeartactivitiessuchasmakingwoodsculptures.Did

thepatientsenjoymakingsculptures?Itisimportantthatpatientsknowhowtohave

enjoymentintheirdailylifeaswellashavingenjoymentinthetreatmentprogram.

Moritadidnotwritedescriptionsaboutartmaterials,thereasonsformakingartorthe

processofcreatingart.ItishardtoknowhowMoritapreparedandfacilitatedwhat

clientsexpressedthroughtheirart.

WhatisclearisthatMorita’sfollowersplacedahighvalueonknowinghowto

talkandinteractwithpatientsduringtheprogram.Forexample,Kitanishi(1987)stated

thatitisimportantforclinicianstohavegoodcommunicationwithpatientswhilebeing

apartoftheworkingprogram.Hesuggestedthatifcliniciansgivetasksthatweretoo

81

easytopatients,clinicianswouldnothaveachancetotalkwithandteachpatients

aboutthetasks.Hepointedoutthatcommunicationandinteractionwereimportant

elementsofeffectivetreatment(Kitanishi,1987).WhatdidMoritathinkabout

communicationwithhispatients?Kitanishistatedlesscommunicationwasless

effectivesuggestingthatcommunicationisimportantforMoritaTherapy.Clinicians

whowanttouseMoritaTherapyshouldknowhowtocommunicatewithpatientsand

thereasonswhycommunicationisimportant.Ifclientscannotexpresstheirthoughts

andafeelingverbally,doescommunicationthroughartprovidetheneededexpression?

WehavenoinformationabouthowMoritamightanswerthisquestion.

AnadditionalgapofinformationisthatwedonotknowhowMoritatookcare

ofhispatients’artwork.Takingcareofclientartisaveryimportantpartoftreatment

becausetheartworkitselfisprivateandneedstobeprotected.Hashimoto(1985)

statedthatbecauseMoritausedhishomeasaninpatientunit,peopledidnothave

chancetoknowthedetailsofMoritaTherapymethods.Itisveryimportantforthe

futuredevelopmentofMoritaTherapythatthescientificcommunityhaveaccessto

moreinformationaboutkeymethodologicalissues.Theseissuesincludetheroleofthe

therapist,theimportanceofcommunicationskills,andtheroleofexpressiveactivities

suchasart.ThatinformationwillhelpMoritaTherapytobemoreeffectiveasastrong

psychologicaltreatment.

82

ClinicalTraining

ThecompetentMoritatherapistdoesnotneedtobeanex‐patient.Moritahad

sufferednervousness.Afterheovercamehisillness,hecreatedMoritaTherapy,

drawinguponhisownexperience.Indeed,thereareadvantagesfortreatmentifa

clinicianhasundergonethesamekindsofexperiencesastheclient.Theclinicianoften

understandstheclient’ssufferingwellandcangiverealisticadviceduringthetreatment

(Ohara,Aizawa&Iwai,1970).However,Kitanishi(1987)specificallystatedthat

cliniciansneednotbeex‐patients.Thatisareasonablestatement.Cliniciansare

expectedtoprovidecompetenttreatmenteveniftheyhavenotexperiencedthesame

thingsastheclient.Moreover,cliniciansneedtohaveanobjectiveperspectiveabout

thetreatmentandtheclients.Itmightbefineforclinicianstohavesomesubjective

perspectives,butoverall,theyneedtobeabletodetachfromthecoreissuesand

maintainobjectivityaboutthem.Ifcliniciansdonothaveanobjectiveperspective,they

arevulnerabletocommittingethicaltransgressionsandpossiblyevenharmingthe

clients.

Shuchiryou‐sei,theclosedtreatmentmethodofMoritaTherapy,continuedfor

quiteafewgenerations.Mariyamaceasedthispracticeby1976(Kitanishi,1989).

Moritahadtaughtthatitwasimportantforpatients’reintegrationintosocietythatone

clinicianhadallresponsibilitiesforthetreatment(Kazamaturi,1980).Thatwasone

reasonthatMoritaopenedhishomeasaninpatientunit.

83

AfterMorita

In1974,longafterMorita’sdeath,JikeiMedicalSchoolhospitalinTokyo,Japan

whereMoritahadbeenaprofessor,builtaninpatientunitforMoritaTherapy(Kitanishi,

1984).AtthattimeAizawa,thedirectoroftheunit,hiredtwoassistantdoctors,a

femalemanagerasamanagerwhoplayedtheroleofmothertotheclients;anda

femaleretirednurseasageneralmanagerfortheunit.Indoingso,hechanged

Morita’soriginalideaofonlyonedoctorhavingalltheresponsibilitiesforthecareofthe

patients.Aizawarecruitednewtreatmentmembersaswell.Theystillcontinuedto

providetreatmentbyadoctor,Shuchiryou‐seistyle.Themanager,whotookontherole

ofmothertotheclients,haddifficultiesbecauseshehadheavyresponsibilitiesbutwas

nottrainedasaprofessionalclinician.Shelaterresigned.Aizawahimselfexperienced

physicalandpsychologicaldifficultiesbecausehehadinsufficienttime.Hesawpatients

onanoutpatientbasisduringthedayinadditiontotreatingpatientsalldayinthe

hospital.However,hestayedonandlivedinthehospitalwiththepatients.

MaruyamatookovertheleadershipoftheMoritaTherapyunitatJikeiMedical

Schoolin1974.Hecontinuedthesamestyle,Shuchiryou‐sei.Moreover,Maruyama

reducedtheresponsibilitiesoftheassistantdoctorsandreintroducedthetreatment

stylethathadbeenusedbyMorita,eventhoughtheunitwasinamedicalschool

hospital(Kitanishi,1984).Twoyearslater,however,Maruyamareconsideredthe

treatmentstyle.HechangeditfromShuchiryou‐seistyletoShyujii‐sei.Shyjii‐seimeans

thateachdoctorhadresponsibilitiesforthetreatmentoftheirownclientsontheunit.

Itwasnolongerthecasethatonlyonedoctorhadtheresponsibilitytocareforallthe

84

clientsontheunit.MaruyamatriedtoreconstructMoritaTherapyasasimplesystem

butusinganupdatedworkingstyle.Cliniciansdidnotlivewiththepatientsatthe

hospitalandwerenotrequiredtospendalotoftime,eventheirprivatetime,withthe

patients.Maruyamafoundawomantotakeonthemotherroleandlivewiththe

patients.InJapaneseculture,womentendtotakeonamotherroleinmanysituations.

Theclinicianswhoworkedatthehospitalbegantohavegroupsupervision.Thisnew

styleofMoritaTherapyopenedthedoortoallowmorefollowersofMoritaTherapy

becauseitbecamemoreclearwhattheclinicianwastodo.

MoritaTherapyToday

Today,theMoritaTherapyunitatJikeiMedicalHospitalinJapanprovides

treatmentforindividualsboththroughinpatientandoutpatientprograms.Some

Moritatherapistsdevelopedtheoutpatientprogramasaresultofthefactthatitis

difficultforclientstocommittolong‐termhospitalizationinmoderntimes.

Additionally,itisdifficultforclinicianstocommittoaheavyworkload.MoritaTherapy

hasbeenusedfordepression,OppositionalDefiantDisorder,anxiety,andpanic

disorders.ThereasonwhyMoritaTherapycontinuestodevelopisthatmanyMorita

therapistshavereassessedthecontentsandmethodsofMoritaTherapyandhave

addressedpastproblems.

Conclusion

MoritaTherapyneedstobeclearaboutitsphilosophyandbeabletodescribeit

clearly.SometimeswhenMoritaTherapyisdescribed,itsadmirersuseZenwordsthat

aredifficultandconfusingtopeoplewhoarenotfamiliarwithJapaneseculture.This

85

maybepreventingsomefromlearningaboutMoritaTherapy.Zenwordsand

philosophyarenoteasytounderstand.EvenZenmonksneedalongperiodoftraining

beforetheycanunderstandsomeZenconcepts.Additionallytherearepeoplewhoare

notinterestedinZenbecausetheyarecommittedtoadifferentreligion.Theymight

feelresistancetolearningaboutMoritaTherapyifitisdescribedentirelythroughZen

language.TheymightnotwanttheircliniciantouseMoritaTherapyfortheirtreatment

ifitisassociatedintheirmindwithBuddhism.

86

Table1:TheContextandHistoryofMoritaTherapy

Year WorldHistory

Medication History

JapaneseHistoryandCulturalPerspective

HistoryofMoritaTherapy

TargetofTreatment

1914 WWI 1919 ‐Fucho‐sei:

Strongpaternalright‐Bigfamilysystem

ShomaMorita,M.D.formulatedMoritaTherapy.Heopenedhishouseasaninpatienthospitalwithhiswife.(Syuchiryousyataisei)

Shinkeisitu‐sho

1923 theGreatKantoEarthquakeinJapan

1926 Moritastartedprovidingtreatmentthroughcorrespondence.

1929 GreatDepression

Moritastartedtoseeoutpatients.

1938 Moritadies. 1941‐1945

WWII

1950‐1953

KoreanWar

1960S Benzodiazepine NewMoritaTherapyInpatientHospitalopened(TokyoJikeiMedicalSchool):

1972 Nuclearfamilysystem

AizawabecomestheleaderofMoritaTherapyatGikeiMedicalSchoolinTokyo.(Syuchiryousya‐sei)

Shinkeisitu‐sho

1974‐1982

MruyamabecomesleaderofMoritaTherapyatGekeiMedicalSchoolinTokyo.

Shinkeisitu‐sho

1980S DSM‐III

87

V:THEINTEGRATIONOFMORITATHERAPYWITHARTTHERAPY

AlthoughArttherapytechniqueshavebeenusedinconjunctionwithmany

Westernpsychologicaltheories,noscholarlyarticlesorbookshavebeenwrittenabout

usingAmericanarttherapytechniqueswithMoritaTherapy.However,Moritahimself

usedartduringthetreatmentheprovided.Heusedartasanassessmenttooland

duringtreatmentinvolvinghislightworkstage.Forexample,heencouragedclientsto

writealetterordiarywiththeirtherapiststoexpresstheiremotionsandfeelings

(France,Cadieax&Allen,1995)becausethroughthisprocess,clientscouldlearnto

understandandobservetheirownthoughts.Ofcourse,thecliniciansalsobenefited

fromthewritingsinceitassistedtheminunderstandingtheclient’sthoughts,and

becomingfamiliarwiththeclient’scognitivestyle(Kubota,2008).Moritaalsolethis

patientsmakewoodsculpturesduringthelightworkphaseoftreatment(Morita,2004).

VarioushistoricaldocumentshaveverifiedthatthatinMoritaTherapy,arthasbeen

usedasatreatmenttoolandasamethodofassessmentduringthetherapyprocess.

However,therearenoreportsthatMoritaorhisfollowersrecognizedthatartandthe

processesinvolvedincreatingitaffectsclientsinpsychologicallyprofoundways.Art

therapyisatechniqueusedintherapythatleadsclientsdeeperintothemselvesand

givesthemtheopportunitytounderstandandfindoutaboutthemselveswiththe

supportofarttherapists.Forexample,thearttherapyprocessilluminatestheinner

dialoguesresultingfromtheclient’sinternalconflictsandaffectivestates.Thatcanbe

particularlyusefulforMoritaTherapyclientsbecauseafocusofthistreatmentison

88

developinganunderstandingofthedifferencesbetweentheirimageofthemselvesand

theirrealselves.Workingwiththevisualisaneffectivewaytounderstandthisconflict.

However,justengaginginartisnotarttherapy.Eventhoughartisdifferent

fromarttherapy,bothartandarttherapyaresimilarinthatbothareavehiclefor

humanexpressionandbothmakehealingpossiblethroughcatharsisandinotherways.

Inaddition,thecreativeprocesscansupportbothpsychologicalandphysical

development.Thatiswhyarthasbeenusedinrehabilitationaswellaspsychotherapy.

However,thoseusesarealsonotarttherapy.Arttherapyistheclinicaluseofart.

AccordingtotheAmericanArtTherapyAssociation,arttherapyhastodowith

theuseofartbyanarttherapistwhohasbeentrainedclinically.Trainedarttherapists

knowaboutpsychologicaldisordersandareabletogivediagnosesandtreatment.

Moreover,theyknowaboutwhichartmaterialsareclinicallyusefulforclients.Art

therapistsusuallychooseapsychologicaltheorytohelpthemframetheirworkwith

clients.Arttherapistsareabletouseanytheorywithwhichtheyarecomfortable.

MoritaTherapycanbeusedwitharttherapy.

Nakamuta(2008)statedthatforeffectiveMoritaTherapyitisimportantto

chooseclientswhoareabletounderstandtheconceptsbehindMoritaTherapy.Chief

amongtheseisthebeliefthatclientsneedtorealizethedifferencebetweentheir

idealizedselfandwhotheyreallyare.Inmakingthisdistinction,arttherapycanbevery

useful.Ifartisusedbyclientstounderstandthemselves,MoritaTherapy’sgoalof

increasedacceptanceoftherealselfcanberealized.

89

Inthissection,wewillexamineMoritaTherapykeepinginmindarttherapy

techniquesfromtheperspectiveofKitanishi’sideaofgoodoutpatientmethodology

(2008).Acasestudywillbepresented,oneinwhichMoritaTherapyandarttherapy

techniqueareused.Asinglecasestudydoesnotconstituteformalevidenceforthe

efficacyofatreatmentmethod.However,itwillprovideanexampleofhowMorita

Therapymightbeenhancedthroughtheuseofarttherapytechnique.

ExampleofArtTherapyInterventionTechniques

ThefollowingexercisesasbasedonKitanishi’streatmentmethodsforoutpatients

(2008).Theyareprovidedasamodelforthepossibleusesofarttherapywithinthe

theoryofMoritaTherapy.

ExperienceHowtoRelatetoEmotions

Directionsfromthearttherapist:Canyouconfusingsayinanotherway?You

candrawapictureormakeacollage.

IbelievethatIshouldbe/havetodo….Reality:Icandothose…Iwanttodothose…

Reality:Ican’tdothose…Idonotwanttodothose…

Figure7.DistinguishingBetweenICanDoItandICan’tDoIt

AvoidFightingwithorSuppressingtheEmotions

Directionsfromthearttherapist:Canyoudescribehowyouaresufferingnow?

90

HonestlyadmittingmyfeelingsFightingmyfeelings

IfIdon’tfightwiththem,Imightfeel…

Figure8.AdmittingVersusFightingEmotions

HoldingtheEmotions

Directionfromthearttherapist:Wehavemanydifferentkindsofemotions.Those

feelingsarereal.Canyouwrite/drawallyourfeelings?Afteryoufinishexpressingthem

onthepaper,couldyoupleaseholdthepaperwithyourarms?Youdonotneedto

judgeyourfeelings.Iwillnotjudgeyourfeelings.Youareabletoholdallyour

emotions.

Me

Allmyemotions

Figure9.HoldingtheEmotions

91

TakingTimetoLettheEmotionsComeDown

Directionfromthearttherapist: Emotionsarenotalwaysthesamelevel.Theyvaryin

intensity.Whenyouremotionsareverystrong,youneedtositwiththemuntilyour

emotionslosesomeoftheirforce.Ifyouwantto,youcandomeditationorwatchyour

breathwhileyougiveyouremotionstimetolessen.Lookatthepicturebelow.Itisan

examplegraphofthedynamicofahumanemotionwave.

Whereisyouremotionallevelnow?Usethegraphandobserveyouremotion’s

dynamic.Howlongdidyouremotionsrunbeforetheybecamecalm?Howdidyour

bodyreact?(breath,heartrate,andphysicalchanges)

Emotion High Emotion Time

Physical Change

Figure10.HoldingtheEmotions‐2

ObservingDynamicEmotions

92

OriginalMoritaTherapysuggestedwritingadiary.Here,clientscanuseartaswellif

theyfeelitwouldbeeasiertoexpressyourfeelingswithouthavingtofindwords.

Directionfromthearttherapist:Canyouusearttoexpressyourfeelingswithcolor?

Youcanaddwordsaswell.

Figure11.ObservingDynamicEmotions

RecognizingDynamicEmotions

Directionfromthearttherapist:Canyoudraworexpresshowyouremotionshavechangedbetweenthepastandnow?

PastEmotions

CurrentEmotions

Figure12:RecognizingDynamicEmotions

Diary

Date:_________ Ifeelandthinktoday.

PictureWords

93

ObservingtheBehavior

Directionfromthearttherapist:Afteryoustartedtreatment,haveyoufeltsomenew

feelingthatyouhaven’tfeltbefore?Inyourmind,doyouwanttodosomethingnew?

Ifso,whatisthat?Youneedtobehonestinyourmind.Youcandrawanythinghere.

Couldyoudraworwritewhatyouwanttodointhispaper?Canyoufindthatwhich

youcando?

Me

Trueself

Iwanttodo...

Figure13.ObservingtheBehavior

TakingActionandHavingExperiences

Directionfromthearttherapist:Couldyoufilloutthispaper?Youwillfindouthow

youfeelafteryoutakeaction.

SomeactionsthatIwanttotake

SomethingIcoulddo NowIfeel…

Figure14.TakingActionandHavingExperiences

94

HavingExperienceMakingDecisions

Clientsoftenhavedifficultymakingdecisionsbecauseofanxiety.Theyneedtopractice

makingdecisionsandtakingaction.

Directionfromthearttherapist:Hasitbeendifficulttomakedecisions?Afteryoudid

so,howdidyoubehave?Whatdidyoudo?Howdidyouthinktomakethedecision?

Iwantedtodo… ButIwasatlosstodo…

Finally,Icoulddo…. AfterImadedecisionandtookaction,Ifelt…

Figure15.MakingDecisions

AvoidPerfectionism

Manyclientstrytobeperfect.Theyneedtoforgivethemselvesandtorealizetheirtrue

abilities.

Directionfromthearttherapist:Nobodycanbeperfect.Youhavetonottrytobe

perfect.Whathaveyoubeenabletododuringthislastweek?

95

IbelievedthatIhadtodothesethingsperfectly…

TheseactionsIcoulddobymyselfforreal.

ThiswassomethinggoodIfoundinmyselfthoughIamnotperfect.

Figure16.AvoidingPerfectionism

HavingExperiencesinWhichActionsChangeEmotions

Directionfromthearttherapist:Youmightworryaboutyouractionbeforeyou

takeaction.Findactionwhichyoucando.Drawapictureyourfeelingsbeforeandafter

theaction.

BeforeItookaction… AfterItookaction,Ifelt…

Figure17.ActionsChangeEmotions

FeelingEnoughEnergytoLive

Directionfromthearttherapist:Afteryoutookaction,howdoyoufeel?Draw

andwritewhatyoumadeandhowdoyoufeel.Givepositivecommentstoyourself.

96

Action Ifoundoutthisnewthing

aboutmyselfSomepositivecommentsaboutmyself

Figure18.FeelingEnoughEnergytoLive

DecreasingSensitivitytoOtherPeople’sOpinions

Clientstendtobeverysensitiveaboutotherpeople’sopinionsandjudgments.They

oftenchangetheirbehaviors,thoughts,andgoalsasaresultoftheseopinionsand

judgments.Clientsoftenneedtolearnthatitisnotnecessarytochangetheirgoals

becauseofotherpeople’sopinions.

Directionfromthearttherapist:Let’sthinkabouthowyouseeotherpeople’sopinions

towardyou.

Otherpeople’sjudgmentstowardme

Figure19.IdentifyingExternalJudgments

97

Directionfromthearttherapist:throughthisfigure,youareabletorecognizehowyou

changedyourbehaviorandreachedatyourgoal.Reflectyourthoughtsandactionwith

thisfigure.

FirstSecondThirdOtherpeopleIwantedtodothisthoughtthisIcouldfocuson&takeaction

Fourth:HowdidIfeelaboutchangingmyactions?WhatdidIdowithmyfeelings?

Rememberwhatmygoalswere!

Figure20.RecognizingtheImpactofExternalJudgments

Changethedynamicbetweengoalsandothers’opinionsDirectionsfromthearttherapist:Let’sconcludeyourtherapysessions.Usethefigures

tofindyourchanges.Inthepast,yourthoughts,feelings,andbehavioraffectedother’s

98

opinions.However,today,throughtherapysessions,youwereabletotakeactionto

reachatyourgoalwithoutother’sopinions.

Past:

Purpose/goals＜others’opinions

Now:

Purpose/goals>others’opinions

Figure21.ChangingtheImpactofExternalJudgments

ArtTherapyTechniqueswithMoritaTherapy

TheoriginalresidentialMoritaTherapyprocedurebyMoritahadfourstages:

IsolationandRest,LightOccupationalWork,IntensiveOccupationalWork,and

PreparationforDailyLiving(Morita,1998).InMorita’sprocedure,arttherapydoesnot

applyduringthefirststage,“IsolationandRest,”becauseduringthisstage,clientsareto

restandanyactivityisprohibited.Duringthesecondstage,“LightOccupationalWork,”

clientsareallowedlimitedactivitiessuchaswritinginajournalanddrawingafter

dinner.Eventhoughtherapistsdonotgiveanytaskstotheclients,theycanhelpin

otherways,suchaschoosingtheclient’sartmaterials.Anotherexamplewouldbethat

theycouldgivedirectionsonhowtoscribbleordoodlewhichmightbeusefulforsome

99

clientsduringthisslow,quietperiod.Also,someclientsmightnotlikewritingajournal,

butmightliketodraw.

Duringthethirdstage,“IntensiveOccupationalWork,”someclientsmayfind

intensiveactivitiesdifficulttoaccomplish.Arttherapistsmaybeabletoprovideart

activities,directionandmaterialsthatengagelargermusclegroupsinanoutside

context.Clientsmaypreferartworktophysicallabor.

Inthelaststage,“PreparationforDailyLiving,”clientsareencouragedto

examinetheirfeelingsandthoughtsaboutthefuture.Clientscanfindmeaningby

acceptingtheirfeelingsorthoughts.Arttherapymaybeusefulforclientsinfinding

themselvesbecausedrawingandvisualizingareoftenhelpfulwaystofindacceptance.

CaseIllustrationofArtTherapyTechniqueIntegratedwithMoritaTherapy

Thefollowingcasestudyisbasedonasampleoftheauthor’sclinicalworkwitha

patientusingarttherapytechniqueswithinthetheoreticalorientationofMorita

Therapy.Namesanddetailshavebeenchangedtoprotectclientconfidentiality.This

caseispresentedasameanstodescribeinconcreteterms,anattempttointegrate

MoritaTherapyandarttherapy.

Alexwasan11‐year‐oldVietnamese‐Americanboy.HewasbornintheUnited

Statesandlivedwithhismotherandsisterinasingleparenthome.Hismaternal

grandmotherand17‐year‐oldmaternalunclealsolivedinthehome.Hisparents

divorcedwhenhewassevenyearsold.Alex’sfatherprovidednosupportand

maintainednocontactwiththefamily.

Whenhewasinthesixthgrade,Alexwasreferredforcounselingforrefusingto

gotoschool.Hetypicallymissedschoolfourdaysaweek.Hecomplainedofdifficulty

100

concentratingandexpressedhighlevelsofanxiety.HisfamilywasBuddhist.Hewasa

pickyeateranddidnoteatwell.Heoftencomplainedaboutsomaticsymptomssuchas

rapidheartbeat,shortnessofbreath,stomachaches,andheadaches,andusedthemasa

waytoavoidgoingtoschool.Alexwasalwaysworriedaboutbeingsickandmostofthe

time,wantedtostayhometorest.

AlexwasbilingualbutpreferredtospeakEnglish.Hisfamilyidentifiedwiththeir

Vietnameseheritage.HiscultureandheritagewereveryimportanttoAlexandhis

family.Alexwasdepressedandexperiencedalotofanxietyandstressaboutdealing

withhisuncle.Thisunclewas17andhadsignificantmentalproblems.

ThegoaloftreatmentwastoincreaseAlex’sschoolattendancebymanagement

ofhisemotionalstressandincreasinghissupport.MoritaTherapyprovidedthe

conceptualframeworkfortreatmentandfocusedonincreasingacceptance‐‐not

resistance‐‐ofhislifeandallhisemotions.Thisshiftedthefocusfromsymptomstolife

style.

ExpressingHisEmotions

Theprimaryclinicalpurposeoftheinitialsessionswiththeclientwastomakeit

possibleforhimtoexpress,recognize,andreflectonhisemotions.Arttherapygave

Alexasafewaytobothidentifyandexpresshisemotions,whichwereoften

complicatedanddifficulttoexpressverbally.

Alexdrewpicturesofenvironmentsthatgavehimsignificantdistress.The

picturebelowclarifiedrightawaythatAlexwasexperiencingsignificantdistressat

home.Thepicturegraphicallydemonstratedhisfeelingsaboutfamilymembers.

101

Figure22.Alex’sFamily

Rapportwasquicklyestablishedwithclientandtherapistthroughthejoint

projectofmakingart.Alexwasabletodiscusswiththisarttherapist,thevarious

emotionshewasfeeling.ThisgreaterlevelofdisclosurehelpedAlextoincreasehis

understandingofthenatureofhisemotionaldifficultiesandproblemswithinhisfamily.

VisualizinggaveAlexgreaterclarityofthoughtsaswell.

Alex’smotherparticipatedinthesecondsession.Alexandhismotherdrew

picturesoftheiremotionsreflectedinthehumanfigure.Alexandhismotherdiscussed

theirfeelingswitheachotherandthetherapistbysharingtheirpictures.Alexclearly

feltsafeenoughtodisclosethathewasstrugglingwithangerandsadness.

102

Figure23.Alex’sPictureofSelf

Hismotherwasalsoabletoshareheremotionalstrugglesthroughherselfportrait.

Figure24:Mother’sPictureofSelf

TheprimaryclinicalpurposeforthissessionwastoteachAlexthatallpeople

haveanxiety.Byviewingthetwopicturesandbeingapartofthedialogueaboutthe

art,Alexcametorealizethathismotheralsofeltanxietyandstress.Hewasthenable

103

tobegintounderstandthatmanypeopleacceptandholdanxietyindailylifesituations.

Eventhoughhismotherhadanxietyandworries,shewokeupinthemorning,cooked

andworkedbecauseshelovedhimandthefamily.Atthissession,Alexbeganto

changehisfocusfromhisemotionalsymptomstohisbehavior.

Inthenextsessions,Alexfurtherexpressed,recognized,andreflectedonhis

emotionsthroughtheartwork.Hediscussedhowangryandsadhewas.Through

thesesessions,Alexlearnedtonotbeafraidofexpressinghisemotions,butatthesame

time,torecognizeandpreparetoaccepthisemotions.Hedrewtemperature

indicators/barchartsportrayinghowmuchanxietyhefelt.

Figure25.AnxietyTemperatureIndicators1

Hispicturesshowedhowmuchanxietyhefeltindifferentsocialenvironments.

WhenAlexdidnotwanttogotoschool,thetemperaturegaugeshowedahighlevel.

Thehighesttemperatureinhispicturewasreservedforwhenhewaswithhisuncle.At

thattime,hepicturedhisanxietyasflowingsostronglythatitwent“throughtheroof”

104

ofthethermostat.Alexsharedhisfeelingsboththroughhispictures,andincreasingly

withhiswordsashetalkedwiththetherapist.

AcceptanceofhisEmotionsandLife

Astreatmentprogressed,Alexwasincreasinglyabletoaccepthisemotionsand

reallife.Heappearedtofeelsafewiththistherapistandseemedtoberelaxingat

times.Inonesession,Alexdiscussedthathecouldnotremovefamilymembersfromhis

life.Hedrewapictureofhisuncleasascarymanwithbarredteeth.

Figure26.MyUncle

Atthesametime,heacknowledgedthateventhoughhedidnotlikehisuncle,hisuncle

wasalsoafamilymember.Alexwasabletoaccepthislifecircumstancesratherthan

resistthem.Hewasbecomingmoreawareoftherealityofhislifesituation.

FocusonLifestyleRatherthanSymptoms

Inthislatterstageoftreatment,Alexwasabletoputmorefocusonbehavior

105

andaction,insteadoffocusingonhisemotions.Alexdrewapictureofwhathecould

dotochangehisdailylife,eventhoughhestillfeltanxietyandemotionalstress.

Figure27.Alex’sActions

WhileAlexdiscussedhispicturewiththisarttherapist,hefoundasolutionto

reducehisemotionstowardhisuncle.Hestatedthat“Iamabletoavoidbeing

physicallyclosetomyuncle.Whenmyunclecomesclosetome,Icanmoveandkeep

distancefromhim.”Moreover,herealizedthatifhefocusedonhisbehavior,hecould

reducehisdistresswhichwasoneofthecausesofhisdepression.Hefoundthat

changinghisbehaviorwaseasierthanchangingorresistingemotions.

106

CaseSummary

Atthebeginningoftherapy,Alexcomplainedabouthisuncle,histeacher,and

hislife.Hewasveryangryanddisappointedabouthislife.Hewasabsentfromschool

atleastthreetofourtimesaweek.Aftertherapysessions,forthenexttwomonths,his

attendanceatschoolincreasedtothreetimesaweek.Hesaid,“Icangotoschoolmore

thanbefore.”Hestatedthatheavoidedphysicallymakingcontactwithhisunclewhen

hisunclewasinabadmoodinsteadoftryingtoeliminatehisunclefromhislife.Hefelt

moreenergythanbeforehistherapy.Alexsaid“NowIjustcango(toschool)and

listen!”

Alexlearnedhowtocopewithhislifecircumstances.MoritaTherapywas

effectiveforhim.Arttherapysupportedtheexpressionofhisfeelings.Itwasan

effectivewayforhimtoexpresshisemotions.Dialoguewiththistherapistusinghis

pictureshelpedhimtoclarifyhisdifficulties,emotions,andissues.Onebigchangetook

placewhenAlexfoundthatallpeopleexperienceanxiety,stress,andsadness,evenhis

mother.Hewasverysurprised.Healsodidnotknowthateveryonehaddayswhen

wedidnotwanttogotowork,butwehadtogoforourfamilies.Afterthatsession,

Alexstartedtogotoschoolmoreconsistently.Heseemedtounderstandthatall

peoplehaveanxiety,buttheyworkintheirlives.

Inhisfinalsession,Alexdrewthefollowingtemperatureindicators/barcharts.

107

Figure28.AnxietyTemperatureIndicators2

ThepictureshowsAlexstillfeelsanxiety,butatalowerlevelthanbefore

treatment.Eventhoughhestillfeltanxious,hewasabletogotoschoolandsetan

appropriateboundarywithhisuncle.

ArttherapytechniquesareaneffectivetoolwithMoritaTherapy.Itiseasyfor

clientstounderstandaboutMoritaTherapyconcepts,aswellasaboutthemselves

throughthevisualmediumofart.MoritaTherapypromotestheexpressionofone’s

emotions,acceptanceofthem,andfocusingonchangesinbehaviorinsteadof

symptoms.Whenarttechniquesareused,ithelpsclientstounderstandthingswith

greaterclarityandcanbeeasierforthemthanthroughverbaldialogue.MoritaTherapy

isuniquebecausehistoricallyithasmadeuseofart.InJapaneseandZenculture,using

artinmanywayshasbeenanacceptedmatter.

Atthispoint,thereareobstaclestobeovercomeinregardstotheuseof

MoritaTherapyinWesternsocieties.MoritaTherapyisnotanevidence‐based

treatmentmodality,iffornootherreasonthannoscientificresearchhasbeendoneon

108

itinrecenttimes.Butthequestionbecomes,whoneedstogetscientificevidencethat

MoritaTherapyiseffectiveforclients?Tothispoint,JapanhasacceptedMorita

Therapyaseffectiveandpartofitsculturalheritagewithoutthescientificvalidation.

Perhapsaspsychologybecomesaworldwideaffair,MoritaTherapywillattractthe

attentionofWesternresearchers.Ifitisfoundtobeausefulformofmentalhealth

treatment,wecanonlyhopethatarttherapywillbeincorporatedintothisinnovative

professionalapproachtohumansuffering.

109

VI:CONCLUSIONS

ThisstudyexploredanintegrationofMoritaTherapywitharttherapytechnique.

TechniqueswerepresentedbasedonKitanishi’sworkwithoutpatientprograms(2008)

allowingfortheintegrationofMoritaTherapyandarttherapy.Kitanishigavedirections

thatwereeasilyunderstood.Thestudyalsopresentedacaseexample,ofthe

integrationofMoritaTherapywitharttherapytechniques.Inthecase,theclient

learnedhowtoexpresshisemotionsandanxietyusingarttherapytechniques.His

anxietyleveldidnotgoaway,asevidencedbyhisfinal“thermostat”picture.However,

theclientshowedimprovementinhisfunctioninginimportantlifedomains.This

indicatesthathewasabletolearntofocusonhisbehaviors,insteadofonhisemotions.

FocusingonbehaviorandnotsymptomsisaprimaryMoritaTherapygoal.Eventhough

theclientstillfelthisanxiety,hewasabletohandlehisdailylifebetterthanpreviously.

Asignificanttherapeuticmomentwaswhenthecliententeredintoadialogue

withthetherapist,usinghisartinwhichhewasabletoclarifyhisrealityandgaininsight

intohisissues.ArttherapytechniquessupportedtheclientinunderstandingkeyMorita

Therapyconcepts.Havingexperiencesisapowerfullearningmethodforclients.Itis

importantforclientstohavetheirownexperiencestounderstandtheirissuesandfind

solutions.Arttherapytechniquesprovidedexperientiallearning,usingastep‐by‐step

process.Goingthroughtheprocesswitharttherapistsisveryimportantforclients

engagedinMoritaTherapy.

Aresultofonecasestudycannotbegeneralized.However,itwasclearthatart

therapytechniquewithMoritaTherapywasusefulforthisparticularclient.The

110

treatmentwaseffective.Arttherapycanbeusedtohelpclientsunderstandthe

underlyingprinciplesofMoritaTherapy.Additionalstudiescouldpresentmorecase

studiesandshowmoreresults.ItishopedthatMoritaTherapywillbecomeaneffective

waytotreatclientsofAsianheritage.Itisalsohopedthatthiswillbehelpfulforsome

clientsfromWesterncultures.

Forthefuture,MoritaTherapyneedstohavemorescholarlypaperspublishedin

Englishforcliniciansaroundtheworld.MoritaTherapywillbeusefulforAsianclients

andclientswhocomefromaBuddhistheritage.Thesedays,scientistshave

demonstratedtheeffectivenessofmeditation.StudiesonMoritaTherapywouldmake

afineadditiontotheprofessionalliteratureonAsiantherapeuticmethodologies.Itis

importantforMoritaTherapytodemonstrateits’methodsandexplainits’uniqueview

ofpathologytotheworld.

Inparticular,studiesonMoritaTherapyshouldbepublishedmoreinEnglish‐

speakingjournals.TherearemanyarticlesaboutMoritaTherapyinthelibrariesof

Japan.However,mostofthemwerewrittenonlyinJapanese.Itisdifficulttofindmany

scholarlyarticlesinEnglishandinscholarlyresearchdatabases.Istronglybelievethat

Moritawantedtohelppeoplewithhisskillsasaclinician.Thatisthereasonwhyhe

createdMoritaTherapy.Hisresearchisfascinatingbecausethebreadthanddepthof

hisknowledgeofmentalillness,humanphenomenon,andEasternandWestern

psychologywasprofound.Eventhoughheisnolongeralive,hisphilosophyisstillliving

andattractsmanypeople.MoritaTherapyisusefulandshouldbeusedintheworldto

helppeople.

111

AlthoughithasbeensaidthatunderstandingMoritaTherapy’stheoretical

constructsisdifficult,arttherapyisabletohelptheclientunderstandandbenefitfrom

theprocess.ForAsians,thereisculturalsignificancetothismethodology.Zen

Buddhismhasusedartandcreativeprocessforbelieverstounderstanditsprinciplesfor

centuries.However,ishasusedartasahealingmethodonlywithintheboundsofits

religiousroleinsociety.ThecombinationofarttherapyandMoritaTherapyexamined

inthispapermakespossibletheuseofZenteachingsformedicalpurposes.This

possibilitybringswithitagreatdealofhope.PeoplewhowereraisedinBuddhist

culturesmayentertherapymorereadilyifMoritaTherapybecomesbetterknown,

becauseMoritaTherapyconceptsandprocessesaremorefamiliartothemthan

Western‐basedtherapies.Therapistsshouldnotpushclientstouseart.However,for

thoseclientswhoarecomfortablewitharttherapytechniques,integratingMorita

Therapyandtheprocessofcreatingartcanbeapowerfulandeffectiveformof

treatment.Abalancedcombinationofarttherapy’samazingabilitytobeacatalystfor

humangrowth,coupledwiththeevolvingstructureofMoritaTherapy’sculturally‐

congruentmethodologymayofferhealingtoabroaderrangeoftheworld’speoples.

112

REFERENCES

Aizawa,S.,Ohara,K.,Masuno,H.,Kojima,Y.&Iwai,K.(1967).Morita ryouhou niokeru   bashoteki jyoken nitsuite [Regardingtheenvironmentalconditionthatis requiredforMoritaTherapy].Tokyo,Japan: NomuraKyojuSyuunin10syunen kinenronbunsyu.Andersen,D.T.(2005).Empathy,psychotherapyintegration,&meditation:aBuddhist contributiontothecommonfactorsmovement.Journal of Humanistic 

Psychology,45,483‐502.

Brook,S.(2004).Tools of the trade: a therapist’s guide to art therapy assessments. Illinois:CharlesCThomasPublisher,LTD.Clements,K.(1996).Theuseofarttherapywithabusedchildren.Clinical Child   Psychology & Psychiatry,1,181‐198.Cumming,S.&Visser,J.(2009).Usingartwithvulnerablechildren.Support for      learning. 24,4,151‐158.Doi,T.(1963). Sieshin ryouhou to seishin bunseki[Psychotherapyandpsychonalysis]. Tokyo,Japan:Kanekoshobo.Dunn‐Snow,P.&Joy‐Smellie,S.(2000).Teachingarttherapytechniques:Mask‐making, acaseinpoint. Journal of American Art Therapy Association, 17,2,125‐131.Eckhoff,A.(2007).Theimportanceofartviewingexperiencesinearlychildhoodvisual arts:theExplorationofamasterartteacher’sstrategiesformeaningfulearlyarts experiences.Early Childhood Education Journal, 35,463‐472.Elkins,D.E.&Stovall,K.(2000).AmericanArtTherapyAssociation,Inc.;1998‐1999 membershipsurveyreport. Journal of American Art Therapy Association, 17,(1) 41‐46.Fenton,J.(2000).Unresolvedissuesofmotherhoodforelderlywomenwithserious mentalIllness.Journal of American Art Therapy Association, 17,24‐30.Frank,D.J.&Frank,J.B.(1993).Persuasion & healing: A comparative study of  

psychotherapy. MD:TheJohnsHopkinsLtd.France,M.,Cadieax,J.&Allen,E.(1995).Lettertherapy:Amodelforenhancing counselingintervention.Journal of counseling and development, 73,317‐381.

113

Fujita,C.(1977).Morita ryouhou ni okeru chiryou wo meguru shomondai [Issues regardingMoritaTherapytreatments].InTakara,T.&Ohara,T.(Eds.),Gendaino Moritaryouhou.Tokyo,Japan:Hakuyousha.Furuta,S.(1982).Nihon no Zen:  Nihonjin no bi‐ishiki[JapaneseZen:Japaneseconcept ofbeauty].Yoshida(Ed.)Zen&arts I(13).Tokyo,Japan:PerikanCo.Gladding,S.&Henderson,D.(1998).TheCreativeartincounseling:Amulticultural

perspective. Arts in Psychotherapy, 25,183‐187.Graham,M.&Sontag,M.(2001).Artasanevaluativetool:Apilotstudy. Journal of the    American Art Therapy Association, 18,37‐43.Gussak,D.(2009).Comparingtheeffectivenessofarttherapyondepressionandlocus ofcontrolofmaleandfemaleinmates. The Art in Psychotherapy, 36,202‐207.Hashimoto,K.(1985).Shinmoritaryouhoutouniokeruchiryoujyounosyomonndai: chiryoukannkyounosetteinohennkatosonoeikyounikannsurukousatsu[Issues ofnewMoritatherapymethod].Morita ryouhou situkiyou, 7,33‐39.Heyes,S.C.(2002).Buddhism&acceptance&commitmenttherapy.Cognitive and   Behavioral Practice, 9,58‐66.Hayes,P.(2001). Addressing cultural complexities in practice.Washington,D.C.: AmericanPsychologicalAssociationPublications.Hofman,S.G.(2008).Acceptanceandcommitmenttherapy:NewwaveorMorita therapy?Clinical Psychology: Science & Practice, 15,280‐285.Hoshino,J.(2003). MulticulturalArtTherapywithfamilies.InMalchiodi(Eds.),   Handbook of art therapy (pp.).CA,NY:GuilfordPress.HoughtonMifflinCompany(2009).The American heritage dictionary of the English   language,(4thed.,)IL:HoughtonMifflinCompany.Ichikawa,M.(2008).Gairai Morita ryohou: sinnkeisyou no tannki cyuchutiryou[Morita Therapyforoutpatient].Tokyo,Japan:Hakuyousya.Inoue,R.,Miwaki,Y.,Seki,N.&FilmArtInc.(2008).Art x therapy chouryu [Artand therapymovement].Tokyo,Japan:FilmArtInc.Ishiyama,F.I.(1990).AJapaneseperspectiveonclientinaction:Removingattitudinal blocksthroughMoritatherapy.Journal of Counseling and Department, 68,566‐ 570.

114

Ishiyama,F.I.(1986).Moritatherapy:Itsbasicfeaturesandcognitiveinterventionfor anxietytreatment.Psychotherapy,23,375‐381.Ishiyama,F.I.(1986).Positivereinterpretationofdeath:aJapanese(Morita) psychotherapyapproachtoanxietytreatment.Psychotherapy: Theory,   Research, Practice, & Training, 23,556‐562.Jordan,K.(2001).Familyarttherapy:Thejointfamilyholidaydrawing.Counseling and   therapy for couples and families, 9,52‐54.Jung,M.&Asawa,P.P.(1994).A history of art therapy in the United States.Alexandria, VA:AmericanArtTherapyAssociationInc.Kazamaturi,H.(1980).Kokoro no yamainikiku kusuri: kousinnyakunyumon [Midication   for mental illness].Tokyo:yuhikakusensho.Kalmanowitz,D.&Potash,J.S.(2010).Ethicalconsiderationsintheglobalteachingand promotionofarttherapytonon‐arttherapists.TheArtsinPsychotherapy,37, 20‐26.Kearney,K.S.&Hyle,A.E.(2004).Drawingoutemotions:Theuseofparticipant‐ produceddrawinginqualitativeinquiry.QualitativeResearch,4,361‐382.Kitanishi,K.(2008).Moritaryohotowa:KihontekiNaKangaekata[Motionpicture]. (AvailablefromMentalHealthOkamotoMemorialFoundation,1‐5‐10Sonezaki KitakuOsaka530‐0057Japan).Kitanishi,K.(1987).Moritaryouhouniokeruchiryousyakanjyakankei[Relationships betweenclientsandcliniciansinMoritaTherapy].Moritaryouhousitukiyo, 9,2‐ 5.Kitanishi,K.(1990).Moritaryouhounokeishotohatten:Jikeiidaidaisanbyouinno kensyunikanrensite[DvelopmentofMoritaTherapyatJikeimedicalschool].   Moritaryouhou gattukai, 1, 96‐98.Kitanishi,K.(2007). Morita ryouhou no subetega wakaru hon[EverythingaboutMorita Therapy].Tokyo,Japan:Kodansha.Kitanishi,K.(1984).Moritaryohoujyuninennochiryoutaiseinohenni[Developmentof MoritaTherapytreatmentsintwelveyears].Moritaryouhousitsukiyou, 6,24‐30.Kitanishi,K.,Toyohara,T.,Nagayama,K.,Hashimoto,K.,Minakawa,K.&Miyake,Y. (2007).Morita ryouho to seishinbunsekitekiryoho [Morita Therapy and   psychoanalysis].Tokyo,Japan:SeishinShobou.

115

Kitanish,K.&Mori,A.(1989).Morita ryouhou no kenkyu: aratana tennkai wo mezashite [StudyofMoritaTherapyfornewdevelopment].Tokyo, Japan:Kongousyuppan.Komatsu,J.,Kitanishi,K.,Mori,A.&et.al.(1985).StatisticalstudyonMorita Shinkeishitsufortwelveyears. Jikeidaishi, 100,293‐307.Kondo,K.(1966).TankiryohoutoMoritaryoho[ShorttermtreatmentsandMorita Therapy].Shinkeisitsu,6,47‐61.Kwee,M.,&Ellis,A.(1998).TheInterfacebetweenrationalemotivebehaviortherapy (REBT)andzen. Journal of Rational‐Emotive& Cognitive Behavior Therapy, 16,1, 5‐43.Kramer,E.(1972).Art as therapy with children.NY:SchockenBooks.Kramer,E.(1958). Art therapy in a children’s community. NY:CharlesC.Thomas.Kubota,M.,(2008).GairaiMoritaRyohonoSusumekata1,[Motionpicture].(Available fromMentalHealthOkamotoMemorialFoundation,1‐5‐10SonezakiKitakuOsaka530‐0057Japan).Lieberman,F.ZenBuddhismanditsrelationshiptoelementsofeasternandWestern arts.RetrievedOctober21,2009,from http://artsites.ucsc.edu/faculty/lieberman/zen.html.Malchiodi,A.C.(1997).Breaking the silence: Art therapy with children from violent   homes (2nd Ed.).NY:Brunner/Mazel.Malchiodi,A.C.(1998).The art therapy sourcebook.LA:LowellHouse.McMurray,M.,Schwartz‐Mirman,O.&Maizel,S.(2000).Arttherapy:Indicationfor treatmentofchoice. The Arts in Psychotherapy, 27,191‐196.McNamee,C.(2005).Bilateralart:Integratingarttherapy,familytherapy,and neuroscience.Contemporary Family Therapy, 27,545‐557.Maeda,F.&Nathan,H.J.(1999).Understandingtaijinkyofushothroughitstreatment, Moritatherapy[Moritatherapytreatmentsfortaijinkyofusho].Journalof PsychosomaticResearch,46,525‐530.

116

Matsumi,T.J.(1979).Culturalfactorsandsocialinfluencetechniquesinnaikantherapy: AJapaneseself‐observationmethod. Psychotherapy: Theory Research &   Practice, 16,385‐390.Morgan,D.(2001).Assimilationfromtheeastandthespectrumifconsciousness. Journal of Psychotherapy Integration, 11,87‐104.Morita,S.(1998).Morita therapy and the true nature of anxiety‐based   disorders   (shinkeishitsu).InKondo,A.&LeVine,P.(Eds.)NY:StateUniversityof New York. Morita,S.(1929/1960/2004)Shinkeishitsu‐no hontai‐to ryohou.Tokyo,Japan: Hakuyousya.McNiff,S.(2009).Cross‐culturalpsychotherapyandartmentalhealth:Areportofthe

surgeongeneral.RetrievedFebruary8,2010,fromhttp://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec5.html.

Milne,L.C.&Greenway,P.(1999).Colorinchildren’sdrawings:Theinfluenceofage andgender.TheArtsinPsychotherapy,1,261‐263.

Nabors,L.,Reyndds,M.,&Quinlan,A.(2000).TheEffectivenessofarttherapy:Doesit work? Journal of American Art Therapy Association, 17,207‐213.Naitou,A.,Seki,N.,&Yamashita,Y.(1995).Arttherapyniokerusozainoimi[Meaning ofartmaterialsinarttherapy].Rinsho Byouga Kennkyu, 10,140‐150.Naumburg,M.(2001).Spontaneousartineducationandpsychotherapy.American   Journal of Art Therapy, 40,46‐65.Nakamoto.(2009).ComparingandcontractingMoritatherapywithwesterntherapies. (Doctoraldissertation,SanDiego,CA:AlliantInternationalUniversitySanDiego).

Nakamura,K.(2008).MoritaRyohonoTekiotoChiryoKeitai,[Motionpicture]. (AvailablefromMentalHealthOkamotoMemorialFoundation,1‐5‐10Sonezaki KitakuOsaka530‐0057Japan)Niifuku,N.(1980).Moritaryouhoudeokorigachina‘seishinryouhoutekifukusayou’ [issuesofMoritaTherapytreatments:sideeffectsofthetreatments]. Kikanseishin ryouhou, 6,16‐23.Nissimov‐Nahum,E.(2009).Useofadrawingtasktostudyarttherapists’personal experiencesintreatingaggressivechildren. The Art and Psychotherapy, 36,140‐ 147.

117

OchanomizuHospitalShinryoNaika.(2007).Tokyo,Japan:MitsuhiroIchikawa. RetrievedJanuary4,2010,fromhttp://www.moritatherapy.com.Ohara,K.,Aizawa,S.,&Iwai,K.(1970).Morita ryohou [Morita Therapy].Tokyo,Japan: Bunkodo.O’Hare,D.&Cook,D.(1983).Children’ssensitivitytodifferentmodesofcolorusein art.British Journal of Educational Psychology, 53,267‐277.Palmer,L.,Farrar,A.,Valle,M.,Ghahary,N.,Panella,M.&DeGraw,D.(2000).An investigationoftheclinicaluseofthehouse‐tree‐personprojectivedrawingin thepsychologicalevaluationofchildsexualabuse.Child Maltreatment, 5,169‐ 175.Pifalo,T.(2007).Joggingthecogs:Traumafocusedarttherapyandcognitivebehavior therapywithsexuallyabusedchildren.Journal of the American Art Therapy   Association, 24,170‐175.Rosen,A.(2009).TheHeartliftoperation.Journal of the American Art Therapy   Association, 26,130‐134.Rubin,J.A.(2001).Approaches to art therapy theory & technique, second edition. EditedbyRubin,J.A.NY:Brunner‐Routledge.Rubin,J.A.(1998).Art therapy: An introduction.PA:Brunner/Mazel.Rubin,J.A.(2005).Artful Therapy.NJ:JohnWiley&Sons,Inc.Rubin,J.A.(1984).Child art therapy: Understanding and helping children grow through   art (2ndEd.).NY:JohnWiley&Sons,Inc.Rustin,T.A.(2008).Usingartworktounderstandtheexperienceofmentalillness: mainstreamartistsandoutsiderartists.RetrievedJanuary4,2010,from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736519/.Reynolds,D.K.(1969).Moritatherapyandthebehaviortherapies. Berkeley: University   of California Press.

Suzuki.C.(1967).Moritaryohounogijyutsutoriron:tokuniningenkankeitochiryouzou womegutte[MoritaTherapy’methodsandtechnique:humanrelationshions]. Seishinigaku. 9, 471‐479.

118

Suzuki,T.(1989).ConceptofneurastheniaanditstreatmentinJapan. Cult Med   Psychiatry 13,2,187‐202

Sansone,D.(2005).Moritatherapyandconstructiveliving:Choicetheoryandreality therapy’seasternfamily. International Journal of Reality Therapy, 25,26.Sorai,K.(2000).Shinri tests[Psychologicaltests].InY.Tokuda,K.Omori,M.Iimori,H. Nakai,&Y.Yamanaka(Eds),Geijyuturyouho:1(PP.162‐172).Tokyo,Japan: wasakiGakujyutushuppanInc.Silver,R.(2009).Identifyingchildrenandadolescentswithdepression:Reviewofthe stimulusdrawingtaskanddrawastoryresearch.Art Therapy: Journal of the   American Art Therapy Association, 26,4,174‐180.Suwaki,H.(1985).NaikananddanshukaiforthetreatmentofJapanesealcoholic patients.British Journal of Addiction, 74,15‐19.Suwaki,H.(1985).Internationalreviewseriesalcoholandalcoholproblemsresearch. Japan, British Journal of Addiction, 80,127‐132. Suzuki,T.(1940).Zen and arts.In1996,Yoshida,S.(Ed.).Zenandarts.Tokyo,Japan: PerikanCo.Suzuki,T.(2005).Zen and Japanese culture.Tokyo,Japan:KoudanshyaInternational Inc.Tatematsu.I.(1986).Nyuinmoritaryouhoucyunochiryouchudankikitokokufuku [IssuesofinpatienttreatmentsinMoritaTherapy].Morita Ryouhou Sitsu  Kiyou,   8, 22‐32.Toneatto,T.(2002).Ametacognitivetherapyforanxietydisorders:Buddhistpsychology applied.Cognitive & Behavior Practice, 9, 72‐78.Tanaka‐Matsumi,J.(1979).CulturalfactorsandsocialinfluencetechniquesinNaikan therapy:AJapaneseself‐observationmethod.Psychotherapy: Theory Research   & Practice, 16.385‐390.Thyme,K.E.,Sundin,E.C.,Stahlberg,G.,Lindstrom,B.,Eklof,H.&Wiberg,B.(2007). TheOutcomeofshort‐termpsychodynamicarttherapycomparedtoshort‐term psychodynamicverbaltherapyfordepressivewomen.Psychoanalytic   Psychotherapy, 21,250‐264.

119

Uchimura,H.(1970).Moritaryouhouniokeru“toraware”tochiryouno“ba”nituite [PathologyofobsessionandthetreatmentenvironmentinMoritaTherapy]. Seishinigaku, 12,741‐784.Vick,M.R.,(2003).A brief history of art therapy,Edi.Malchiodi,A.C.(2003).Handbook ofarttherapy,NY:GuilfordPress.Wadeson,H.(2000). Art therapy practice.NY:JohnWiley&Sons,Inc.Wadeson,H.(1987,1995).The Dynamics of art psychotherapy.NY:JohnWiley&Sons, Inc.Wallace,J.,Yorgin,P.D.,Carolan,R.,Moore,H.,Sanchez,J.,Belson,A.,etal.(2004).The useofarttherapytodetectdepressionandpost‐traumaticstressdisorderin pediatricandyoungadultrenaltransplantrecipients.Pediatric Transplantation,   8,52‐59.Wegman,P.&Lusebrink,V.(2000).KineticFamilyDrawingscoringmethodforcross‐ culturalstudies.The Art in Psychology, 27,179‐190.White,C.,Wallace,J.&Huffman,L.(2004).Useofdrawingtoidentifythrough impairmentamongstudentswithemotionalandbehavioraldisorders:An exploratorystudy.Journal of the American Art Therapy Association, 21,210‐ 218.Wicks‐Nelson,R.&Israel,A.C.(2009).Abnormal child and adolescent psychology. NJ:PersonPrenticeHall. Yanagida,S.(1982).Nippon no zen, Nipponjin no biisiki [Japanese Zen and Japonese   sense of beauty].InYoshida(Ed.)Zen&artsI(13).Tokyo,Japan:PerikanCo.Yoshida,S.(1985). Nippon Bunka to Zen [Japanese culture and Zen],In1996,Yoshida (Ed.)Zen&artsI(13).Tokyo,Japan:PerikanCo.

120