The experiential therapy of Shoma Morita: a comparison to contemporary cognitive behavior therapies.
Cognitive-behavioral therapy (Research)
Psychotherapy (Health aspects)
Spates, C. Richard
Seim, Richard W.
Sheerin, Christina M.
|Publication:||Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2011 American Psychotherapy Association ISSN: 1535-4075|
|Issue:||Date: Spring, 2011 Source Volume: 14 Source Issue: 1|
A recent trend in psychotherapies has been to utilize techniques that have an unmistakable Eastern signature, such as mindfulness and acceptance-based strategies. Although these approaches have been met with widespread clinical and empirical support, an analysis of the origins of these approaches has so far been limited. This paper will redress this tendency by highlighting a Japanese form of treatment known as Morita Therapy, note the development of this approach, and outline how it is currently practiced. A further objective is to delineate how this approach aligns with contemporary cognitive behavior therapies (sometimes known as "third wave" therapies) such as Acceptance and Commitment Therapy, Dialectical Behavior Therapy, and Mindfulness-Based Cognitive Therapy in regards to case conceptualization, diagnosis, and intervention. It is hoped that this effort will open a stronger narrative regarding the core processes of these approaches and foster a greater integration and synthesis of contemporary Eastern and Western therapies.
Science is a constantly evolving enterprise. While well-known ideas are outright challenged and ultimately either embraced or cast away, more obscure or culturally isolated ideas often fade into history, only to be resurfaced, reinvigorated, or completely rediscovered years later. Like all sciences, this occurs with psychotherapeutic modalities and techniques. For example, many have applauded the increased use of mindfulness and acceptance-based strategies in behavioral and cognitive-behavioral therapies, and various approaches, such as Acceptance and Commitment Therapy, Dialectical Behavior Therapy, Mindfulness-Based Cognitive Therapy, Mindfulness-Based Stress Reduction, and Buddhist-inspired substance abuse treatments have arisen from both basic and applied research validating the efficacy of these techniques.
Though it is a controversial distinction, some have seen these collective approaches as a "new wave," a "third wave," or a paradigm shift in empirically based treatments (Hayes, 2004). However, while this may be a new movement within the cognitive-behavioral tradition, these techniques have been an integral part of Eastern therapies for years. This paper will elucidate a Japanese form of treatment know as Morita Therapy. Since its inception, Morita Therapy has developed into an established brand of psychotherapy in Asia, and some have commented on the similarities between third-wave cognitive behavior therapies and Morita's approach (e.g., Hofmann, 2008).
The point of this paper is not to highlight the proprietary nature of Morita's work but to shed scholarly light first on the core features and processes of Morita Therapy to a degree that has been absent from the ongoing discussion. Also, by identifying original or early sources for what might have proved to be difficult-to-access works on Morita Therapy, we intend to examine how these processes align with Western therapies at a level of depth heretofore unaddressed. In a similar vein, we hope Easterners will be able to appreciate the relevance of concepts heretofore thought uniquely Eastern and how they interlace or hold a central conceptual position in contemporary cognitive behavior therapies. It is also hoped that by doing this, we will foster a greater degree of communication, integration, and synthesis of Eastern and Western approaches and spur more informed clinical research.
THE DEVELOPMENT OF MORITA THERAPY
Morita Therapy was developed by Shoma Morita, a Japanese psychiatrist who lived during the Meiji Period in Japan, a period roughly beginning in 1864 and ending around 1925. During this period, Japan had adopted an "empirical science" approach to education that emphasized the importance of direct observation in analyzing events (Fruhstuck, 2005; Kitanishi & Mori, 1995). This approach was adopted in part from China and was further expanded through contact with the West, notably Germany and Great Britain (Low, 2005).
After graduation from medical school, Morita began working with a series of patients presenting with a problem then known as neurasthenia (Beard, 1880; Charcot, 1877; Dubois, 1908; Freud, 1896/1962; Mitchell, 1900), a constellation of symptoms including fatigue, anxiety, and somatic issues. While neurasthenia had been documented in German, British, French, and American medical literatures, it was not well understood and was considered especially difficult to treat. Given the difficulty in treating such problems, Morita initiated a telegram correspondence with Sigmund Freud seeking advice. Although much of the Western world had adopted Freud's approach, Morita reported that his patients did not seem to respond well to psychoanalysis, and he later took serious issue with a number of Freud's concepts (Morita, 1928/1998). Instead, Morita began borrowing ideas from the works of Mitchell (1900), Dubois (1908), and Binswanger (1911), which emphasized the importance of direct experiences and the paradoxical nature of emotional control. He assimilated these ideas into his own approach, which he continued to develop and revise over time (Kitanishi, 1991; Kitanishi & Mori, 1995).
After conducting his initial studies on psychotherapies, Morita believed that the definition of neurasthenia was too broad and impractical to be of any diagnostic or clinical utility. Instead, he used the term shinkeishitsu to describe mood, anxiety, and psychosomatic concerns that arise due to a "hypochondriacal temperament" or a tendency to overly focus on the state or functioning of one's body and to exhibit hyperreactivity to both mental and physical symptoms. Morita argued that shinkeishitsu was not a biological disorder but a mental attitude or a mode of living (Fujita, 1986; Ohara, 1975).
Morita believed that physical and psychological pain are normal reactions to one's circumstances and should not be seen as problematic. However, when an individual perseverates on these reactions, views them as intolerable, and attempts to control them, problems occur. As one contemporary Morita therapist stated, "The patient's attempt to cure the disorder ... has the opposite effect, similar to one's awareness of becoming more mentally tenacious in remembering something the harder one tries to forget it" (Fujita, 1986). Thus, instead of allowing his or her discomfort to wane naturally, the patient inadvertently exacerbates his or her symptoms, leading to a vicious circle of anxiety, avoidance, and more anxiety (a term used most extensively by Hurry, 1915). Over time, this pattern may cause some to confuse their subjective experiences with reality (Morita, 1928/1998).
Therefore, for Morita, the goal of therapy was to provide patients with a set of direct experiences that would teach them to let go of the struggle to control their private experiences and to eventually reach an acceptance of one's self, one's symptoms, and one's reality "as it is" (known as arugamama in Japanese). Morita argued that an abstract understanding of this goal was insufficient; arugamama could only be attained through situations where patients could not escape or avoid their emotions (Kitanishi, 1991). He believed that, through regular contact with these situations, patients eventually learn to accept their emotions, and the mind returns to a natural state of balance (Morita, 1928/1998).
Morita advised clinicians to focus on their patients' ability to live a "constructive" or "purposeful" life, and he warned them to not become preoccupied with treating their patient's symptoms. These preoccupations, he said, are like "killing the ox by attempting to reshape the horns" (Morita, 1928/1998). He also urged therapists against using the patient's discomfort as an indication of the severity of his or her disorder.
THE PROCESS OF MORITA THERAPY
Although it Is now delivered in both outpatient settings and residential clinics (e.g., the Jikei University Center for Morita Therapy in Tokyo and Sansei Hospital in Kyoto), in its classical form, Morita Therapy was delivered primarily as an inpatient treatment. Before beginning treatment, new patients would be introduced to the theory and practice of Morita Therapy through informal meetings known as keigaikai where they could interact with past and current patients and hear lectures from clinic directors. After this orientation, the four-stage process of treatment would begin.
During the first seven to 10 days of treatment, patients were required to remain in bed in a single room, with time permitted only to go to the toilet, maintain bodily cleanliness, and have meals. The purpose of this stage was to help patients learn to mindfully observe their anxiety without engaging in distracting activities. A variety of psychological and somatic reactions have been noted to occur in patients during this phase, and recent research has examined biological rhythm patterns along with autonomic and CNS reactivity during this period (Zhang, Nan, & Wang, 2007). Because the goal of this stage was to help patients fully encounter their anxiety and experience its natural rise and fall, the length of each patient's bed rest was individually tailored (Fujita, 1986).
Light Work Period
During this stage, which lasted one or two weeks, the patient was required to go outside to experience fresh air and silently observe others working in the garden. Morita advised patients to write about their daily experiences at the clinic but not about their Symptoms. In fact, he recommended that therapists be "strategically inattentive" (known as fumon or the non-inquiry technique) to patient reports of symptoms through all stages of treatment. Morita provided brief written feedback and advice to his patients during this stage, and he encouraged them to act only according to their "desire to live fully." The goal of this period was to promote spontaneous activity following natural impulses and curiosity and to "break down the client's self evaluating attitudes by de-emphasizing a focus on feelings or comfort and discomfort." Fujita (1986) suggests:
Heavy Work Period
During this stage, the patient was to engage in more significant tasks, such as cleaning, gardening, assisting with cooking, shopping, or participation in maintenance of the group milieu. Morita believed that this occupational therapy helped to promote awareness of oneself in relation to external reality, as opposed to a focus on the patient's subjective experiences. Furthermore, it was thought to stimulate surrender to the present situation and promote an adaptation to nature with or without symptoms still present (Fujita, 1986). It was during this stage that the patient began to experience the joy and confidence of work achieved through his or her own efforts. For Morita:
The goals of this stage were usually achieved in one or two weeks in classical Morita Therapy, but the duration of this stage tends to be extended in recent practice. This stage is terminated when the patient notices that he or she is busy every day with the work that needs to be done, and this marks the point for proceeding to the next stage (Fujita, 1986).
Training Period for Practical Living
During this final stage, which lasted from a few weeks to one month, the patient prepared to return to his or her usual life in society. A primary goal of this stage was to help each patient to continue to focus on external reality as opposed to subjective experiences and to encourage engagement in valued actions, regardless of whether or not symptoms were still present. One way of practicing this was through reading exercises. Morita (1928/1998) instructed his patients to "open the book to any page at random and read silently without making any special effort to understand or remember the content." This training was thought to decrease a patient's anticipatory emotions that arise from perfectionistic values, such as focusing on symptoms of being unable to concentrate, unable to comprehend, complaints of being distracted by noises, etc. Morita reported that after a few days his patients began to read calmly despite any such distractions. Through this, "Clients are trained to adjust to changes in external circumstances," (Morita, 1928/1998). In so doing, they are believed to be better prepared to return to a natural rhythm of life.
This classical model of Morita Therapy has since been altered in recent years. It is now often used in conjunction with pharmaco-therapies, and many therapists place less of an emphasis on the Zen Buddhist philosophy endemic to traditional Japanese culture. But, arguably, the most significant change has been the shift from Morita Therapy being used mainly in residential settings to it being predominantly used in outpatient centers. This shift largely occurred as a response to modern limitations on insurance reimbursement, changes in health care policy in Japan, and prohibitive expense (Fujita, 1986; Nakamura, 2000). Some have also called attention to contemporary changes in Morita Therapy being brought on by the changing cultural context of contemporary Japan in response to what is recognized as a change in shinkeishitsu and evolving characteristics of contemporary patients seen by Morita therapists (Kitanishi & Azuma, 2005; Nakamura, 2000). These patients are said to resist the authoritarian style of the doctor/patient relationship commonly seen in Morita's day and prefer the egalitarian relationship fostered in many outpatient settings.
The therapeutic targets of this modern approach are very similar to those in classical or residential Morita Therapy, with the visible deletion of absolute bed rest. Goals such as clarifying the concept of vicious circle that maintains anxiety, increasing awareness and acceptance of one's emotional and physiological states, and encouraging constructive actions are met during one or two sessions per week along with the continued use of diary feedback through verbal interviews with patients (Nakamura et al., 2009). In many ways, the outpatient implementation takes on a more didactic format than one based on direct experiences arranged by the therapeutic environment of the inpatient or residential setting.
While adhering to many of the traditions laid forth by its progenitor, contemporary Morita Therapy is adapting to face modern problems, such as dealing with patient drop-out, encouraging adherence to treatment, and recognizing the need for greater client-therapist rapport (Fujita, 1986; Fujita, 1992; Kitanishi & Mori, 1995). In addition, some scholars, such as Ishiyama (Ishiyama, 1991, 1994, 2000, 2007; Ishiyama & Azuma, 2004) have reported extensively on the use of outpatient Morita Therapy and adaptations found necessary within a cross-cultural, non-exclusively Japanese context. Moreover, efforts are being undertaken to standardize the practice of Morita Therapy. The Consensus Guideline for the Implementation of Outpatient Morita Therapy has been prepared by the Japanese Society for Morita Therapy (Nakamura et al., 2009), and the English version of this guideline was published early in 2010.
CONTEMPORARY COGNITIVE BEHAVIOR THERAPIES
Contemporary behavioral and cognitive-behavioral therapies are best understood as an applied progression of conventional behavior therapy toward the incorporation of techniques and approaches that bear an Eastern signature. Among these contemporary approaches are Acceptance and Commitment Therapy (ACT), Dialectal Behavior Therapy (DBT), Mindfulness-Based Cognitive Therapy (MBCT), Mindfulness-Based Stress Reduction (MBSR), and certain aspects of Behavioral Activation (BA). In this section, we first provide an overview of several representative contemporary behavioral/cognitive-behavioral approaches and then compare them to Morita Therapy with the goal of contributing to the continuing discussion surrounding their similarities and differences (see also Corrigan, 2001; Gibson, 1974; Hayes, 2008; Hofmann, 2008; Spates, 2004).
Acceptance & Commitment Therapy
One of the more public comparisons (cf. Hayes, 2008; Hofmann, 2008) has been made between Morita Therapy and Acceptance and Commitment Therapy, otherwise known as ACT. ACT was born out of problems regarding the persistence of maladaptive behaviors due to language-based rule governance (Hayes, Barnes-Holmes, & Roche, 2001; Hayes, Strosahl, Bunting, Twohig, & Wilson, 2004). The attempt to resolve these problems led to a new approach to the study of language, titled Relational Frame Theory (RFT), and a revived philosophy of science that married pragmatism and functionalism into a view referred to as functional contextualism. Putative principles derived from RFT were then assembled into an approach to treatment known as ACT. By incorporating the notions of cognitive fusion/defusion, advances in the understanding of the paradoxical nature of thought suppression (e.g., Wegner, Schneider, Carter, & White, 1987), and techniques borrowed from other therapies (e.g., Gestalt therapy), ACT became a systematized treatment package amenable to scientific inquiry.
ACT starts from the contention that psychological pain is not pathological and that all healthy individuals will regularly experience emotional pain and distressful thoughts (Hayes, Strosahl, & Wilson, 1999). However, ACT goes further to differentiate this pain from suffering (Eifert & Forsyth, 2005). While pain results from the mere existence of these thoughts and emotions, psychological suffering is due to an insidious four-step process: (1) The individual becomes excessively attached or "fused" to the literal content of thoughts, causing him to view these experiences as highly meaningful while turning attention away from the present moment. (2) He or she views these private events as pernicious and unacceptable and develops an unwillingness to experience them. (3) Out of this unwillingness, the individual begins the vain effort to control these private events, known as experiential avoidance (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). (4) The individual then mistakenly assumes his thoughts and emotions are the causes of distress, which allows him to justify these unworkable coping strategies and rendering the symptoms less responsive to real contingencies in the environment (Strosahl, Hayes, Wilson, & Gifford, 2004).
Based on this conceptualization, the goals of ACT are to help the individual accept these unwanted private experiences, identify a set of valued life directions, and commit to acting in accordance with these values in spite of negative thoughts and feelings (Hayes et al., 1999). To accomplish these goals, ACT utilizes metaphors, experiential exercises, and various other techniques culled from numerous psychotherapeutic disciplines. These are all designed to help individuals distance themselves from the literality of their thoughts, become more aware that their thoughts do not constitute their identity, to undermine reason-giving, live more in the present moment, and commit to patterns of valued action (Strosahl et al., 2004).
Dialectal Behavior Therapy
Dialectical behavior therapy (DBT) developed out of clinical work with patients with borderline personality disorder. Through this work, it was suggested that traditional cognitive-behavioral interventions, which focused exclusively on symptom change, tended to make clients feel invalidated, while humanistic treatments, which focused almost exclusively on validation, rarely addressed timely change (Sanderson, 2002). Rather than choosing one or the other perspective, Linehan (1993a) reported she eventually found that a balance between these two strategies led to the most favorable treatment outcomes. This dialectical stance was also found to be a way to understand the dichotomous patterns of thinking and behaving seen in individuals with Axis II behavior problems, and, coupled with principles from Zen philosophy and behavioral theory, eventually developed into a comprehensive and multi-modal treatment package (Sanderson, 2002).
According to DBT, psychological suffering occurs when individuals over-regulate and avoid their private experiences in attempts to please others. This is believed to lead to an invalidation of those experiences and a tendency to oversimplify the ease with which one should be able to solve one's problems (McMain, Korman, & Dimeff, 2001). The individual is said to use vain attempts to regulate emotions, resulting in feelings of desperation, impulsivity, and a low threshold for distress, which leads to further hypersensitivity and often harmful coping strategies (Linehan, 1993a).
To counteract this cycle, the primary goals of DBT are to teach more effective coping skills, help the client stop thinking in rigid, black-or-white terms, and foster emotional engagement as opposed to emotional avoidance. Numerous therapeutic techniques are utilized in the context of group and individual psychotherapy to meet this end, including teaching mindfulness skills, distress-tolerance skills, interpersonal effectiveness skills, etc. (Linehan, 1993b; Linehan, Cochran, & Kehrer, 2001).
Mindfulness-Based Cognitive Therapy
Work in Mindfulness-Based Cognitive Therapy (MBCT) began through the study of factors of why some people are more likely to relapse than others after a major depressive episode. It was ultimately found that those who are able to distance themselves or be mindful of their thoughts were less likely to relapse (Teasdale et al., 2002; Teasdale et al., 2000). Thus, through a union of Becks cognitive therapy (Beck, Rush, Shaw, & Emery, 1979) and components of the Mindfulness-Based Stress Reduction program of Kabat-Zinn (1990), this empirically supported relapse prevention program was developed (Teasdale et al., 2000).
The core of MBCT case conceptualization is the differential activation hypothesis--the notion that negative, self-devaluative, hopeless thinking patterns become associated with one's depressed mood states. Once this relation is established, even minor feelings of low mood can elicit a downward spiral of maladaptive thinking patterns (Segal, Williams, & Teasdale, 2002).
The main goals, then, of MBCT are to cultivate "a detached, decentered relationship to depression-related thoughts and feelings" (Teasdale et al., 2000) and provide the patient with skills necessary to prevent the escalation of such thoughts in the future. To reach this end, the patient is taught to not alter the content of his thoughts but, rather, to examine the way these thoughts are experienced and to develop a meta-cognitive awareness of the thoughts through meditation and other mindfulness exercises (Fennell, 2004).
ANALYSIS OF SHARED CORE FEATURES
It is acknowledged that each of the aforementioned treatments has unique characteristics both in conceptualization and approaches to intervention. Such differences include Morita Therapy's classical use of absolute bed rest and work therapy as the principal vehicle for achieving therapeutic aims, DBT's emphasis on teaching coping skills, ACT's focus on undermining maladaptive language processes, and MBCT's attention to the prevention of relapse. In addition, each treatment has made an identifiable empirical contribution to treatment process and outcome literature. However, it can be seen that the treatments are united by several core concepts, leading to striking commonalities in case conceptualization and treatment process. Further, a more complete understanding of these similarities may foster a greater appreciation and potential integration of these treatments toward the end of better patient care. But beyond this, such an exercise may lead to higher quality strategic research that evaluates pertinent core components shared across these interventions and eventually to "constructive research designs" that lead to the most powerful empirically supported therapies for patients (Borkovec & Castonguay, 1998). In this section, we provide a comparison of these shared core features.
The Normality of Suffering. Morita Therapy and many of the contemporary behavior therapies are aligned in the notion that much psychological suffering is a consequence of our reactions to normal psychological processes that are common to us all. Morita discussed this in terms of sei no yokubo, or the self-actualizing tendency (Reynolds, 1976). Each of us has the desire to live life fully and actualize our unique potential. However, in striving to be the best we can be, we inevitably encounter pitfalls, setbacks, and pain. None of these, in this view, should be considered pathological or deviant. Contemporary cognitive behavior therapies largely concur with this notion. For example, the DBT standpoint is that pain and distress are normal, unavoidable facts of life (Linehan, 1993a). Likewise, ACT rejects the notions of happiness being a normal state of humans, and similarly rejects the idea that psychological pain is a "mental disease" to be isolated and extracted from the individual's thinking. Instead, it offers the assumption of a destructive normality; the notion that otherwise adaptive psychological processes sometimes tend to inadvertently lead to suffering (Hayes, et al. 1999).
Maladaptive Focus of Attention on One's Symptoms. Morita Therapy and contemporary therapies also agree that psychological problems are not due to symptoms per se but to hyper-attention on these symptoms and the confusion of thoughts with reality known in Morita Therapy by the Zen term akuchi). Morita believed that neurotic symptoms (shinkeishitsu) begin through a process known as seishin kogo sayo, or "psychic interaction" (Morita, 1928/1998). This is the observation that psychological problems arise when one does not permit the mind to flow naturally from one idea to another but, instead, becomes fixed or obsessed on bothersome thoughts or sensations (Fujita, 1986; Reynolds, 1976). Central to MBCT is the idea that problems occur when the client adopts the notion that "my thoughts are who I am" (Fennell, 2004), thus identifying the self according to the content of the thoughts and not merely his or her relationship to those thoughts (Segal, Williams, & Teasdale, 2002). This tendency leads the individual to become overly attentive to even minor psychological symptoms, triggering a downward spiral towards symptom relapse. ACT presents a similar conceptualization that problems occur when individuals identify themselves as the content of their thoughts (self-as-content), rather than simply the context for them (self-as-context). The individual is said to then focus on, or become fused to, to the literal meaning of these thoughts (cognitive fusion), diverting attention away from the present moment. In discussing the development of emotional dysregulation, DBT presents a similar notion, in that after experiencing a stressful event, the individual has difficulty reorienting his attention and returning to an emotional baseline (Sanderson, 2002).
The Vain Attempt to Control Private Events. Focusing on these thoughts and sensations often leads to the erroneous conclusion that these events are negative and must be controlled. The attempt to manipulate one's private events and bring them in line with one's desires was called shiso no mujun by Morita (1928/1998). He suggested that disorders are based in the faulty belief that one ought not to have private sensations and cannot live life normally until they are eliminated. The "vicious circle" formed between these ideas on the one hand, and attempts to control symptoms (toraware) on the other, becomes an early focus of therapeutic intervention in Morita Therapy. Similar concepts can be found in contemporary behavior therapies. DBT argues that the inability to accept pain as a part of life leads to frustrating attempts to over-regulate and invalidate one's experiences (McMain et al., 2001). ACT believes that an unwillingness to have private events and futile attempts to avoid them are at the heart of suffering. And MBCT argues that the tendency to see minor dysphoric moods and depressive thoughts as catastrophes is the catalyst of further distress (Segal et al., 2002).
The Perpetuation of Symptoms. Morita Therapy and most of the contemporary cognitive behavior therapies agree that a vicious circle leads to the escalation of psychological symptoms. After over-attending to his or her thoughts and sensations, viewing them as negative, and engaging in a fruitless attempt to control them, the individual is said to recoil from life and focus even more on such events, thus perpetuating suffering.
Another commonality between Morita Therapy and contemporary therapies is the downplaying of syndromal classifications and a greater emphasis on functional diagnoses (Hayes, et al. 1996; Reynolds, 1976; Morita, 1928/1998) and their indications for treatment. As a physician, Morita advocated the use of thorough assessment and accurate diagnoses, but he argued that these diagnoses should not be construed as a way of pathologizing the patient or his or her problems: "I think that assessment and diagnosis requires a scrutiny of the client's environmental living conditions, characteristics and the origin of her or his symptoms. However, no policy for treatment or prognosis can be established on the basis of diagnoses from symptoms alone" (Morita, 1928/1998). Like many contemporary therapies, which argue that pathologizing problems is a hallmark of an invalidating environment (Linehan, 1993a) and all individuals' problems differ only in degree, not in kind (Hayes et al., 1999; Sanderson, 2002), Morita believed that the diagnostic emphasis should convey how much the patient is like other humans (Reynolds, 1976), and the patient's distress should not be seen as an intractable disease. Through his mentor, Shuzo Kure (a student of Emil Kraepelin), Morita was only a generation removed from Kraepelin's teachings, yet he rejected many of the structural notions found in that diagnostic system.
The Goal is Valued Living, Not Symptom Amelioration. Due to the conceptualizations of problems, each above referenced approach focuses not on a specific set of techniques, but on the processes of therapeutic change. For example, underlying all of these treatments is the common overarching goal to help the client live a valued life. After receiving Morita Therapy, "the patient may still have fears, unhappiness, or other symptoms. If, however, his behavior has changed, if he is capable of carrying out his living regardless of his symptoms, he is qualified for discharge," (Reynolds, 1976). Similarly, contemporary behavior therapies will seek not to "alter the content of (one's) cognitions ... (but) the nature of the patient's relationship to them" (Segal, Williams, & Teasdale, 2000); not the pain they are experiencing, but the suffering that is compounded by their hyper reactions to symptoms (Hayes, Strosahl, & Wilson, 1999); and to resolve, not the patient's view of the presenting problem, but the behavior that is interfering with the individual's life (Linehan, 1993a).
Separating Thoughts from Reality. One's thoughts, perceptions, and desires sometimes correspond with one's reality, but often they do not. Becoming entangled in one's thoughts--perhaps even fearing them--is a path to psychological suffering. Thus, Morita Therapy and the contemporary behavior therapies all advocate a distinction between private events and the context in which they occur. For example, in Morita Therapy, "clients are discouraged from becoming attached to and preoccupied with their thoughts, from depending on their subjective ideals, or from behaving to satisfy their emotions and infatuations" (Morita, 1928/1998). Likewise, through cognitive defusion/meta-cognitive awareness exercises, cognitive content versus context distinctions, and de-centering techniques, contemporary cognitive behavior therapies seek to help clients begin viewing their "thoughts as transient mental events, rather than aspects of the self or reflections of objective truth" (Segal, Williams, & Teasdale, 2002).
Contact with the Present Moment. Simple recognition of the distinction between one's private events and one's reality is not sufficient. In each of these therapies, individuals must learn to accept themselves, their symptoms, and their reality "as it is" (a concept Morita termed arugamama). This is achieved by becoming open and attentive to one's surroundings (mushoju-shin), confronting one's emotions, and directly experiencing the rise and fall of these emotions as natural (Morita, 1928/1998). A salient parallel can be seen in ACT, which emphasizes the importance of accepting one's private events (undermining the dominance of emotional control and avoidance) and fostering willingness to make contact with the present moment (Strosahl, Hayes, Wilson, & Gifford, 2004). Such parallels are also prominent in both DBT and MBCT, which place great emphasis on the development of mindfulness and acceptance.
Valued Action. Many argue that true happiness comes not from psychological insight but from effective engagement in life. Morita realized this fact early in his career and made it one of the key principles of his therapy. By shifting his patients' attention away from their "symptoms" and toward meaningful or constructive activities, Morita was able to help them experience greater self-worth and joy in the simple tasks of everyday life.
Therapy is not based on those principles that encourage momentary happiness or superficial pleasure; rather therapy is conducted on the basis of the principles that highlight practice. In this way, clients will experientially understand that to make an effort is to move towards true contentment; true happiness is achieved by making an effort. This presents a more accurate view of life (Morita, 1998).
Not only is this found in ACT (i.e., values clarification exercises and commitment to action strategies that are aligned with personal values), DBT (i.e., emphasis on opposite action, decreasing mood-dependent behaviors, and simultaneous reinforcement of socially effective behaviors), and MBCT (i.e., use of mastery activities), but this is also intrinsic to many other contemporary therapies, such as Functional Analytic Psychotherapy (Kohlenberg & Tsai, 1991), Behavioral Activation (Addis & Martell, 2004), Integrative Behavioral Couples Therapy (Jacobson, Christensen, Prince, Cordova, & Eldridge, 2000), and Buddhist-inspired CBTs (e.g., Darnall, 2007; Witkeiwitz & Marlatt, 2007).
In this paper, we have attempted to provide an overview of Morita Therapy and selected contemporary cognitive behavior therapies to supply a richer sense of the parallels between them. As Tanaka-Matsumi (2004) has indicated: Like contemporary therapies, Morita Therapy "attempted to free patients from preoccupying fears and anxieties by encouraging acceptance of them without avoidance."
However, it was not the purpose of this paper to laud the works of Morita or argue for the novelty or originality of his work or the work of any contemporary therapy. In fact, Morita dearly acknowledged that many of his ideas were borrowed from his Western contemporaries, such as Mitchell (1900), Dubois (1908), Binswager (1911), Beard (1880), Freud (1896/1962), and Kraepelin. Rather, Morita's real significance was that he was able to synthesize these pre-existing ideas and package them in a way that made them accessible to his culture while conducting a functional account of the effects. Perhaps, modern progenitors of new therapies should also be commended for attempting similar strategies. Therefore, it would prove impossible to argue persuasively that any therapy is wholly original, as all scientific thought is inspired and influenced by intellectual predecessors. More than this, the repackaging of existing therapies in new or creative ways did not begin in the late 20th century. Even Mitchell was accused of borrowing his technique of isolation and bed rest therapy from his predecessors (see Mitchell, 1900).
We hope that our portrayal accomplishes its mission of permitting a primarily Western audience of contemporary behavior therapists to peer into an Eastern counterpart that has much in common with its basic functional approach, therapeutic processes, goals, and selected techniques for accomplishing them. Although Morita Therapy is a well-respected therapy in the East, its attempts to empirically validate its techniques and export them to the West have so far been underwhelming. This paper is an attempt to redress these deficits and make the process of this therapy more explicit so it can come under better scientific investigation and scrutiny. In addition, we hope that this discussion permits Eastern therapists to peer into contemporary developments within the Western tradition and appreciate the distance this field has come from its original focus on animal learning and conditioning.
It is readily acknowledged that both Morita Therapy and contemporary cognitive behavior therapies have their own identifiable strengths, but we hope that we have made a point that these treatments, though developed separately, are united in many features, processes, conceptualizations, and techniques. Furthermore, we believe a better understanding of these core processes could encourage more constructive research and foster a greater appreciation and potential integration of these treatments rather than the promotion of mere therapy "branding" alone.
In our opening, we addressed the process of the scientific evolution of ideas. It is propitious, therefore, that we end on a similar theme concerning the pivotal therapy that has been the subject of this review. According to Morita, "My study is not complete, of course, and my interpretations may be mistaken. However, I hope that other investigators will understand my intentions, discuss them, and exchange opinions." And "I hope that further research in this field will be developed more vigorously by those who are stimulated by this book" (Morita, 1928/1998). We could collectively hope for nothing better pertaining to these and other emerging evidence-based therapies.
POST CE TEST QUESTIONS (Answer the following questions after reading the article, pages 22-27)
1.Which of the following contemporary therapies does not regularly incorporate mindfulness and acceptance techniques?
a. Acceptance & Commitment Therapy (ACT)
b. Dialectical Behavior Therapy (DBT)
c. Mindfulness-Based Cognitive Therapy (MBCT)
d. Mindfulness-Based Stress Reduction (MBSR)
e. Beck's Cognitive Therapy (CT)
2. Which of the following is NOT one of the four stages of classical Morita Therapy?
a. Bed rest
b. Cognitive restructuring
c. Light work
d. Heavy work
e. Training for practical living
3. What was Morita's term for anxiety, mood disorders, or psychosomatic concerns that arise due to hyper-attention on the functioning of one's body?
b. Shiso no mujun
d. Cognitive fusion
4. Morita developed his therapeutic approach after achieving poor results with the techniques pioneered by this man:
a. Sigmund Freud
b. Carl Jung
c. John B. Watson
d. Alfred Adler
e. Viktor Frankl
5. How has Morita Therapy changed in modern times?
a. It is never used in conjunction with psychotropic medications
b. Greater use of outpatient versus inpatient treatment
c. Efforts to standardize treatment between providers
6. True or False: Morita Therapy and contemporary cognitive behavior therapies argue that uncomfortable thoughts and emotions are a sign of disease:
7. Morita Therapy and contemporary cognitive behavior therapies contend that psychological suffering results from:
a. A maladaptive over-attention on one's symptoms
b. Vain attempts to control one's thoughts and emotions
c. Negative thoughts about the self, the world, and the future
8. Which of the following is NOT a treatment goal shared by Morita Therapy and contemporary cognitive behavior therapies?
a. Separating thoughts from reality
b. Staying in contact with the present moment
c. Amelioration of negative emotions
d. Engaging in values-based activities
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This work is an outcome of a collaboration between psychotherapy researchers in the United States and Japan. C. RICHARD SPATES, PhD, RICHARD W. SEIM, MA, and CHRISTINA M. SHEERIN, MA, are in the Department of Psychology at Western Michigan University in Kalamazoo, Michigan. Their work focuses on contemporary evidence-based treatments for anxiety and mood disorders. AYUMU TATENO, MD, and KEI NAKAMURA, MD, are at the Jikei University Center for Morita Therapy in Tokyo, Japan, where they utilize inpatient and outpatient Morita Therapy to help clients suffering from anxiety, mood, and psychosomatic concerns. Spates spent a sabbatical experience studying at the Morita Therapy Center. Tateno spent a sabbatical year at Western Michigan University studying contemporary behavior therapies.
The actual severity of a disorder does not always coincide with or run parallel to the sufferer's awareness of the symptoms. Some fatal illnesses carry no subjective symptoms, while others are not a matter for alarm regardless of severe suffering. When the physicians and therapists regard only subjective symptoms as important in treating an illness, they may be concerning themselves with minor details and neglecting fundamental points (Morita, 1928/1998).
Around the third and fourth day of this stage, interest in physical and mental work will accelerate gradually, much as when an infant begins to find pleasure in manifesting his or her vitality by taking some sort of action.... Around this time, a patient's facial expression, attitude and manner of speech become charged with vitality, as if he or she were a new person compared to his or her condition before entering therapy (1986).
Such experiences foster a subjective attitude in the client that invigorates her or his self to endure pain, overcome difficulty, and engage in lively and spontaneous mental and physical activities. The experiential understanding of confidence and courage, represented by the idea that much is possible in life, can be regarded as a kind of spiritual enlightenment (1928/1998).
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