There’s a strong emphasis on psychological tests here in Japan. Also, understandably you can also see among therapists here the native formal and indirect style of communicating. More academically and philosophically speaking, you can also see a general indoctrination to be unquestioning; here, this translates to simply and unquestioningly using whatever methods and philosophies that one was taught as they were taught. This all adds up to something that is pretty different from what I’m used to in the US.
One area that all of these aspects impact has to do with the therapeutic relationship, and accordingly, the person who the therapist is. From my perspective, the therapist’s role is to develop the therapeutic relationship and accordingly always strives to be someone who can relate well, including honing one’s self-awareness and the capacity for acceptance. Another part of the role has to do with conceptualizing and developing the sense to truly have insight about the client and continually form sound hypotheses about the client, including from the relationship and continual questioning.
The dominant therapy frame here is based on psychoanalysis, and respectively you can glean the therapist’s way to see people, understand how change happens, and relate to the client.
We can expect that a client will, according to his existing tendencies, start to form a relationship with the therapist that has similarities to the relationships that he has outside of therapy. He will follow certain impulses, inclinations, and scripts. Some of these will be specifically, especially in the beginning, geared toward relationship with a stranger, an authority figure, a potential threat, etc. – however the client perceives the therapist. One way that the relationship evolves is along the lines of psychodynamic theory, where the client starts to project on to the therapist his patterns and tendencies that he has relative to parents, mate, and possibly other significant people in life. I believe this happens through the process of the client disclosing more and more of his inner life to the therapist, and thus closing the distance and/or opening the doors, and generally being less and less with all of the sophisticated form that comprises his life.
The therapist can guide the evolving relationship in several ways, intentionally and unintentionally. One way is to intentionally maintain distance and control the client’s disclosing and other behaviors that increase intimacy, thereby controlling projection, etc. The kind of therapy that might happen, accordingly, is more of the consulting and advising kind, such solution-focused brief therapy (SFBT). With SFBT for instance, this is in accordance with the kind of therapy that is done, in which the past and unconscious feelings are not examined, but current decisions and cognitions, and possibly motivations, are the focus. Another way is for the therapist to increase the client’s disclosing, and thereby encourage the client to provide, or access, his inner world which will be the focus of therapy. On the therapist’s end, this can happen by the therapist not interacting very much but guiding the client to be active and disclose, such as by the line of questions; it can also happen by the therapist being more active, conveying much to the client, such as empathy, acceptance, encouragement, etc. Again, these would intentionally be done according to the therapy that the therapist is trying to do.
In my own training and also experience of therapy, I am closer to the latter end of the spectrum, in which the therapist’s engagement with the client is more with the therapist’s inner world and not just intellect or expertise. In the old-school, traditional ways of medicine and psychiatry, the former way has been more characteristic. In many ways, in Japan, it could be said that psychotherapy is done the old way i.e., the therapist’s way of relating and conducting his role is more distant, less personally active, etc. The benefits for the therapist are straightforward: he can focus all his energies on the client without spending/wasting it on looking at himself; he does not have to deal with the consequences of looking at himself e.g., dealing with his own issues and inner dynamics; he can also be safe from distraction as well as any need for development in the use of his knowledge, expertise, and sense. However, it is not as simple as simple as the therapist maintaining his comfort and safety.
Culturally and historically, the clients may also be old-school. They may feel more comfortable, safe, and reassured with a therapist fulfilling the expert role. They want to be told what’s going on and what to do. The client can have an idea of what to expect, insofar as what work and how much work the expert will do; the client will have a sense of how the relationship will be and remain, and accordingly what he is likely to experience and how he should behave in the transaction.
Another aspect is more specific to individual cultures: how interpersonal distance is managed and the form that this management takes e.g., what is off limits, what is prescribed as essential. The Japanese culture (like American rural culture) may almost be contrary to the very essence of psychotherapy, which is all about going into off limit areas. A psychology-related presenting issue of a client may be due to something that should be staying off limits crossing the line and coming, unwelcomed, into that person’s life and creating problems. Many clients who want to keep what was off limits as just that, off limits, want therapy to help them continue to not deal with it – maybe just help them instead to bolster the “fence” to keep the thing off limits. And so the therapist that works best with this client may be one who is in agreement with the client of what the problem is and how it can be handled. In this case, the psychiatrist who treats solely with medication is comfortable for the client to accept.
In many cases, medication is not the best or only answer. It’s important to consider why that unwelcome thing has come over the client’s “fence” at all, why or whether it needs to stay on the other side of the “fence” in the first place, and whether the client may be open to the possibility of conquering that unwelcome thing, or living without needing that “fence”. These are the territory of the psychotherapist. But this territory also inherently requires the client to do something that he is not used to – often, in fact, something that he has likely spent a lot of energy so far in life not doing. And then the cultural question is, how to go about helping such a client to have the best likelihood of using his, the client’s, own inner and outer resources to overcome the problem. The process of tackling the problem almost certainly has its own pace – too fast and it’s not only ineffective, but the client will be overwhelmed or adversely impacted; too slow, and it will also be ineffective, and the client will continue to experience the problem, experience the lack of success in tacking the problem, though he may experience the comfort of familiarity.
Culturally speaking, in Japan, I believe people tend to err on the side of going too slow. My sense of things, of course, is from my background in the US. So sometimes this sense tells me whether a process of tackling a problem is too fast or too slow. And since it’s always relational, this includes my sense of whether I myself am moving things along fast or slow. I am also informed by my culture of how processes and outcomes look. For instance, I might have a certain range of expectations of how much time someone takes to recover from depression and how they are looking when they’re telling me they’re feeling better. If it’s true that some things in Japan go more slowly, then maybe depression as it manifests in Japan is also something that recovers slowly, or otherwise according to other norms that I am not accustomed to. Maybe the therapeutic rapport and relationship develop more slowly in general here. Still, it’s hard to see someone suffering for a length of time and in ways that I’m not used to leaving alone.
Conceptually, the native therapist may have ways of seeing and doing things that are going to be more effective insofar that the native client will have an easier time getting his head around them and accepting them. But another part of my ‘potential complaint’ here is that, I suspect, sometimes the therapist is not doing something because it works or fits better, but doing it just because it was what he was taught. When something has no basis for being done, it also confounds the possibility of adopting something new and better, because there is no way to compare. It also confounds or convolutes the process of a foreigner such as myself learning directly from a native clinician’s explanation of what, how, and why they’re doing what they’re doing; in many cases, at best I get a rote answer that the person himself was taught, which I’ve usually found or figured out for myself before asking.
Not that this is unique to Japan, but I feel that I often encounter people’s – even those that might be instructors’ – inability to explain about what they do. If it’s not “I don’t know”, then usually it’s an explanation that comes straight out of a textbook. Even when there is acknowledgment of the real world being more difficult or complicated than the textbook, what they say seems to lack the process that they themselves go through, such as the confusion/frustration or what they did to adapt. (What I personally find perplexing is the person describing their adaptation process as basically ignoring or dissociating from the complicated pieces so that they achieve an end result of applying their training/framework as it was taught.) What I experience as the person listening to these kinds of explanations is a sense of numbness or dissociation. What comes to mind is how much people in this culture are indoctrinated from an early age to turn off parts of their brain, and turn on other parts, such as that which pays attention to what other people are doing so that you can do whatever they’re doing, and that which pays attention to what is socially frowned upon but not what you yourself notice and prefer, etc.
Sometimes the therapist is not doing something because it works or fits better, but doing it just because it is what he feels as natural. In this case, it is often just as invisible and idiosyncratic as the unintentional forming of relationship as discussed above, and just as unexplainable by the therapist who does things this way. Interventions that are intuitively more suitable according to the native’s sense are not necessarily bad or ineffective, but it’s important to keep awareness of whether comfort and familiarity are being used as the top criteria for choosing a method.
Regarding the client’s process of confronting that which is unfamiliar and uncomfortable of himself: part of a therapist’s expertise, ideally, is to provide some stability for the client, who is going through an experience of uncertainty, and simultaneously to remain engaged, present, and available to the client. In this sense, an active therapist must have some so-called “ego strength” as well as personal drive and self-awareness. A less active therapist, who works more on an intellectual, authoritative and disengaged level, is not under the same demands.
I return to the fact that it’s about my personal beliefs: in this case, my belief that the difficult processes for which the client has bothered to seek outside help requires more than an intellectual authority. There are self-help books, videos, and more and more on TV and the internet, resources that tell you exactly what you should do. A person probably has in their own life friends and relatives who give good advice, and maybe even potential role-models who the person simply doesn’t know how to take advantage of. Helping the person experience that “Yes, it’s possible” (to mobilize resources, to look inside without being overwhelmed, etc.) is, I believe another human being. And if a client hasn’t found the right adviser or counsel in his normal life, and he is taking the trouble to seek your help as the therapist, then you’re obliged to try other things to help the person.
Psych Tests (to be continued…)