Original Article
Examining the Effects of the group intervention using SAT to ameliorate mental distressamong Cancer Survivors

Tsunetsugu MUNAKATA1), Noriko HIGUCHI2), Kazue NAKASHIMA1), Kiriko MURAKAMI1), Yoko WATANABE3), Yutaka
YAMAGUCHI1), Hiroko IKENO1), Yuka IWANAGA1), Wen-yan HU1), Yoko ICHINOSE4), Atsushi NOMOTO5),
1) Graduate School of Comprehensive Human Sciences, University of Tsukuba
2) Faculty of Languages and Cultures, Meikai University
3) Teikyo Heisei Nursing Junior College
4) Tsukuba Medical Center Hospital5) NPO Midorinokaze Health Support Japan
E-mail address: munakata21@yahoo.co.jp■Abstract
The present study examined the effectiveness of SAT, a “next generation” CBT, to ameliorate
mental distress among cancer survivors. CBT has been focusing primarily to change negative
thinking patterns first in order to bring about positive behavior. However, SAT as a next
generation CBT strives to change negative emotions first to enact positive behavioral actions.
Both biometric and psychometric tools were utilized to estimate the effectiveness of theintervention between and within the study groups. Study participants were 17 female cancer
survivors (mean age 51 years). Another group of 7 female survivors (mean age, 53 years) werethe control. The intervention, which comprised a group lecture regarding the “result of a study on
immuno-competence and gene defenses to overcome cancer by SAT therapy” and followed bygroup approach using SAT, sought to reconstruct the (1) self-image, (2) 3-generation image and(3) ancestral-generation image scripts of the participants from the negative to positive ones inorder to decrease their mental distress. The results showed that the SAT therapy was effective:
Participants showed decreased cortisol and increased SIgA post-intervention. Post persistenceInternational Journal of Structured Association Technique No.4

43

temperament as stress temperaments were lower than baseline. Also psychologicalcharacteristics such as Trait Anxiety (STAI), depression(SDS), self-repression, difficulty inemotion recognition, and self-pity significantly decreased. Between baseline and the 4-monthfollow-up, those psychological characteristics continued to decrease while problem-solving ability
increased. In the non-intervention group, these psychological characteristics did not change
pre-post and 4-month later. The facilitatory effects of immune defenses and mental resilience on
positive mental health were discussed.

Keyword: cancer survivor, immuno-competence, mental resilience, SAT therapy, mental health

1. Introduction

In Japan the incidence of cancer survivors is high. The statistics rose from approximately 3.65 million at theend of 2004 to about 5 million by 2015 (Yoshimura 2002). These survivors tend to have a high risk of serious
mental distress compared to persons without cancer history (Hoffman et al. 2009).

It has been pointed outthat mental health problems in cancer survivors increase. In Japan and elsewhere, they fear recurrence andmetastasis every day (Kuromaru 2009; Aarts et al.

2008). Such fear induces stress that interferes with theirself-healing powers. The effects of psychosocial factors on cancer have been studied. These studies reportassociations between cancer and type C personality type (Temoshok 2003), which is characterized bysuppression and denial of emotional expression.

Other characteristics of the type C personality include

stress-coping failure and resignation tendencies such as hopelessness and helplessness, which may
precipitate the onset/progression of cancer (Temoshok 2003). Maeda et al. (2006) reported that the personality
traits of gastric cancer patients included self-repression (persons who repress their emotions to obtain a goodevaluation from others) and emotion recognition deficit (those who are unlikely to realize their emotions and try
to solve problems by themselves, without any help). In other words, they are unlikely to realize and express
International Journal of Structured Association Technique No.4

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their real feelings and emotions and tend to be patient and adamant. Munakata(2007) added that cancer
patients might be of the following types: dissociative identity types (who try to consider themselves as anotherperson in order to calm themselves down), problem avoidance types (who have extremely positive thinking
and try to handle problems without seeing the actual content of the problems) and the self-pity types (who feelsorry for themselves and work too hard). These persons were unlikely to realize their real feelings andemotions or ask for other’s help. Moreover, the patients are likely to be extremely positive because they do notunderstand the seriousness of the situation.

Some have interpreted that such personalities who cannot express their discomfort but wrestle seriously withdaily tasks and accumulate stress may experience tumor immuno-incompetence. Various prospective cohort
studies on the causal relationship between a cancer-prone personality and the onset of cancer reported thatthe onset of cancer might be related to cancer patients’ tendency toward depression and tendency to repress
their emotions(Shekelle et al. 1981; Persky et al 1987; Bleiker et al. 1996). However, some of these studies
reported no definite relationship between them (Hahn et al. 1988; Almada et al. 1991).

Personality consists of “temperament” which core is determined by genes and “self-image script,” which isconstructed from temperament. The stress-related personality comprises mainly of genetic characteristics,
which create susceptibility to stress (or anxiety temperament and persistence temperament). In addition, they
are aware of their other-rewarding personality, which is likely to excessively react to the above-mentioned
stress caused by their experiences of birth trauma and/or infant trauma and subsequent repetition of suchtrauma. This becomes the script of their behaviors and establishes their stress-sensitive personality such as
the self-repression type, emotion recognition deficit type, and the problem avoidance type.

The stress-sensitive personality is likely to have sympathicotonia, which results in the continuous secretion ofadrenaline. As a result, the number of lymphocytes decreases while granulocytes increases. The active
oxygen species released from the granulocytes rid the body of foreign bodies. At the same time, they damage
International Journal of Structured Association Technique No.445cells, nuclei, and genes, which may cause cancer (Abo 1997). Regardless of whether a person is aself-repression type, emotion recognition deficient types, or problem avoidance type, stress-sensitive
personality is formed through “other-reward” seeking behaviors.

The behavior is motivated in early childhood

to increase reward responsiveness to “pleasure” as seen in the facial expressions, voice tones, and actions ofchildren to avoid aversive expressions of anxiety, anger, and sadness by their parents and guardians. Whenthey grow up, other-reward oriented behavior is motivated and sustained by the responsiveness of significant
others in the population instead of parents and guardians.

On the other hand, activities representing own pleasure such as solitary play, play with friends, adventure, art
work, sport activity, care of plants, pets and other people in early childhood motivate children to form andindulge in “self-reward” oriented behaviors. A self-reward oriented behavior elicits self-reward satisfaction. Own
pleasure, interest, emotion, determination, accomplishment, growth, self-satisfaction, appreciation, andempathy are derived. Failure in self-reward oriented activities do not attract as much mental distress as withthe other-reward oriented behaviors.

There are reports that cancer patients tend to possess strong persistence temperament, neglect their feelingsand emotions, try to accomplish something by themselves without asking for help, and exhibit other-reward
oriented behaviors to obtain good evaluations from others. They tend to have little communication or poorinterpersonal relationships with their family members (Munakata 2007; Kobayash et al. 2007),. Some psychotherapies based on the hypothesis that stress influences the onset of cancer have been
performed on cancer patients in Japan and overseas. An intervention psychological study in patients withbreast cancer metastases, which was a randomized controlled study, reported that there was a survival benefit
in the psychological intervention group (supportive–self-expression group therapy) (Spiegel 1989). A
subsequent study disagreed with the previous study result about life prolongation, but demonstrated that thetherapy decreased psychological stress and increased mitigation (Goodwin et al. 2001). There are also reportsthat the ratio of natural killer (NK) cells of the patients who underwent surgery for malignant melanoma wasInternational Journal of Structured Association Technique No.4

46

greater in the short-term cognitive behavior therapy group than the control group (Fawzy et al. 1990; Goodwin
et al. 2001). According to the study by Rehse et al. (2005), meta-analysis of adult cancer patients to evaluate
the effects of psychosocial intervention indicated that psychosocial intervention improved their quality of life
(QOL). On the other hand, randomized psychosocial intervention studies have reported that such interventions
had no effect on the prolongation of survival time (Chow et al. 2004; Boesen & Johansen 2008). A number ofstudies regarding psychosocial intervention effects have been conducted, but the research is still insufficient.

Cancer survivors are classified into short-term survivors who survive less than 5 years after diagnosis andlong-term survivors who survive 5 years or more after diagnosis, which are defined in terms of the outcome ofcancer therapies by the medical profession. Recently, the meaning has been changed. “The National Coalition
for Cancer Survivorship” in the US has announced a new concept of “cancer survivorship,” which “not onlymeans long-term survival but also means that cancer patients remain cancer survivors from diagnosis to theend of life regardless of the presence or absence of cancer and/or the therapeutic effect” (National Coalition
for Cancer Survivorship 1998). Endo (2004) stated that we should create “the significance of living your life” asthe necessary support for cancer survivors based on the new concept . We also thought that surgicalprocedures for cancer did not sufficiently support cancer survivors in the true sense. Therefore, we studied andreported that cancer patients understood that they have had cancer and learned how to live a satisfactory life
with cancer, which improved their immune-competence and enhanced the effect of mental resilience
improvement on the transition to self-reward oriented behavior (Higuchi & Munakata 2009).

According to our surveys and clinical studies, structured association technique (SAT) therapy encouraged
cancer patients by performing self-reward oriented behavior to realize their true feelings and enjoy who they
are, communicate with others, and decrease other-reward oriented behavior including the self-repression typeand emotion recognition deficit types (Munkata 2007). The therapy also significantly increased
immuno-competence (increases of lymphocytes and activation) and the expression of tumor suppressor genes(Munakata 2007; Kobayashi 2007). Furthermore, the first and second authors developed a stress
International Journal of Structured Association Technique No.4

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management system using DVDs and Web content on the basis of SAT therapy in order to improve the mental
health and immuno-competence of cancer survivors (Higuchi & Munakata 2009).

This study aimed to understand any changes in cancer survivors, including decreases of stress, changes inlifestyle, improvement of laboratory outcomes, and improvement of their QOL, by a group approach to shift
other-reward oriented behavior to self-reward oriented behavior. It was hypothesized that -(1) SAT would improve trait anxiety and depression level to a greater degree in the intervention groupthan the non-intervention group (mental health improvement).
(2) The group approach using SAT altered the personality to cause their stress to become chronic due
to other-reward oriented behavior including the self-repression type, problem avoidance type, and emotion
recognition deficit types greater in the intervention group than the non-intervention group (the facilitatory effectof mental resilience).
(3) The group approach using SAT changed the secretory immunoglobulin A (SIgA) antibody andadrenocortical hormone in saliva in the intervention group (the facilitatory effect of immune defenses).

We will explain how SAT therapy is a new generation cognitive behavior therapy. SAT therapy does notchange emotion by changing their way of thinking, which causes mental stress, as in conventional cognitive
behavior therapies. The therapy changes emotion first and then changes their way of thinking as a result of thechange of emotion. Changing the way of thinking not only improves mental health, but it also changes theirstressful emotion in response to physical diseases and/or workaholic tendencies and/or bulimia in the case of
the problem avoidance type, dissociative identity type, and emotion recognition deficit types. Therefore, they
feel well. Moreover, sympathicotonia lasts and the immune system decreases, which leads to increased
granulocytes that release significant active oxygen species.

As described above, according to the theory of SAT therapy, which is a new generation cognitive behavior
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therapy, the stress-sensitive personality has stress tendencies and remembers the facial expressions, voice
tones, and actions of their parents and guardians, which are associated with their fear and tend to induce
stress. Therefore, SAT therapy employs a hypothesis that “we can go back to the past* to change our past andimprove our growing conditions,” in order to change the images of the facial expressions of their parents andguardians in their memory. Then, the intrinsic expression of the parents and guardians, which is made byunconditional care, is visualized by various imagery techniques of meditation regression, in order to plant asubstitute facial expression in their mind by continuously viewing photographs, pictures, religious statues, andbronze statues that look like their parents and guardians. Thus, they are encouraged every day to view thesubstitute facial expressions portrayed in the photographs, pictures, religious statues, and cartoons instead of
their real parents and guardians in order to fix the improved images of their parents and guardians. If it issuccessful, the substitute facial expression will change their feelings and relax their body.

*Note 1 Evolution starts from the Big Bang of the universe—elementary particles, nuclei, atoms, molecules, proteins, and organisms
evolve into human being as times goes by. The life cycle of a human being starts from their ancestors and parents and continues
through their birth and growth. Their self-image should be improved by travelling back to a certain time point in the past throughself-image script changing therapy, which is described as follows.
(1)

3-generation imagery therapy – Technique to correct aversive images of the womb interior by using meditation regression

imagery of the womb through the three generations to change the image script of their parents and guardians and to change theircurrent self-image script.
(2)

Ancestral generation imagery therapy - Technique to promote solving life-threatening risk factors in the past throughmeditation regression imagery of the womb in order to change the image script of their ancestors & parents and to change theircurrent self-image script.
(3)

Evolutional imagery therapy – Threats experienced as a particle and an organism are solved by using meditation regression

imagery of the womb in order to change the image script of their parents and to change their current self-image script.

2. Study method
2.1

Subjects

Intervention group: After a lecture regarding the “result of a study on immuno-competence and gene defenses
to overcome cancer by SAT therapy,” which was conducted in September 2009 in I prefecture, Japan, theInternational Journal of Structured Association Technique No.4

49

objectives and overview of a “practical study on group SAT therapy for cancer survivors” (multidisciplinary
study of the University of Tsukuba) were explained to the study volunteers. The number of study volunteers
was 18, and the number of participants in the first guidance was 12 (all females). Among them, 10 females
who participated in the study of 3-generation imagery therapy of SAT therapy using group counseling wereselected as subjects, and 7 females who participated in individual continuous intervention were selected as
subjects when the intervention for psychological characteristics was studied.
Non-intervention group: Author asked the chairperson of the incorporated nonprofit organization of a cancer
survivors club M in I prefecture in Japan to explain the objective and provide an overview of the “practical
study on group SAT therapy for cancer survivors” (multidisciplinary project study of University of Tsukuba) andto recruit study volunteers. Of the nine volunteers, seven females who answered three questionnaires wereselected as subjects.

The study period was from October 2009 to April 2010.

2.2

Intervention group(1) 1st intervention: October 2009

Guidance was provided about the intervention using SAT therapy. SAT therapy employs a hypothesis method
using a meditation regression imaging method to imagine the evolution of the human being from self →parents and guardians → ancestors → organism → particle and provides images of their past beingchanged; they are subsequently raised under the improved growing condition. The meditation regression
method constructed is based on the body sensations of clients' and is used to create a growing environment
with unconditional care, which has not been conveyed from their ancestors, and to urge them to realize thenecessary environment and behavior to form the future self-image. The meditation regression imaging method
visualizes the facial expressions of parents and guardians who provide unconditional care and finds substitutefacial expression including photograph, pictures, religious statue, and bronze statues that look like theirInternational Journal of Structured Association Technique No.4

50

parents and guardians. They are encouraged to continuously view them to frequently stimulate the visual
center of the cerebrum and fix the facial expression as well as to change their aversive emotion to a rewarding
emotion. In addition, they are encouraged to understand the communality between past unsolved problems
and current problems as scripts and realize the behavioral objectives to improve such scripts (large,
intermediate, small objectives). The above-mentioned procedures are 3-generation imagery therapy topromote emotion modification, thinking modification, and behavior modification.

(2) 2nd intervention: November 2009

3-generation imagery therapy was performed by group counseling. The therapy is a method used to correct
aversive images of the womb interior by meditation regression imaging of the womb through the 3 generationsof grandparents, parents/guardians and self to change current self-image script.

(3) 3rd intervention: December 2009 and January-February 2010

The patients participated in at least 2 sessions to undergo the 3-generation imagery therapy and theancestral-generation imagery therapy. The therapy is a method to promote the resolution of life-threatening
risk factors in the past that are imaged by meditation regression imaging of the womb in order to change theimage script of their ancestors & parents and to change their current self-image script.

In interventions (1) and (2), the immuno-competent change was measured by using the psychologicalattributes inventory and a saliva test before and after the intervention by a SAT Health Psychotherapist
certified by the Academy for Health Counseling. In (3), the psychological attributes inventory was performed
before and after the intervention by a SAT Health Psychotherapist certified by the Academy for HealthCounseling.

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2.3

Non-intervention group

The questionnaires were sent to the subjects in October and November in 2009 and February 2010 and
subjects were asked to perform a self-administered questionnaire.

2.4

Ethical considerations

We explained to the subjects of the intervention group and non-intervention group at the time of the guidanceand before starting the study, respectively, that they were not identified in the study and analysis. In addition,
they were told that they could participate in this study with free will so that they could decline their cooperation
or withdraw from the study at any time and that there would be no effects on their daily life. Finally, we
obtained their written informed consent. This study was approved by the epidemiologic research ethics
committee of the University of Tsukuba.

2.5Structure of questionnaire

The questionnaire used in this study consisted of (1) attributes of a subject (age, gender, occupation,
composition of family, type of primary cancer, age at diagnosis, medical history of previous cancer treatment,
type of cancer at present, and the presence or absence of current treatment and type of treatment if any) and(2) psychological index stress temperaments (persistence temperament, anxiety temperament), andpsychological characteristics as measured by the self-esteem scale (Rosenberg, 1965), scale ofself-repression (Munakata, 1990), emotional support network scale (Munakata, 1986), scale ofproblem-solving behavioral trait (Munakata, 1990), interpersonal dependency inventory (McDonald-Scott1988), scale of state-trait anxiety (Spielberger et al., 1970), elf-rating depression scale (Zung, 1965), scale ofdifficulty in recognizing emotions (Munakata, 2007), scale of self-pity (Munakata, 2007), scale of the
dissociative identity (Munakata, 2007), scale of self-denial (Munakata, 2007), and scale of the post-traumaticInternational Journal of Structured Association Technique No.4

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stress syndrome (Munakata, 2007).

2.6

Biochemical index

This study measured SIgA and cortisol (adrenocortical hormone) by using a saliva test. SIgA is found in highconcentrations in the saliva, lacrimal fluid, nasal discharge, respiratory tract, mucus, digestive juice, and milk,
which is functionally involved in local immunity in the mucosal surfaces. Cortisol is one of glucocorticoids, theessential adrenocortical hormones for the human body, which inhibits carbohydrate, sugar, and protein
metabolism. Cortisol is the most abundant in the body among the 3 glucocorticoids and accounts forapproximately 95% of glucocorticoid activity; it is released by stress as well. It sometimes increases bloodpressure and blood sugar level and decreases the immune function depending on the secretion.

2.7

Analytical method

Each parameter of the psychological characteristics was measured at baseline (after the guidance), at the timeof completion of the 3-generation imagery therapy, and at the time of the ancestral-generation imagery therapy.
The changes between these time points were statistically analyzed using statistical software SPSS17.0J for
Windows. The Wilcoxon signed-ranks test was used to compare immuno-competence before and after theintervention.

3.

Results

3.1

Intervention group

The subjects who underwent the group therapy using the 3-generation imagery therapy were 10 females witha mean age of 50.90±11.27 years. In terms of the stress temperaments, their persistence temperament was
3.30 (1.49), which was moderate, and their anxiety temperament was 3.80 (1.40), which was moderate. Their
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cancers were breast cancer (7 subjects), ovarian cancer (1 subject), thyroid cancer (1 subject), andleiomyosarcoma of the left popliteal fossa (1 subject). The subjects who subsequently received the individualintervention were 7 subjects with a mean age of 52.57 (SD±11.370) years. In terms of their stress
temperaments, their persistence temperament was 3.57 (SD±1.27), which was moderate, and their anxiety
temperament was 4.14 (SD±1.22), which was also moderate. Their cancers were breast cancer (5 subjects),
thyroid cancer (1 subject), and leiomyosarcoma of the left popliteal fossa (1 subject).

3.2

Non-intervention group

The subjects in the non-intervention group were 7 females with mean age of 53.00 (SD±7.84) years old. With
respect to stress temperaments, their persistence temperament was 3.86 (SD±1.22), which was moderate,
and their anxiety temperament was 3.00 (SD±1.73), which was also moderate. Their cancers were breast
cancer (3 subjects), uterine cancer (1 subject), gastric cancer (1 subject), renal cancer (1 subject), and coloncancer (1 subject).

3.3

Changes by the intervention(1) Changes of the biochemical index
Changes of the biochemical index before and after the group therapy intervention using the 3-generation
imagery therapy. The adrenocortical hormone levels in the saliva tended to decrease from before and after theintervention (Wilcoxon signed-ranks test, z = -1.82, p = .069). The SIgA levels in the saliva immediately after
the intervention were significantly greater than those before the intervention (Wilcoxon signed-ranks test, z =-1.99, p = .047).

(2) Changes of psychological characteristics
According to the comparison of psychological characteristics between at baseline and at the completion of the
3-generation imagery therapy, the scale of self-repression significantly decreased (Wilcoxon signed-ranks test,
International Journal of Structured Association Technique No.454z = -2.21, p = .027); the scale of difficulty in emotion recognition significantly decreased (Wilcoxon
signed-ranks test, z = -1.89, p = .058); the scale of self-pity significantly decreased (Wilcoxon signed-ranks
test, z = -2.03, p = .042); and PTSS significantly decreased (Wilcoxon signed-ranks test, z = -2.03, p = .042).

The comparison between at baseline and 4 months later when the intervention of the 3-generation andancestral-generation imagery therapy were completed demonstrated that the scale of self-repression(Wilcoxon signed-ranks test, z = -2.20, p = .028), the scale of difficulty in emotion recognition (Wilcoxon
signed-ranks test, z = -2.21, p = .027), the scale of self-pity (Wilcoxon signed-ranks test, z = -2.12, p = .034),
the scale of dissociative identity (Wilcoxon signed-ranks test, z = -2.23, p = .026), and PTSS (Wilcoxon
signed-ranks test, z = -2.03, p = .042) significantly decreased, and that the scale of problem-solving (Wilcoxon
signed-ranks test, z = -2.22, p = .027) significantly increased.

In the non-intervention group, the scale of self-repression (Friedman test, χ² = .75, p = .687, the scale ofdifficulty in emotion recognition (Friedman test, χ² = .64, p = .727), the scale of self-pity (Friedman test, χ² =
1.06, p = .589), the scale of dissociative identity (Friedman test, χ² = 0.00, p = 1.0), and PTSS (Friedman test,
χ² = 3.55, p = .170) did not change between at baseline and 1 month and 4 months later. On the other hand,
there were changes between at baseline and 1 month and 4 months later in the scale of problem-solving andthe interpersonal dependency inventory (Friedman test, χ² = 6.77, p = .035; χ² = 7.58, p = .023, respectively).
The comparison of the scale of problem-solving between at baseline and 1 month later showed it tended tosignificantly decrease (Wilcoxon signed-ranks test, z = -2.03, p = .042), while there were no significant
differences in the scale of problem-solving between at baseline and 4 months later (Wilcoxon signed-ranks
tests, z = -1.52, p = .129). There were no significant differences in the interpersonal dependency inventory
between at baseline and 1 month later (Wilcoxon signed-ranks test, z = -1.51, p =. 131), while theinterpersonal dependency inventory significantly decreased between at baseline and 4 months later (Wilcoxon
signed-ranks test, z = -2.27, P = .023).

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In the group that received continuous intervention by SAT therapy, self-repression, difficulty in emotion
recognition, self-pity, dissociative identity, and problem-solving, which are likely to induce chronic stress, were
improved, and PTSS decreased. In the non-intervention group, the scale of problem-solving tended todecrease or remained low, and the interpersonal dependency inventory decreased 4 months later.

In addition, trait anxiety and depression in the intervention group between at baseline and after completion of
all of the interventions were compared by using the Wilcoxon signed-ranks test.

The median score of trait anxiety in the intervention group at baseline was high at 55.0, which indicated thatthey were always anxious. The score after completion of 3-generation imagery therapy was 28.0 (Wilcoxon
signed-ranks test, z = -2.20, p = .028) and that after the ancestral-generation imagery therapy was 27.0
(Wilcoxon signed-ranks test, z = -2.20, p = .028), which was significantly lower than that at baseline andshowed a decrease of their anxious tendencies.

The median score of depression in the intervention group at baseline was 47.0, which showed their tendenciesof slight depression. The score after completion of the 3-generation imagery therapy was 25.0 (Wilcoxon
signed-ranks test, z = -2.20, p = .028) and significantly decreased. The score after completion of theancestral-generation imagery therapy was 26.0 (Wilcoxon signed-ranks test, z = -1.86, p = .063), whichshowed a tendency to be significantly lower than that at baseline. On the other hand, there were no significant
changes in the scores of trait anxiety and depression in the non-intervention group (Friedman test, χ² =.07, p=.964; χ² = 0.26, p = .878, respectively)
Table 1 Biochemical index
SIgA
self-image script

Cortisol

3-generation image script

3-generation image script

BeforeAfter

BeforeAfter

BeforeAfterMedian325.95385.55148.85317.60.26.16Interquartile

203.58307.80117.75264.45

.29

.07

range
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Table 2 Psychological characteristics< Intervention group >Self-esteem
Baseline

Self-repression

2-3months

3-4

after

monthsBaseline

2-3months after

3-4 months after

3-generation

Ancestral-generation

after
3-generation

Ancestralgeneration

Median

7.00

10.00

9.00

11.00

6.00

4.00

Interquartil

5.00

2.00

1.00

7.00

6.00

6.00

e range

Recognition of emotional support network (byRecognition of emotional support network (byfamily members)

people other than family members)

Baseline

2-3 months

3-4 months

after

after

3-generation

Ancestral-Baseline

2-3 months

3-4 months after

after
3-generation Ancestral-generation

generation
Median

10.00

10.00

10.00

6.00

8.00

8.00

Interquartile

5.00

1.00

2.00

4.00

4.00

4.00

range
Problem-solving
Baseline

Interpersonal dependency

2-3 months

3-4 months

after

after

Baseline

3-generation Ancestral-generation

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

Median

11.00

10.00

17.00

9.00

4.00

4.00

Interquartile

5.00

13.00

6.00

7.00

3.00

2.00

range

International Journal of Structured Association Technique No.4

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Trait anxiety
Baseline

Depression

2-3 months

3-4 months

after

after

3-generation

Ancestral-Baseline

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

generation
Median

55.00

28.00

27.00

47.00

25.00

26.00

Interquartile

18.00

16.00

15.00

16.00

11.00

14.00

range
Required level of health counseling
Baseline

2-3 months

3-4 months

after

after

Difficulty in emotion recognition
Baseline

3-generation Ancestral-generation

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

Median

8.00

1.00

2.00

11.00

4.00

5.00

Interquartile

9.00

4.00

3.00

7.00

6.00

6.00

range
Self-pity
Baseline

Dissociative identity

2-3 months

3-4 months

after

after

Baseline

3-generation Ancestral-generation

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

Median

6.00

3.00

1.00

3.00

1.00

1.00

Interquartile

8.00

6.00

3.00

5.00

3.00

2.00

range
Self-denial
Baseline

PTSS

2-3 months

3-4 months

after

after

Baseline

3-generation Ancestral-generation

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

Median

2.00

.00

.00

4.00

.00

.00

Interquartile

2.00

1.00

.00

3.00

2.00

3.00

range

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< Non-intervention group >Self-repression
Baseline

1 month

Problem-solving

4 months later

Baseline

1 month later

4 months later

laterMedian

5.00

5.00

7.00

11.00

10.00

11.00

Interquartile

11.00

4.00

4.00

4.00

6.00

2.00

range
Interpersonal dependency inventory
Baseline

1 month

4 months

later

later

Trait anxiety
Baseline

1 month later

4 months laterMedian

4.00

4.00

3.00

39.00

38.00

41.00

Interquartile

2.00

1.00

1.00

8.00

12.00

21.00

range
Depression
Baseline

Difficulty in emotion recognition

1 month

4 months

later

later

Baseline

1 month

4 months later

laterMedian

32.00

32.00

33.00

5.00

5.00

4.00

Interquartile

5.00

5.00

14.00

2.00

4.00

7.00

range

Self-pity
Baseline

Dissociative identity

1 month

4 months

later

later

Baseline

1 month later

4 months laterMedian

7.00

7.00

6.00

2.00

3.00

3.00

Interquartile

5.00

3.00

4.00

3.00

4.00

2.00

range
PTSS
Baseline

1 month

4 months

later

later

Median

1.00

2.00

2.00

Interquartile

1.00

2.00

5.00

range

International Journal of Structured Association Technique No.4

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4.

Discussion

4.1

Facilitatory effect of immune defenses

Changes in the biochemical index of the psychosocial intervention group and the non-intervention group werestudied. The result indicated that the adrenocortical hormone levels in the saliva tended to decrease (p< .07 )while the SIgA levels in the saliva significantly increased in the intervention group, which was the sameas the result of significant increase( p < .05) of the SIgA level in the saliva before and after SAT intervention
described in our previous DVD study. The SIgA level in the saliva represents mental and physical stress anddecreases by the stress load on the body or negative feelings (Labott1990). The SIgA level in the saliva

receives attention as the index to reflect moderate stress, but there are only a few reports on the relationshipbetween the SIgA level in the saliva and stress; future evidence accumulation is expected. However, the SIgA
levels in the saliva increased immediately after the start of this study, which suggested the stress relief effectby the psychosocial intervention.

Van der Pompe et al. (1997) performed a 13-week psychosocial intervention for breast cancer patients andreported the blood concentration of adrenocortical hormone decreased. Our 1-day intervention result also
indicated that the adrenocortical hormone levels in the saliva decreased. It has been reported that the freecortisol in the blood transfers into the saliva depending on the blood concentration, and that the adrenocortical
hormone levels in the saliva increase especially in response to mental and physical acute stress. This study
result indicated that the adrenocortical hormone levels in the saliva decreased as the SIgA level increased andconfirmed that the intervention had a stress relief effect and relaxation effect.

This intervention does not aim to provide a relaxation effect but aims to change behavior to self-reward pursuit
behavior, which does not accumulate stress. Therefore, a measurement to evaluate the long-term effect isneeded.

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4.2

Facilitatory effect of stress resilience

Resilience is defined as the “absolutely essential psychological characteristics to stand and overcome
adversity and to maintain sound mental activity emotionally, cognitively, and socially” (Mori et al., 2002) andthe “universal capacity which allows a person, group or community to prevent, minimize or overcome thedamaging effects of adversity” (Grotberg EH, 2003). People with high resilience can rapidly and easily escapefrom undesirable events and recover from psychological impacts. In addition to the above-mentioned profile,
the roles of resilience in daily living have been studied (Oshio, 2002).The concept of resilience varies
depending on the researchers. In fact, there are various points of view. We consider resilience as “self-reward
oriented behavior that persons use to realize their real feelings, enjoy themselves, live positively, andcommunicate with family members and others and seek self-satisfaction, as opposed to a behavior of working
hard to win rewards from others.” Resilience supports them to increase their self-rewarding behavior.

No improved changes except for the interpersonal dependency were observed in the non-intervention group,
while there were significant changes in the intervention group that continued the intervention using SAT
therapy, including changes in the self-repression scale, scale of emotion recognition deficit, scale of self-pity,
scale of the dissociative identity, scale of problem-solving and post-traumatic stress syndrome. These findings
indicated that their mental resilience was improved, that is, they could honestly express themselves, ask forsupport if necessary without worrying alone, and face problems with self-absorbing thought if needed.

There is a conventional intervention, Simonton therapy, which was developed by Carl Simonton (1978), and it
helps patients visualize their immune cells destroying the cancer cells. Simonton clarified that there was a
relationship between the optimism level of cancer patients and resistance against cancer. In addition, there
were similar reports on the relief of depression and the case of a terminally ill cancer patient who recoveredfrom carcinomatous myelopathy using combined therapy of Simonton therapy and biofeedback, which
demonstrated that patients could reestablish their “identity” and control their disease by themselves by imaging
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that lymphocytes destroyed the cancer cells. Our group intervention program also uses many images in theprocess to approach to potential stress, which turns to symptoms and signs in the process to resolve problems.
As the 5-year- study by SAT individual therapy of Munakata & Kobayashi (2007) demonstrated, continuouschanges of the images may have a big effect on the autonomic nervous system, endocrine system, andimmune system in all imageries by group intervention using SAT.

.

This intervention program was different from conventional psychosocial interventions including cognitive
behavior therapy. The conventional interventions consciously removed cognitive distortions at the beginning toaccelerate the modification of emotion expression and behavior modification, while this intervention naturally
corrected cognitive distortions using modification of emotion expression. In more detail, this intervention
method employed the method of re-scripting facial expression, which “improves the internal representation ofparents and guardians” at the beginning to give a sense of security. Such sense of security improved themodification of emotion and enabled the subjects to change their self-cognition. As also seen in the descriptive
data on changes and opinions of the psychological index, the transcripts during the intervention process
revealed the patients’ emotion and thinking were changed to “I can be myself” and “I can tell them my honest
feelings” after the completion of the improvement of images of their parents and guardians. Thus, thisintervention clarified the process of their behavior modification, such as “I can frankly express my feelings,”
and also might prolong the facilitatory effect of stress resilience by the effective reconstruction of a positive
self-image script. Cognition and behavior are decided by their self-image from information based on theirexperiences and memories. Therefore, if they try to modify their behavior by changing their cognition withoutchanging their past self-image, they will not be able to change anything about their lifestyle. This intervention
program visualizes their “authentic being” when they are protected without any conditions and live their own
lives. Then, they compare the “authentic being” with the “actual self” and realize the difference, which will
enable them to live their lives according to self-reward pursuit model. The biggest factor towards
accomplishing the above-mentioned goal might be the complete removal of their past aversive memory andthe image work to reconstruct their authentic self during this intervention, which might contribute to theInternational Journal of Structured Association Technique No.4

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prolongation of the survival period of cancer survivors.

4.3

Mental health improvement

There were no significant changes in trait anxiety and depression level in the non-intervention group, but they
were remarkably improved in the intervention group. The modification of their self-image and behavior to aself-reward pursuit type with high resilience resulted in increase in their positive self-image and decrease in
their anxiety, impatience, and depression. They found their future hope and improved their mental health.

The conventional psychosocial interventions for cancer survivors include educational intervention,
psychological support, relaxation methods, and cognitive behavior therapies to alleviate anxiety, and thesevarious methods have been studied. Edward et al. (2008) performed a meta-analysis of psychotherapy inbreast cancer patients and reported that two cognitive behavior therapies and three types of
supportive—existential psychotherapy provided some psychological effects. However, the effects lasted only
for a few months and did not prolong their survival period. The supportive—existential psychotherapy is a typeof group intervention performed according to a manual with six goals, including the development of a
supportive environment, relief of sadness, reconstruction of negative thoughts, improvement of coping skill andproblem solving abilities, and encouragement of having a hope. As described above, the psychologicalintervention used in this study is an original method to achieve self-reward behavior.

Unlike this group intervention using SAT therapy, these interventions need a certain period and frequency andhave neither intensive effects nor short-term effects. Cancer patients and cancer survivors fear to express“myself as I am” and accumulate malignant stress because they try to adjust themselves to society first. SAT
therapy is a new cognitive behavior therapy to resolve their past unsolved problems caused by codependentattachment, which has been previously learned to survive in the other-rewarding society. The conventional
cognitive behavior therapies focus on cognitive distortions, which prioritize removal of their cognitive
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distortions and uncomfortable feelings in order for them to think and judge according to their current situations.
In order to break out of the cycle of “thinking–emotion–behavior–further thinking,” their extreme pessimistic
thinking and depression should be removed. Therefore, these therapies encourage the patients to write out theactual situations in which they experience the anxiety, feelings, and behavior as well as their functional
alternative thinking and behavior at that time in order to reconstruct their cognition. Thus, these therapies
change the “thinking habit” of malignant stress to adaptive thinking. Despite the modification in thinking andachieving short-term effects, stress will later turn to somatization disorders if those are only theoretical.
Therefore, it is essential not only to modify thoughts but also to modify cognition and behavior directly fromchanges of emotion. This group intervention using SAT therapy will be effective as a new cognitive behavior
therapy based on such standpoint.

This intervention is also characterized by a group intervention by a support group. The intervention proposedby Spiegel et al. (1989) as described above was performed in a free talking style to discuss their distress andproblems between a few patients as well as a psychiatrist and social workers. Psycho-oncology in Japan has
been performed as a “medical intervention” in the medical field according to the diagnosis of an “adjustment
disorder” by a doctor and performed to “share their feelings” in the support group in the nursing field. In theirstudy on the use of psychosocial intervention in form of a supportive group to address the problem of cancer
with companions, Fawzy et al. (1990) reported that the five-year mortality in the intervention group was one
third of that in the control group. The previous studies have reported that mutual support and the establishmentof identity are essential in order to overcome cancer. This group intervention using SAT therapy also supports
the modification of their life that they live together with others, so that cancer survivors can realize who they
are and awaken themselves. Furthermore, cancer survivors who undergo this intervention “share their feelings
and understand others” in the same support group and nurture themselves as in the self-reward pursuit typeusing their empathy and empowerment, which may enable them to achieve the goal even if the intervention
period is short.

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This study demonstrated the usefulness of SAT therapy in cancer survivors by showing that they could change
their behavior to self-reward pursuit behavior and improve resilience and mental health. In the future, practicalsupport using SAT therapy should be performed on a large scale in cancer patient associations and support
groups.

4.4

Limitations and future tasks

This study aimed to evaluate the short to moderate term effectiveness of this intervention, but did not evaluate
whether immuno-competence and the facilitatory effect of resilience endure or not. The survival benefit andsurvival rate by this intervention shall for the basis for future research.

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