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International Journal of Brief Therapy and Family ScienceVol. 8, No. 1, 2018

CONTENTS
Original Paper: Research and Experiment
Development of Young carer psychological scale Japanese version- Reliability and validity examinationShigeki Okuyama .................................................................................................................... 1-22

Original Paper: Research and ExperimentComprehensive Stress Response Inventory for Children:
Construction, Reliability, and Validity
Taku Hiraizumi Koubun Wakashima Keigo Asai
Ituki Andou Yui Akama Yu Shimizu

Gen Takagi Daisuke Kobayashi

Risa Kurita........................................................... 23-33

Original Paper: Case Report
Advantage of empty-chair dialogue over emotion-focused couples therapy for a Japanese
couple with marital infidelity: A case study,FOKJ:PLPUBOJ
ShigekiOkuyama .................................................................................................................... 34-48

International Journal of Brief Therapy and Family Science
2018 Vol. 8, No.1, 1-22
< Original Paper: Research and Experiment >Development of Young carer psychological scale Japanese version- Reliability and validity examinationShigeki Okuyama 1)1), Graduate Sch0ol of education, Tohoku University

ABSTRACT. In recent years, reports on young people and children who take care of their own parents and grandparents in theirhomes are getting picked up in the media. Based on the Ministry of Internal Affairs' Employment Structure Basic Survey (2014), it isreported that in Japan there are nearly 180,000 people who have such a role. It has been noted that such young people and children
are at high risk of suffering various influences on academic work, employment and even mental health, in connection with engaging
in care for their families, the necessity of support has been pointed out from the previous research including the UK. Even in Japan,
there are some aspects that are gradually being clarified from the media reports and the interview survey for the parties asmentioned above, but the number of empirical studies is very limited. In this study, we proceeded empirical research on young
people and children (hereinafter referred to as Young carer) who provide nursing care and care to such families of diseased anddisabled adults, and developed a psychological scale that can be index to contribute to accumulation of useful knowledge for its
support. Items were prepared through Japanese translation of the content of young carer of Inventory Revised (YCOPI-R) by Cox etal (2014) and back translation. Using the Internet survey, we analyzed the responses of 174 people (including 59 Young carers) fromthe obtained data. As a result of factor analysis, the same structure as Cox et al (2014) was observed. It was also shown that
reliability and validity are sufficient .It was considered that it is necessary to empirically investigate mental health, relationship withfamily function and structure, adaptability fulfilled by maturity perceived by the parties, in the future research using the developed
scale.
KEY WORDS: Young carers, Family caregiver Young caregiver nursing care,

Introduction

its families but also local communities and（1）Problems with family caregivers

society act as a whole support nursing care but

In recent years, with the background of

the reality is that the burden is still being borne

progressive aging in Japanese society, problems

by families. According to the survey conductedconcerning nursing care of family members areby the Ministry of Health, Labor and Welfare inbeing treated as social problems. Although the

Fiscal Year 2016, 60% of the caregivers who

nursing-carebeenprovide the main care to the requiring

introduced and it has been touted that not only

caregivers consist of family members living

CORRESPONDENCE TO: Shigeki Okuyama Tohoku

together such as spouse and child (Ministry of

University, gaduate school of education, 27-1

Health, Labor and Welfare, 2017).This survey

Kawauchi, Aoba-ku, Sendai 9808576 JAPANshows nearly 70% of the family caregivers aree-mail: okuyama.shigeki@gmail.com

complaining about the suffering in daily life

insurancesystemhas

1

2

Okuyama.

and the existence of stress. From these current

answered that they have experience of nursing

circumstances, attention is now being focusedcare for their families. Also in media coverage,on the mental health of family caregivers who

it has become increasingly seen to discuss on

care

and

family care and young people and children

psychological aid is being practiced for those

responsible for care of their families (Asahi

people. However, when discussing such topics,

Shimbun published on January 27, 2016,

the assumption as "family caregivers" is often

Nikkei published March 15, 2016) and themore than adults, and the research dealt withexistence of youths and children who are"family caregivers" of young people and"family

children under age are little.

recognized and the attention is also being paid（2）Young people and children as family

to the conflicts and sufferings of the parties.

caregivers（3）Who is Young carer?

According to the results of the Basic Survey

These young people and children who are

on Employment Structure in Fiscal Year 2012

responsible for family care are called young

conducted by the Ministry of Internal Affairs

carer and it has been targeted for research andand Communications, it is estimated that thepractical support mainly in the UK. The

number of people under the age of 30 who aredefinition of young carer was recognized by the

responsible for care of their families is as highcountry in which the survey was conducted,

as about 180,000 in Japan (Ministry of Public

and there are differences mainly on the age. For

Management, 2014). Considered this survey

example, within the guidelines internationallycovers those the age of 15 or older, it isindicated by UK’s support groups, it is defined

expected that actually a larger number of young

as “Young carer” should be taken to include

people will be involved in family care.

children and young people under 18 whoforAccordingpatients

toinrecentShibuya

years,(2014),

caregivers"isgradually

being

who

provide regular and ongoing care and emotional

investigated social workers in Tokyo, it is

support to a family member who is physicallyreported the experience concerning the casesorthat 35.3% of the respondents said that those

substances"(ADASS et al., 2012), and strictly

under the age of 18 are playing the role of theemphasizes that it is limited to those under the

primary caregiver within their families. In

age of 18. On the other hand, the Australian

addition, in the survey targeting teachers ofGovernment Department of Social Welfare

public junior high schools, 20% of respondents

Bureau's statement on the website considers

say that there are students in charge of nursing

family caregivers under 25 years old as a young

care and care for their families in the classcarer and has provided public services for them

(Kitayama / Ishikura, 2015). Additionally,(Australia Government Department of Social

according to Okuyama’s survey (2016) with

Service, 2016) , and family caregivers up to 25

college students, 5% of all responses are

years old is publicly recognized as young carer.

mentallyill,disabledormisuses

“Development of Young carer psychological scale Japanese version”

3

In the UK, young caregivers up to 25 years old

exposure to stress experienced in various

are distinguished as being referred to as Young

aspects in family care.

adult carers, but it showed that they are in the

While such social adaptation risks are being

same situation as young carer for suffering

clarified, positive aspects by caring for families

greatly with restrictions on daily life as listed

as young carers are also mentioned (Aldridge &later.

Becker, 1993; Dearden & Becker, 2004). It can

It is clear that “care” provided by young carers

be divided into three aspects from its contents.

to families is not limited to "nursing care" acts

One of them is the improvement of familysuch as side assistance or assistance forrelationship, such as getting close within

mobilization, but also emotional support suchfamilies compared to previous family situation.

as encouragement and it is easily extended toAlso,housekeeping acts on behalf of families who

self-awareness of internal mature in the person

cannot function fully due to illness or disability,

by care of the family himself, or mastering theand the area of involvement has been shown tolife skills such as acquiring living skills andbe diverse. It is pointed out that because of suchknowledge to be obtained as a result of

an increase in burden, health becomes impaired

experiences as a young carer.

both physically and mentally by excessive(4) Difference between adult caregiver andamount of care.

"Young carer"

A survey targeting young carers in the UK

Young carer and an adult care giver are the(Dearden & Becker, 2004) shows that various

same in terms of burden and restrictions onrisks and negative influences are generated insocial life as being responsible for family care,the parties as a result of their high involvement

but due to their chronological differences it isin family care. First, there are many social

expected that the psychological development

restrictions, such as loss of opportunity when

aspects of the parties will be affected for young

choosing career such as admission to university

career. For example, many of young careers areor employment. It also points out thatin the stage of receiving education and it isinterpersonal relationships such as bullying

clear that lowering academic ability, latecaused by no opportunities to spend time witharrivals and absences become more frequent byfriends of the same age due to care of theirtaking care of family members (Dearden &families, or being in a family environment

Becker, 2004). In addition, infringement ofdifferent from those of same age groups

such educational opportunities leads not only tooccurs.Besides, there are emerging of problem

academic achievement but also to the lack of

behavior such as decrease in mental health,opportunities for interaction with friends of theself-harm, suicide and drug abuse caused bysame age as young carer, which will have apressure from inside and outside of family

great influence on the acquisition of sociality at

against them taking care of family andschool age is expected. In addition, since youngthepositive

aspects

such

as

4

Okuyama.

carers will bear more responsibility than their

psychology and welfare study. When the scale

age-appropriate, they are also said to fulfill

is developed, it may contribute to the"spurious maturity" by being pressed for anunderstanding of young carer which is not yet

emotional maturation that is unlikely at theclear in Japan and the construction of its

stage of their growth (Mitomi, 1997), thesupport.

possibility of influencing personality aspects is

For the definition of young carer used in thisexpected as well. In addition, it is considered

research, “Young carer” in the broad sensethat such effects will affect not only at that

including youth adult carer in the UK will bepoint but also will spread after children /dealt first. This is because knowledge aboutadolescents who are young carers become

young carer is not accumulated in Japan, and it

adults. Medium and long term effects on thewas concerned that the number of survey

emotional development of these parties seems

subjects will be short in case of limiting toto exert different difficulties on young carerminors. As for the upper limit of the age at thisthan the influence on adult caregivers. Due totime, following the official definition of young

such specificity, examination with an index

carer used in Australia, those who are less thandifferent from that of adult caregivers seems to

25 years old at the time of the survey shall bebe necessary for young carers.

subject to "Young carer". In addition, there are(5) Purpose of this researchcases in which siblings are also included in

In this way, although there are overlapping

families who receive such care in previous

parts in terms of action, it is expected that there

research, but due to low social cognitive on

will be differences in aspects affected by adultyoung carer in Japan there is a risk the survey

caregivers and young carer who is in the middle

will include those who take care of the youngerof development. In recent years, researchsiblings as part of the help in the home, so in

focusing on them has been done mainly in thethis research it limits to only who provide thefield of social welfare in Japan, and it has beencare to adults such as parents and grandparents.

made clear that the they have experienced

Also, we set the standard on period of care as

strongThe

more than 1 year in this research, and exclude

provision of psychological support for suchthose who do not satisfy them from survey

difficulties seems to be an issue, but in Japansubjects.

there are few studies that took up young carers

Based on these facts, in this research, weand accumulation of research aimed at young

define the definition of young carer as "thosecarers is considered necessary in order towho have had experience of providing nursing

contribute to the future support.

care / support to an adult family member

With these backgrounds, this research aims to(grandparents, relatives or parents who lives increate a Japanese version of psychological scale,the same house) who is in need of support andwhich is an index of young carer research incare for physical and psychological diseases /difficulties(Morita,2010).

“Development of Young carer psychological scale Japanese version”

disabilities, dementia, etc for more than one
year before 25-year-old.
AlthoughnumberIn order to obtain attributes of survey
cooperators, we got responses on age, sex,

psychologicalmarital status, presence of children, occupation,measures on burden of care targeting carers

and final academic background from all thehave already been developed in Japan (Arai,

respondents. In addition, for those who qualify

2002, etc.), it is considered necessary to

as a young carer experienced person, the family

developthecomposition, care recipients, disability grade ofpsychological scale for adult caregivers since it

care recipients and degree of care required,is expected to affect differently to young carer

time to care per day, frequency of care permainly on the emotional development due toweek, the number of years involved, thedifferences in age from adults caregivers andcontent of care, relationship with others who

the "nursing care" acts and "care" acts

also provide the care within their families, theperformed by young carer are different.

number of care providers in their families, as to

Therefore, in this research we will create awhether hospitalization or hospital visit of carescale specialized for young carers.

recipient and use of facility, the reasons for

a

a

5

different

of

index

from

finishing involvement in family care (apply
Methods

only to experienced parties) were questioned.

(1) Survey method② Young carers psychological measure of

We conducted an internet survey in January

Japanese version:2017. All the survey cooperators were those

One of the psychological measures for young

who registered the monitor to the survey

carer is Young carer of Parent Inventory

company. We stated in the text prior to survey

Revised (hereinafter referred to as YCOPI-R)

that research cooperation is free will, thedeveloped by Cox & Pakenham (2014).

answers obtained are not used for other thanYCOPI-R is a revision of Young carer of Parent

research purposes, if mental suffering occurs by

Inventory (YCOPI) developed by Pakenham,

responding they can stop anytime, it takes

Bursnall, Chiu, Cannon & Okochi (2006), andabout 20 minutes to complete, and asked toin addition to questions of actual experience ofparticipate only when agreement is made.

children and adolescents taking care of parents,(2) Subject

the questionnaires also includes about emotions

Respondents were recruited from youngthat are expected to be experienced in a spilling

carers under the age of 30 at the time of themanner from such a situation, such as a strong

survey as well as those who did not have suchsense of responsibility to families and isolated

experience for the purpose of considering thefeelings from the surroundings. In Cox &validity of their development scale.

Pakenham (2014), they recruited from schools,(3) The structure of questionnaire

regions, support groups, etc. in Australia and①Face sheet:developed 2336 subjects including 576 young

6

Okuyama.

carers who were responsible for parent care. In

comparability with the general youth, there is apart A it is designed to measure care experience

point that it was used also in the previous study

in daily life in families in youth general, andwhich studied the psychological aspect ofgeneral young people and children other than

young carer, YCOPI-R was considered to be ayoung carer can also answer, so comparative

useful indicator in promoting young carerstudy is possible between them. As a specificresearch in Japan as well. Therefore, with thefactor, there are 6 factors of "Activity

permission from the original author, we

restrictions: Global", "Activity restrictions:translated YCOPI - R contents to Japanese andStudycreated a scale in this research.

/Work","Isolation","Perceived

maturity", "Caregiving responsibilities", andAs for the translation of each item, the"Worry about parents" in part A. On the otherresearcher translated the English item, thenhand, Part B consists of items that measure

asked

peculiar experiences only for young people

specializing in academic translation, and under

who care for families with health conditions

the confirmation of other graduate students andsuch as disease and disability, and only young

academic advisor the decision was made. Also

carer parties can answer. There are 5 factors ofin both of the original YCOPI and YCOPI-R,"Caregiving guilt", "Caregiving isolation",each item limited the recipients of care to"Caregiving"Caregiving

parents, but since we do not limit carediscomfort", and "Caregiving information /recipients to parents only in this study wesupport" in part B. In addition to the originalmodified the expression on the item restricted

English version, a Dutch version has also been

to "Parent" to "Family" or "Other family

created (Sieh, Visser-Meily, Oort, & Meijer,

members". Regarding modification of these2012). Many applications of the previous

expressions, we also obtained permission fromstudies see the relationship between family caretheexperience reflected in part A and otherconventional YCOPI-R, we made two parts

variables, as demographic variables such as thewith part A (26 items) and part B (18 items),

type of disease, the number of family members,

and both were prepared by the five methods

age, sex, race Influence on family care("not true at all "to "very true").

experience (Pakenham & Cox, 2015), relation③ Zarit nursing care burden scale Japanese

betweenversion (J - ZBI):

confidence",familyinternalization

care

issuesexperience
and

and

back

translation

original

authors.

foracompany

Followingtheexternalization

It was used to examine the validity of the

problems (Sieh, Visser-Meily, Oort, & Meijer,

part B part of the young carer psychological2012) and stress effects (Romijin, 2015) havescale Japanese version. The original was The

been studied.

Zarit Burden Interview (ZBI) developed by

In this way, in addition to the two features

Zarit (1980), Japanese translation version was

YCOPI - R has a variety of item contents anddeveloped by Arai et al (1997). Zarit defines

“Development of Young carer psychological scale Japanese version”

7

the nursing care burden as "degree of damagefamily cares, it was considered that J-ZBI isthe caregiver suffered in terms of emotional,

appropriate as an external standard from thephysical health, social life and economic

content of the item. From the significance ofcondition as a result of caring for a relative,"the correlation coefficient between the subscaleand J - ZBI also measured the nursing carescore of the factor derived from the analysis

burden by this definition. It has been pointed

result and J - ZBI, the validity is examined. In

out that the scale consists of two factors:

addition to the item contents related to negative

Personal Strain (the burden caused by thefeelings from sense of burden on the original

nursing care act itself) and Role Strain (thescale, items of semantic content relating toburden caused by losing the life by playing thepositive emotions that shows confidence forrole of care for the family) (Whitlatch et al,family care are also provided. Among them, it1991). Regarding the expression "patient" inis expected to see the significant correlationeach item, the respondents were requested towith J – ZBI on the factors with a negative item

consider the person who was responsible forcontent, and uncorrelated relationship with thecare in the home for answer. We got permission

burden feeling reflected on J – ZBI on theon the use of the scale and notes on reply fromfactors with positive item content.

the right holder of the Japanese version scale

For the reliability test, we decided toprior to conduct the investigation.

examine it by Cronbach's α coefficient in both

(4) Reliability and validity examination

part A and part B.

Regarding the Part A, when developing(5) Ethical consideration

YCOPI by Pakenham et al (2006), the validity

This research was conducted after obtaining

was considered by a significant difference inthe research permission from the Ethics Review

score between young carer and others. In thisCommittee

research, following the original thesis, we also

Education, Tohoku University.

of

the

Graduate

Schoolofconsider the validity by calculating thesignificant difference of the subscale scores forResults

each factor between young carer experienced(1) Young caring situation

persons and others. As items in the original

We got the cooperation from 206 people withscale are prepared from the contents obtained

young carer experience. Among them, thoseby previous studies targeting young carer andwho do not conform to the definition of younginterviews with the parties, in this result as wellcarer in this research, those who was suspected

as Pakenham et al (2006), it is expected that thevalidity of the response contents from the item

young carer group will score significantly

reaction (answers with the same number onhigher on all the subscale scores at part A.

multiple scales, a big contradiction between the

Regarding the part B part that measurescontent of the entry etc) were excluded frompsychological burden feeling due to engage in

the analysis. Also, because it was predicted that

8

Okuyama.

Table 1 : The opponent young carer provide the care (including multiple answers)
Number of respondents
Father8

Mother

12

Grandfather

9Grandmother

29

Uncle

2

Aunt

9

Other relative0

married persons and those with child-rearing

Regarding this, with the same conditions forexperience could become confounders in terms

experienced young carer mentioned above,of care for their families, those who havethose who suspected the appropriateness of themarried and their children also were excluded

response content from the response to the item,from the analysis data. Furthermore, as it was

married persons and experienced childcare

considered

conditional

experience were excluded from the data. As adifferences with those who do not have family

result, data of 115 people in total who did notcare experience, those who responded to bothhave experience of involvement in family care"one day a week" and "less than one hour" on(hereinafter referred to as target groups) were

the question regarding the the time per day andused, and 174 subjects were analyzed as afrequency per week involved in care werewhole.

difficult

to

find

excluded. In addition, we recruited researchcollaborators

includingpersons,

considering

but

past

experienced

was 24.17 ± 3.91 years, and there was noofsignificant difference between the groups

responses by recall method, we targeted only

(Young carer group M = 24.64 ± 3.75 years old:those who are performing family care at thecomparison group M = 23.92 ± 3.98 years old).

time of the survey. A total of 59 people who

There was a tendency for females to be larger

remained

exclusionin both young carer group and comparison

conditions were considered as young carergroup (young carer group 19 males and 40

experienced persons (hereinafter referred to as

females: comparison group 31 males and 84

young carer group).

females). There was no significant difference in

We also gained survey cooperation from 206

the final academic background of the subjects

people who did not have experience inbetween the groups, and those who had the

involvement in family care, the same number offinal academic background over college or

people who experienced young carer.

university graduation occupied the majority inafter

setting

distortions

The average age of the surveyed subjectsthese“Development of Young carer psychological scale Japanese version”

9

Table 2 : The degree of care required for famil
family and classification of certificate(including multiple answers)
Number of respondents
handicapped certificate (1st degree )11handicapped certificate (2nd degree )7handicapped certificate (3rd degree or below )2certificate classification unknown

10

certificate required support (1)9certificate required support (2)8certificate of long-term care needs (1)0certificate of long-term care needs (2)7certificate of long-term care needs (3)6certificate of long-term care needs (4)4certificate of long-term care needs (5)2certificate of long-term care needs unknown

12

not possess the certification for handicapped nor long0term care

8

needs

both groups.

familiesinsevere

The grandmother was the most opponent who

Regarding the time for care per day there wereyoung carer had offered care, followed by

39 people under 3 hours, and regarding the

grandfather, mother, aunt, father, uncle (Table

frequency of days involved in care per week 23

1). Though there are multiple answers, thepeople involved in family care almost every

reasons for care and nursing care required wereday (Table 3). With regard to the content of

34 cases of physical disorder, 30 mental

care that the young carers handle, the most ofillnesses including dementia and intellectual

them were housekeeping or help on it, and the

impairment and 29 disabilities with physicaldomestic assistance such as assisting mobility

disability. Regarding the degree of careand providing medicines was also carried out inrequired for the family receiving care and thelarge part, (Table 4). There were 35 people who

type of physical disability certificate, 11 wereshared care with two or more families besides

the most frequent people who care for families

themselves, but the remaining 24 persons

with certified disability grade 1. There are 12

handle the care alone or shared care withpeople who care for families who require 3 oranother person within the family.

more degree of nursing care and in a state of(2)Preparation of young carer psychological"almost full care needs", and more than certain

scale

number of people experienced the care for

examination of reliability and validity

Japanese

conditionversionpart(Table

A

2).

and

10

Okuyama.

Table 3: Time and number of days spend on family careTime per day

Number of

Number of days per

Number of

respondents

week

respondents

less than 1 hour/day

15

once a week5

less than 3 hours/day

24

less than 3 days/week19

less than 5 hours/day

9

less than 5 days/week11

less than 7 hours/day

6

almost everyday

23

less than 10 hours/day

1

more than 10 hours/day

1effect in any item, analysis was made assumingwashave to help my family members."

confirmed for each item. Since the result shows“Because of helping my family members I

no noticeable bias such as floor effect or ceilingsometimes feel too tired or too busy to do mynormal distribution of data in subsequent

study/work so much to support my family that I

analyzes.

cannot study," and it was named "restriction /Factor analysis by maximum likelihood

restraint feeling". The second factor consists ofmethod was performed on 26 items of Part A

3 items, and it shows a group with strong

part. As a result, it was shown from theworries and concerns for families such as “Ieigenvalue and the reference of the Scree plot

worry about my family members” and “Ithat the same five factor structure as thealways wonder if my family members are safe"

original YCOPI is valid. After that, in theand it was named "fear of family conditions".

process of repeating the analysis, the three

The third factor is from 4 items such as "items whose load amount fell below .40 ("I take

Others expect me to help my family members "on more responsibility around the house thanand " Other family members expect me to help

other people my age.", " I know more aboutcare for them " and it was named “Expectation

looking after a household than other people mywithin family”. The fourth factor consists of 2age."," I feel as though I am missing out on

items such as “I am more grown-up and maturethings that other people my age are doing ")than other people my age” “I feel more like anwere excluded and the final factor pattern was

adult than other people my age" and it wasmade (Table 5).

named "awareness of maturity". The fifth factor

The first factor is composed of 12 items

is composed of 3 items such as “I sometimes

meaning restrictions on life such as studies due

feel alone " and " I wish that I had other people

to involvement in families and restraints, as

to talk to about my feelings and worries” and it" I sometimes miss school/work because I

was named "Loneliness".

Initially,

the

distribution

of

score

“Development of Young carer psychological scale Japanese version”

11

Table 4: The care acts responsible as young carer (including multiple answers)
Number of respondents
housekeeping or help on housework47

help in daily life such as mobility assistance or medicine management36

help on social aspect such as money management or public procedure

13

emotional support such as encouragement or reception

24

physical support such as at bathroom or clothes removal

17

provide childcare to other siblings

4

assist outside of house such as visit to hospital or facility

25

others0

The correlation between factors ranged= 172 p <.05; "expectations to support family" tfrom .113 to .701, and in particular the second= 5.05 df = 172 p <.001; "awareness offactor "fear of family conditions" was shown tomaturity" t = 3.43 df = 172 p <. 01;

be low correlated with other factors in general.

"Loneliness" t = 2.43 df = 172 p <.05). From

After establishing the factor structure, we

this,calculated the subscale scores for each factor in

Psychological Scale Japanese version of part A

order to examine the reliability.

created in this study has a high possibility of

After that, as the result of α coefficient ofhigh scores in young carer’s respond, from the

Cronbachfactordiscrimination possibility it was conceivable"loneliness" was somewhat lower at .69 but thethat the scale had certain validity. Details aboutother factors showed high reliability from. 81

the score and standard deviation are shown into .89, the overall scale was considered to have

Table 6.

reasonable reliability.

(3) Preparation of young carer psychologicalshowed

that

the

fifth

As in the method of validation of Pakenham
et al (2006), we also conducted T test in this

scale

it

shows

Japanese

that

the

version

young

part

B

carer

and

examination of reliability and validity

study to compare the score between young

Part B got responses only from the young

carer group and the comparison group for eachcarer group. Since Part B does not show

subscale as a study of the validity of the scale.

distribution bias which can be regarded as the

As a result, a significant difference was shown

floor effect and the ceiling effect as well, an

between the young carer group and theanalysis method based on the assumption ofcomparison group on the score for each factor

normal distribution was used in the subsequent("restriction / restraint feeling" t = 8.06 df = 172

analysis.

p <.001; "fear of family conditions" t = 2.18 df

As a result of factor analysis by the
maximum

12

Okuyama.

Table 5: young carer psychological scale Japanese version Part A factor analysis result
maximum likehood method Promax rotation N=174

item

II

III

IV

V

.98

.09

.27

.00

.07

.93

.09

.02

.14

.03

.82

.03

.07

.11

.04

.74

.01

.10

.06

.01

.71

.06

.07

.05

.10

.56

.01

.21

.00

.02

.55

.02

.09

.12

.02

.53

.10

.27

.10

.06

.52

.01

.16

.14

.04

.45

.17

.03

.08

.00

.43

.03

.12

.05

.13

Item description
I sometimes miss school/work because I have to

5

Ihelp my family members
Because of helping my family members I
sometimes feel too tired or too busy to do my14

study/work
I sometimes feel tired at school/work because I

23

have been helping my family menbers
Helping other family members stops me from3

doing a lot of things that I want to do
If I do not take on extra responsibilities the house6

will fall apart
My family members rely on me to help them with

24

house-hold chores
My family members rely on me to do the shopping

25

and budgeting16

I have to look after my other family members
My family members rely on me to make sure our26

family is organized
I have a lot of time to do the things that I want to

21(R)
Helping other family members stops me from10

doing paid work

7

I miss out on a lot of activities because of my home

.43

.05

.34

.01

.03

1

I worry about my family members

.07

.87

.12

.01

.10

8

I always wonder if my family members are safe

.08

.82

.08

.03

.04

.09

.66

.17

.04

.04

.01

.05

.92

.01

.03

.09

.09

.64

.04

.07

.17

.18

.55

.04

.03

I worry about what will happen to my family
19

members

11

Others expect me to help my family members
Other family members expect me to help care for

15

them
My family members rely on me for emotional

12

support such as making them feel better

“Development of Young carer psychological scale Japanese version”

I am more grown-up and mature than other people my

13

I

II

III

IV

V

.01

.06

.01

1.02

.05

20

age

17

I feel more like an adult than other people my age

.01

.07

.03

.79

.06

13

I sometimes feel alone

.01

.07

.09

.03

1.03

.06

.19

.16

.07

.42

.13

.01

.15

.02

.41

I

II

III

IV

V

.26

.70

.42

.44

-

.32

.30

.11

-

.39

.41

-

.25

I wish that I had other people to talk to about my feelings
4

and worries

22

Oher people do not understand me and my situation
Factor correlation
I

-

II
III
IV
V

-

likelihood method for 18 items of Part B.

related to family care such as “I find it hard

It seems that 4 factors are reasonable from theexplaining to my friends that my family

eigenvalue

factormembers have an illness /disability ” and " I

analysis was repeated based on the assumption

feel guilty when I don't help out at home " andof a 4 factor solution, multiple factors which

it was named "negative emotion accompanying

were hard to interpret were calculated, and thefamily care" (M = 3.02 SD =. 89). The second

result was same with factor analysis with 5

factor consists of a group of items showing

factors as in the revised edition (Cox et al,

self-confidence that they support their families2014). Next, based on the original Pakenham et

and the strength of self-recognition such as " I

al (2006), we conducted the analysis on theam good at helping my family members and I

assumption of a 3 factor solution. After that,always know what to do and how to help ", " I

items whose factor load amount is less than .40

know exactly what to do to help my familysuch as ("I cannot tell my family's anxiety andmembers" and it was named "confidence toconcern about my family in order to avoid the

support the family"(M = 3.14 SD = .85). The

disturbance of the other party", "I wish I could

third factor consists of 4 items that call for

invite a friend to my house") were excluded,

assistance to the present situation such as “Iand finally the 16 items with 3 factor structures

wish there was someone who was able to look

was confirmed (Table 7).

out for me “I wish I could talk to other people

Factor 1 is composed with a group of items tomy age who also have a family members withbe considered to reflect a negative emotion

an illness/disability” and it was named “helpvalue.

However,

when

14

Okuyama.
Table 6: The test result on Part A subscale score t between young carer group and general sample
group N=174
Young carer

Comparison

group

group

M

SD

M

SD

t value

restriction/restraint feeling

3.10

.77

2.21

.63

8.06 ***

fear of family conditions

3.64

.97

3.30

.99

2.18 *

expectation to support family

3.30

.94

2.54

.93

5.06 ***

awareness of maturity

3.12

1.06

2.54

2.06

3.43 **

loneliness

3.38

.98

3.02

.90

2.43 **p<.05, **p<.01, ***p<.001

seeking”. (M = 3.26 SD = .86).

considered that the validity of "confidence toIn the correlation between each factor, thesupport the family" is guaranteed by notvalue is low between the second factor

showing a significant correlation between"confidence to support the family" and other"Personal Strain" and "Role Strain" shown in"negative emotions accompanying family care",J-ZBI. As a result of the correlation analysis, a"help seeking", and it shows that “confidence tosignificant positive correlation was foundsupport the family” is content-independent.

between "Role Strain" and "Personal Strain" inAfterstructure,both "negative emotion accompanying family

Cronbach's α coefficient was calculated forcare" and "help seeking”. In addition, there waseach factor. As a result, it was considered thatno significant correlation between “confidence

each factor had sufficient reliability because it

to support the family” and “Role Strain” andlies between .74 and .86.

“Personal Strain” (Table 8). From these results,

With respect to the factors of "negative

part B was also recognized to be adequate as aemotion accompanying family care" and "helpscale from the relationship with externalseeking" out of factors of part B, it wasstandards.

establishingthefactorconsidered to show correlation of both theburden feeling and significant positive from

Discussion"Personal Strain" and "Role Strain" measured(1) Reliability and validity of the scale

by J – ZBI from items that reflect negative

developed in this researchemotions of the parties. On the other hand,

The purpose of this research was to develop a"Confidence to support the family" waspsychological scale that could be a usefulconsidered to be more positive in terms of theindicator for researching young carer in Japan.

item content and the low correlation from

The results of the study showed that both Part

previous two factors. Therefore, it was

A and Part B of the development scale have“Development of Young carer psychological scale Japanese version”

15

Table 7: Factor analysis result of young carer Psychological scale Japanese version
Part B maximum likehood method Promax rotation N=59
item

Item description

I

II

III

illness /disability

.83

.09

.08

15

I feel guilty when I don't help out at home

.74

.15

.03

2

I feel embarrassed about my family member’s illness/disability

.66

.21

.15

7

When I am out with friends I feel that I should be at home instead

.66

.07

.03

4

I feel guilty when I go out and have fun

.60

.02

.19

6

I wish that I did not have to help my family members as much as I do

.50

.38

.46

.41

.00

.19

do and how to help

.06

.86

.01

I know exactly what to do to help my family members

.14

.80

.16

llness/disability

.14

.55

.09

I am confident that I can care for other family members

.27

.50

.12

illness/disability

.11

.49

.03

I wish there was someone who was able to look out for me

.20

.22

.98

members with an illness/disability

.16

.11

.55

I wish that someone else could care for my family members

.27

.22

.46

.07

.25

.43

Factor correlation

I

II

III

I

-

.22

.53

-

.23

14

16

3
9
10
17
12
13
5
1
18

I find it hard explaining to my friends that my family members have an

I find it difficult to ask other people for help in my caring role when I
need it
I am good at helping my family members and I always know what toI wish I had more information about my family member's

I am included in making decisions about other family member’s

I wish I could talk to other people my age who also have a family

I wish the doctors would talk to me and explain things about my family
member’s illness/disability

II
III

-

sufficient reliability and adequacy as a scale.

& Pakenham (2014)", from the similarity of its"Fear of family conditions", "Awareness ofcontents. In addition, between "expectations tomaturity" and "Loneliness" shown in Part A as

supportfactors can be considered the same with "Worry

Responsibilities", "restriction / feeling of

About Parents", "Perceived Maturity" "in Cox

restraint" and "Activity Restrictions: Global"

thefamily"and"Caregiving

16

Okuyama.

and "Activity Restrictions: Study / Work" each

is more imminent unlikely the one of others.

Table 8: Correlation analysis result between young carer psychological scale Japanese version
Part B and J-ZBI
Personal

Role

StrainStrainnegative emotion accompanying family care.55

confidence to support the family.14

help seeking

.64

***

.69

***

.10
***

.61

***

*p<.05, **p<.01, ***p<.001

can also be considered to have the same content,

In part B, the three factor structure with

we can consider that the Japanese version scale"negative emotions accompanying family care",reflects the same contents as the original scale"confidence to support the family" and "helpthroughout.

seeking" was recognized. With regard to

In the correlation between the factors of part A,"Confidence to support the family" and "helponly the "fear of the family situation" wasseeking", it can be said that it corresponds toweakly correlated with other factors, and the"Caregiving

other factors were strongly correlated among

Information / Support" in Cox & Pakenham

each other. This can be because the items(2014). In addition, the first factor "negative

included in "Fear of family conditions"emotions

included items that are likely to give highconsidered to be a comprehensive of negativevalues also in the comparison group not

emotional experiences felt by caring for

responsible for family care (for example, "I amfamilies, and a summary of "Caregiving

worrying about my family”), and as a result ofGuilt” ," Caregiving Isolation "and" Caregivinga difference between other factors the whole

Discomfort " from the grouping of the item

correlation between the factors got weakened.

contents, and like Part A, Part B also seems to

However,ameasure similar content with the original scale.

significant difference between the groups, in(2) The relationship between part A and partterms of worrying about families, it is expectedB

to be different in degree from "family oriented"

Among the scales created in this study, part A

held by young people and children living inand part B seem to be measuring different

families. In Okuyama (2016), young people

regions respectively. According to Cox &with young carer experience have been shown

Pakenham (2014) which is based, part A is said

to have a tendency to be significantly higher

to measure care experience in the family inwith characteristic uneasiness, compared withyoung people in general, and concerning part B,

general college students, and it is pointed out

care is taken on families who are in healththat young carer’s worry about family situation

condition such as disease and disability, it isbecause

they

also

showedConfidence"accompanying

andfamily"Caregiving

care"

is

“Development of Young carer psychological scale Japanese version”

17

said to measure specific experience only toto consider what factors are strongly associatedyoung people who take care of unhealthy

with the distress caused in young carer.

condition family members.

It is also considered necessary to examine theAmong them, the experience of care in thefunction or structure of the family to whichfamily reflected in part A is expected toyoung carer belongs. It has been revealed fromincrease the influence on school work andmultiple previous studies of adult caregivers

social life such as becoming unable to havethat relationships within their families affect thefriendship with friends as increasing the degree,

sense of care burden. For example, in a study

and it is considered that it focuses on thetargeting caregivers for adults, the low conflict

influence on social life by caring for the family.

betweenOn the other hand, since part B is composed(Townsend & Franks, 1995), the intimacy ofwith items that questions the emotions thethe relation (Williamson & Schulz, 1990) ,parties often feel such as "When I go out withcondition of family relations (Yoshida,· Minami,

my friends, I feel I should rather stay home" or·& Kuroda, 1997) are related to nursing care

"I wish that I do not need to care for my family

burden. Therefore, the necessity to support inlike now", it is considered that it focuses on

the relationship between the care recipient andemotional aspects that are actually experienced

the caregiver in the family when supportingwith caring for families.

family caregivers was pointed out (Kurosawa,(3) Issues and limitations on this study2011). Even with young carers, considering

The issue and the limitations on this study arewhat kind of family factors are related to young

the unevenness of the population by Internet

carer's social adaptation risk may lead to an

survey and the small number of samples. In theeffective supportive intervention suggestion.

future,through

In addition, it is also necessary to consider thecooperation of parties' groups of Carers andadaptability of emotional maturity in youngsocial welfare organizations. Particularly in thiscarer. Regarding emotional maturity, althoughstudy, since the average age was around 24

the parties often report as positive aspects

years old it was desirable to secure young

accompanying the experience of family care,survey cooperators including minors, andresearchers have expressed negative sense suchreanalysis with the addition of new data may

as "shame maturity" (Mitomi, 1997). Regarding

also be necessary.

maturity, although it is considered that it acts

(4) Future development using this scale

positively for psychological adaptation, it isAmong future developments, it is expected toalso considered that maladaptive aspects suchbe used for empirical research for young carer.

as "pseudo-maturity". In Yamada, Hiraishi,

For example, considering the relationship

Watanabe (2015), it highlights over adaptation,

between aspects and mental health of young

high emotional dependence, “commu-phobic"

carers reflected on this scale may be a material

tendency, low trust of others as a feature of

weshouldalso

recruitcaregivers

and

care

recipients

18

Okuyama.

pseudo-maturity. The condition that parents not

Carers,giving emotional support to children andhttps://www.dss.gov.au/disability-and-cchildren giving emotional support to parents,

arers/carers （Retrieved July 12 2017

parents imposing excessive expectation to

Aldridge, J. & Becker, S.

(1993).

children as a caregiver are considered to

Punishing children for caring : The

promote pseudo maturity for children. Amonghidden cost of young carers,

these promotion conditions, providing theChildren & Society, 7, 376-387.

emotional support from children to parents andAsahi Shimbun(2016）.Support for Young

excessive expectation as a caregiver fromcarer who take on nursing,parents to children are expected to be the same

http://www.asahi.com/articles/ASJ1W2

with young carer, and it is also possible that the

GHBJ1WUBQU005.html［in Japanese］

maturity reported in existing surveys may be

Retrived January 10 2017
Arai, Y., Kudo, K., Hosokawa, T., Washio,

pseudo maturity.
In the previous study of the social welfare area,

M., Miura, H., & Hisamichi, S. (1997)

it is often pointed out the necessity for

Reliability and validity of the Japanese

psychological support to young carer. However,version of the Zarit Caregiver Burden

from a methodological limit, it is not clearlyInterview,stated from the viewpoint of "what kind of

Psychiatry Clinical Neurosciences,

support" is needed. Under such circumstances,51, 281-287.

empiricallyexaminingtheemotional

Cox,

K.

&

Pakenham,(2014).

experience of young carer is expected to lead to

Confirmatory

stepping into the point of "what support" whichinvariance testing of the young carer of

was difficult to examine so far, and toparents inventory (YCOPI),

contribute to the realization of practical andRehabilitation Psychology, 59, 439-452.

highly effective support.

factorK.

analysisandDearden, C. & Becker, S. (2004). Youngcarers in the UK: The 2004 report,
London: Carers UK

Reference
ADASS., ADCS., & The Children ’ sSociety.

Kitayama, S & Ishikura, K. (2015 ） .

(2012). Working together toSurvey on actual situation of Young

support young carers and their families.

carer -Junior high school students with

http://www.adcs.org.uk/download/positi

excessive domestic role-, The Journal of

on-statemants

school education of hyogo university of/2012/MoU%20young%20carers%20201

education, 27, 25-29. [in Japanese]

2.pdf Retrieved January 10, 2017

Kinoshita, Y. (2007). Carer support inAustralia Government Department ofAustralia, The review of comparative

Social Service （2016）. Disability andsocial security research, 184, 57-70. [in“Development of Young carer psychological scale Japanese version”

Japanese]
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(2011)).

The

present

psychological aspect seen in Youngconditions and issues of a familycarer - through comparison with young

support for the elderly with dementia,

people of the same age -, Japanese

Human welfare studies, 14, 121-128.

journal of family psychology of the 33th[in Japanese]annual meeting [in Japanese].

Ministry of health, labor and welfare.

Pakenham, K., Bursnall, S., Chiu, J.,(2017）. Comprehensive survey of living

Cannon, T., & Okochi, M.

conditions in 2016,

The psychosocial Impact of caregiving

http://www.mhlw.go.jp/toukei/saikin/hon young people who have a parent

w/k-tyosa/k-tyosa16/dl/05.pdf

withRetrieved June 23 2017 [in Japanese]

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Ministry of public management. （2014）.

Caregivers

Basic Survey on Employment
Structure in 2012,

anillnessor(2006).

disability:

Between

and

Young

Noncaregivers,

Rehabilitation Psychology, 51, 113-126.
Pakenham, K. & Cox, S.

(2015).

The

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effects of parental illness and other ill

ndex2.htm Retrieved February 10 2017

family members on youth caregiving[in Japanese]experiences, Psychology & Health, 30,

Mitomi, N. (1997). Children responsible
for family care in the UK, The journal857-878.
Romijn, S. (2015).

Effects of copingof Economic Research of Shizuoka

strategy, caregiving impact, and parent

university, 2(1), 1-65.

attachment on stress in children of[in Japanese]parental illness, Master thesis, Leiden

Morita, K. (2010). The experience ofUniversity.

children with a parent with mental

Shibuya, T. (2014). Recognition of young

health problem: life story of a young

carers by health and social service

adult carer who care a parent withprofessionals:

anxiety disorder, The journal of social

questionnaire survey of "tokyo medical

welfare research of rissho university,

social workers", Japanese journal of12, 1-10. [in Japanese]social welfare, 54(4), 70-80.

Nikkei. (2016）. The loneliness of "Young
career" chased by nursing care,

Analyzinga[in Japanese]
Sieh, S., Visser-Meily, J., Meijer, A., &http://www.nikkei.com/article/DGXMZOort, F. (2012).

O98436160V10C16A3CZ8000/

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Child & Adolescent Psychiatry, 21(8),459-471.
Ministry of public management. （2014）.
Basic

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Employment

Structure in 2012,
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2/index2.htm Retrieved February 102017 [in Japanese]
Whitlatch, J., Zarit, H., & von, Eye, A.
(1991). Efficacy of interventions withcaregivers : A reanalysis, Gerontologist,
31 (1), 9-14.
Williamson, M. & Schulz, R. (1990).
Relationship orientation, quality ofprior relationship and distress among
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patients,

Psychology and Aging, 5, 502–509.
Yamada, T.; Hiraishi, K. & Watanabe, K.
(2015). Study of Parent-Child Role
Reversal in University Students : In
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The
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1-18.[in Japanese]
Yoshida, K.; Minami, Y. & Kuroda, K.
(1997). Exhaustion amongst care givers
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Medicine , 15, 7-13. [in Japanese]
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Relatives of the impaired

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“Development of Young carer psychological scale Japanese version”

Appendix 1
Young carer psychological scale Japanese version Part A

21

22

Okuyama.

Appendix 2
Young carer psychological scale Japanese version Part B

International Journal of Brief Therapy and Family Science
2018 Vol. 8, No.1, 23-33< Original Paper: Research and Experiment >Comprehensive Stress Response Inventory for Children:
Construction, Reliability, and Validity

Taku Hiraizumi 1)

Koubun Wakashima 2) Keigo Asai3)
Ituki Andou4) Yui Akama4)

1)

Tohoku Fukushi University

2)

Tohoku University, Graduate School of Education

3)

Hokkaido University of Education

4)

Sendai City Board of Education

5)

LITALICO lnc.

6)

Sendai City Elementary School Teacher

Gen Takagi2) Daisuke Kobayashi2)

Yu Shimizu5) Risa Kurita6)

ABSTRACT. The objective of this study was to develop a new measure of stress response in children, the Comprehensive StressResponse Inventory for Children (CSI-C). The items and response options of the original CSI, which was designed for use withadults, were modified using expressions more accessible to children. This measure was then used to conduct a self-report survey
among 500 respondents, who were first-grade elementary to third-grade high school students, located in the Tohoku or Kanto
regions of Japan at the time of the Great East Japan Earthquake. A confirmatory factor analysis of the CSI-C demonstrated thevalidity of its four-factor structure, and Cronbach’s alpha test indicated the scale to be reliable. Concurrent validity was confirmedwith both the DSRS-C and PTSSC-15. Finally, cutoff values were determined using an ROC analysis, at 21 points for general stressresponse and 12 points for disaster stress response. The CSI-C uses a four-factor system, in accordance with prior theory, and our
findings suggest that it provides sufficient reliability and validity as a measure of stress response in children.
KEY WORDS: comprehensive stress response, children, reliability, and validity

responses, is an essential first step in designing

Introduction
Accurate evaluation of both the peculiar
stressresponse

manifested

inchildrenfollowing a disaster, as well as everyday stressan appropriate support plan for these patients.
Japanese-language

optionsforevaluating

posttraumatic stress responses in children
throughself-report

includethe

CORRESPONDENCE TO: Hiraizumi Tohoku Fukushi

internationally-employed

UCLA

PTSD

University, Faculty of General Welfare, Department of Welfare

Reaction Index for DSM-IV (Steinberg, Brymer,

Psychology, 1-8-1, Kunimi, Aoba-ku, Sendai-city, 981-8522,

Decker, & Pynoos, 2004; rights to the JapaneseJAPAN.

language version held by Hyogo Institute for

e-mail: t-hiraizumi@tfu-mail.tfu.ac.jp

Traumatic Stress), as well as the Trauma

23

24

Hiraizumi et al.

Symptom Checklist for Children (TSCC)

fact that it specializes in PTSD symptoms and(Briere, 1996; Nishizawa, Nakashima, & Miura,

the depression factor; it is potentially restricted1999), which evaluates effects of abuse or otherfromrecurrent trauma on children age 8 to 16. Inreactions.

catchingchildren’s

diversestressaddition to these measures, the Impact of

In regards to the characteristics of stress

Events Scale Revised (IES-R) (Weiss &responses in children following disasters,

Marmar, 1997; Asukai, 1999), which is

Okuyama (2012) reports that children of about

intended to assess PTSD symptoms in adults

8 years or older exhibit a wide range offollowing a single episode of trauma, has also

responses in addition to the typical responses

been employed in studies of children.

seen in adults. This includes responses

Therefore, there is a growing body ofparticular to children (vague feelings ofresearch in Japan regarding measurements ofuneasiness or regression, physical symptoms),

stress in children following disasters. However,and responses outside of those typicallya number of shortcomings have yet to be

associatedaddressed, including a failure to evaluate

accurately measure stress responses in children

reliability and validity in these measures (Saito

following disasters, it is essential that we screen

et al., 2005). For example, the TSCC inventory

for not only the particular response seen inhas 54 items. A 44-item version exists which

PTSD but also generally occurring stressomits items concerning sexual trauma, yet this

responses including anxiety, depression, anger,

still falls short of ideal in terms of ease of

temper, and autonomic symptoms.

with

PTSD.

Accordingly,

toexecution and burden placed on respondents.

It is with these thoughts in mind that we haveSome research has attempted to apply thedeveloped a comprehensive scale of stress

IES-R to children (Asukai, 2006). However,

response in children with the aim to maximize

this inventory is intended as a measure of

the number of factors covered, using a

PTSD

Sufficient

minimum number of items. Our result is theevaluation of data obtained about children

Comprehensive Stress Response Inventory forusing this method has yet to be conductedChildren (CSI-C).

symptoms

inadults.

(Saito et al, 2005); thus, we believe prudence

The CSI, on which the CSI-C is based, isshould be exercised in choosing to apply thiscomposed of two scales, one each formeasurement to children. Post-Traumatic Stressmeasuring general stress response and disaster

Symptoms for Children (PTSSC), which wasstress response (Asai, Morikawa, Hiraizumi,

developed

symptoms,

Usami, & Wakashima, 2013). Following a

includes the eight-item PTSD factor andcatastrophic event, the two scales are employedseven-item depression factor, thereby ensuring

together, whereas in the absence of a disasterminimaleasy

the general stress response inventory is usedapplication. Nonetheless, it is limited by thealone. The disaster stress response inventory is

tomeasureburdenon

PTSD

childrenandComprehensive Stress Response Inventory for Children

25

composed of 8 items and covers 1 factor. In its

and have performed a four-factor analysis ofcreation, careful examination was made of

the new measure in the same manner as Asai etexisting

response.

al (2013). We have further determined cutoff

Established items characteristic of PTSD werevalues to differentiate high-stress individuals

selected for use in the CSI, and additional items

frompertaining to memory were added to theresearch evaluated whether stress response

inventory.

varies based on age and gender.

measuresTheofgeneralstressstressresponse

low-stressindividuals.

Finally,ourinventory is composed of 17 items and covers 3
factors (“anxiety and tension,” “temper andanger,” and “autonomic symptoms”). It is

Methods
Participants and procedures

Surveysintended to evaluate change in the subject’s

were conducted from March 2016 to May 2016.

general stress response over time. Asai et al

Eligible(2013) investigated reliability and validity offirst-grade elementary to third-grade highthe CSI during its design. Wakashima et alschool students located in the Tohoku or Kanto(2016) confirmed cross-validity of the CSI

regions of Japan at the time of the Great East

using confirmatory factor analysis in a study ofJapan Earthquake. A sample of 500 subjects

university students who had not been subjected

was recruited through Rakuten Research, Inc.,

to disaster conditions. The CSI is, therefore, not

an online marketing research company with

only capable of the accurate measurement of

2,279,275 registered users as of September

stress response in subjects who suffered a

2015. Genders and age groups were equallycatastrophic event, but it is also a valid andsampled (for elementary school, 97 boys and 70

reliable measure of general stress response ingirls; for junior high school, 102 boys and 65

the absence of trauma. However, as no surveys

girls; for high school, 102 boys and 64 girls).

of school-age children have been conducted

Self-report surveys were administered via thewith the CSI, it is possible that the factorial

website, and data was collected according tostructure of the CSI differs in children.

the order in which subjects completed andFurthermore, before the CSI is suitable for use

submitted their surveys. Eligibility for thewith children, we believe that item content

survey necessitated informed consent from bothshould be carefully constructed in a way that is

the subject and the subject’s guardian. The

easy

and

subjects themselves responded to the survey

consideration should be given to the reduction

items, with guardian assistance only at theof the psychological burden imposed onrequest of the subject.

forchildrentocomprehend,children when answering the inventory.
To

this

end,

we

have

modifiedsubjects

Basic attributes

were

those

who

were

Subjects were asked about

thetheir age, gender, level of school (elementary,

expressions used in the CSI inventory such thatjunior high, high school), year in school,

children are able to respond to them more easily,

prefecture of current residence, and prefecture

26

Hiraizumi et al.

of residence at the time of the Great East Japan
Earthquake (March 11, 2011).
CSI-C TheAsameasureofcomparison, our study used The PosttraumaticandStress Symptoms for Children 15 items

response options of the CSI were modified to(PTSSC-15) (Tominaga, Takahashi, Yoshida,

be easier for children to respond to. On the

Sumimoto & Kajikawa, 2002). The PTSSC-15

measure of general stress response, theis composed of 8 items to measure for PTSD,

following changes were made: the phrase “Inand 7 items to measure for depression.

comparison with before…” in item instructions

Response options use a six-point scale: 0 =was replaced with “…than I used to.”completely disagree, 1 = mostly disagree, 2 =Furthermore, changes in wording were made topartially disagree, 3 = partially agree, 4 =items 6 (from “I feel depressed” to “I feelmostly agree, and 5 = completely agree, with adown”),

heart

greater number of points indicating a greater

palpitations” to “I feel my heart beating fast”),

degree of posttraumatic symptoms. Koseki,and 17 (from “I feel tense” to “I feel nervous”)

Koseki, Ohtani, & Ito (2013), in order toon the CSI. On the measure of disaster stressexamine PTSD symptoms resulting from theresponse, changes were made to items 7 (fromGreat Japan East Earthquake, referred to the“When I think about the event, the emotions I

survey of traumatic experience in infliction andhad at that time well up inside me” to “When I

receipt of bullying by Tominaga et al (2002),

think about the event, the feelings I had at thatand set the criteria for PTSD symptoms at 19

time come back strongly”), and 8 (from “Ipoints. Our research uses these same criteria.

16

instructions,

PTSSC-15

(from

“I

items,

experience

experience heart palpitations” to “My heart

DSRS-C

Our study also employedbeats fast”). In this study, the phrase “thatthe Depression Self-Rating Scale for Children

event” is assumed to refer to the Great East

(DSRS-C) (Murata, Shimizu, Mori, & Oshima,

Japan Earthquake. Response options were also

1996). The DSRS-C is a depression screeningchanged: “1 = completely disagree” on the CSI

test designed for children, and is composed of

was changed to “1 = not at all”, and “4 =18completely agree” was changed to “4 = very

Respondents are asked about their feelings overmuch.” A phonetic guide was added to all kanji

the past week, and items such as “I feel like I

characters appearing in items and responsewant to cry” and “I feel all alone” areoptions. We consulted with one elementaryself-evaluated using a three-point scale: 2 =school teacher and performed a preliminary

always, 1 = sometimes, and 0 = never. The

survey with 83 students from elementary school,

cutoff value on this measure is 16 points.

middle school, and high school to confirm theitemsmeasuring

Ethical considerationsfordepression.

Before beginningsuitability of these modifications, and thenthe survey, all subjects received explanation

determined validity based on the presence orthat answers to all items were voluntary, thatabsence of missing values.

they could choose to end the survey at any time,Comprehensive Stress Response Inventory for Childrenthat the content of their answers would be

Whenprocessed statistically, and that they would not

adjustments were made within a theoreticallybe individually identified. Particular care waspermissible extent, and we determined agiven in explaining that questions “pertaining

correlation setting among the subfactors. The

to stress and to your disaster experience in the

only adjustments made were to the observed

Great East Japan Earthquake” would be asked,

variables comprising each subfactor in order tothat the subjects were able to discontinue thecompensate for error variables. The model’ssurvey at any time they felt discomfort orlevel of fit after these adjustments was GFIdifficulty in answering a question, and that= .90, AGFI = .86, CFI = .96, and RMSEA

there were no consequences for choosing to= .06, and it therefore met permissible levels

discontinue the survey. Only subjects who

under statistical criteria (Table 1).

expressed their consent and understanding
participated in the study.

settingtheConcurrent validity

error

covariance,

27

our

To evaluate the

CSI-C and its individual subfactors, correlation
coefficients were calculated with the PTSSC-15
and DSRS-C (Table 2). A moderate positive

Results
Data was analyzed using SPSS ver. 19.0 for
Windows and Amos 19.

correlation was observed between the CSI-C
and both the PTSSC-15 and DSRS-C (p < .001

Cronbach’s alphafor both tests). A moderate correlation was also

was calculated for each subscale. Values

observed between the CSI-C’s subfactors andobtained were α = .92 for “anxiety andboth the PTSSC-15 and DSRS-C (p < .001 fortension,” α = .90 for “temper and anger,” α

all tests).

Internal consistency= .82 for “autonomic symptoms,” and α = .94

Basic attributes and correlation with thefor “disaster stress symptoms.” As all factors

CSI-C

demonstrated an alpha coefficient greater

scores or CSI-C subscores varied based onthan .80, we determined that the CSI-C is agender or year in school, we performed an

sufficiently reliable measure of stress response.

independent two-way ANOVA (p < 0.05;

Confirmatory factor analysis

We

In order to evaluate whether CSI-C

between-subjects). The independent variables

performed a confirmatory factor analysis towere gender (male, female) and age group

determine the validity of the four-factor(elementary school, junior high school, highstructure. As for the criteria for screening, we

school). The dependent variables were theused GFI > .90, AGFI > .90, CFI > .90, and

CSI-C scores (four-factor score, three-factor

RMSEA < .10. Our results yielded the following

score, “anxiety and tension” score, “temper andfit levels for the four-factor model: GFI = .79,

anger” score, “autonomic symptoms” score,

AGFI = .74, CFI = .88, and RMSEA = .10. We“disaster stress symptoms” score). This test didthennot show a significant difference.

adjusted

for

error

variableswithconsideration given to the modification index.

Cutoff values

As no significant difference

28

Hiraizumi et al.

Table 1. Results of the CSI-C confirmatory factor analysis (standardized estimate)
F 1

F 2

F 3

F 4

Anxiety and Tension (a =.92)
1. I feel uneasy more often than I used to.

.56
.62
.85
.83
.81
.84
.77
.82
.81

2. I get scared more often than I used to.
5. I feel down more often than I used to.
6. I feel lonely more often than I used to.
9. I feel sad more often than I used to.
10. I get angry at myself more often than I used to.
13. I feel rushed more often than I used to.
14. I find myself with racing thoughts more often than I used to.
17. I feel nervous more often than I used to.

Temper and Anger (a =.90)
3. I lose my temper more often than I used to.

.81
.85
.80
.91

7. I feel angry more often than I used to.
11. I get irritated more often than I used to.
15. I get offended more often than I used to.

Autonomic Symptoms (a =.82)
4. I get headaches more often than I used to.

.72
.76
.64
.81

8. I feel dizzy more often than I used to.
12. My stomach hurts more often than it used to.
16. I feel my heart beating fast more often than I used to.

Disaster Stress Symptoms (a =.94)
18. I avoid things that might make me remember the event.

.77

I try to keep the event out of mind. (I try not to think about it, ignore it, don’t talkabout it, etc.)
20. When I think about the event, the feelings I had at that time come back strongly.
When I think about the event, my body reacts. (My heart beats fast, I have21.
trouble breathing, I start sweating, etc.)
Memories of the event will suddenly pop into my head even when I wasn’t trying
22.
to think about them.
23. I have bad dreams about the event.
24. I have trouble remembering important details about the event.
25. I find myself feeling or acting like I am back at the time of the event.

.78

19.

Interfactor Correlations
F1
F2
F3
F4

.79
.86
.86
.84
.80
.75
F1
―

F2
.83
―

F3
.85
.76
―

F4
.69
.53
.64
―

Table 2. Results of correlation analysis of variables (Pearson correlation coefficient)
PTSSC15PTSSC-15
Depression
Total

－

PTSD

DSRS-CCSI-C three-factor.62***.60***.62***.50***CSI-C four-factor

***

.63

***

.60

***

.64

.50***

Anxiety and Tension.61***.57***.61***.49***

***

***

***

Temper and Anger

.60

.57

.60

.48***

Autonomic Symptoms.53***.53***.52***.41***

***

***

***

.40***

Disaster Stress Symptoms
***

.51

.47

.52

p <.001

CSI-C four-factor represents the total score for general stress response measure and disaster stressresponse
PTSSC-15 : Posttraumatic Stress Symptoms for Children 15 items
DSRS-C : Depression Self-Rating Scale for ChildrenComprehensive Stress Response Inventory for Children29

was observed between age group (by schoolwith a score of 0 to 7 deemed false-positive andlevel) and scores as regards the relationship

8 to 15 deemed true-positive. As a result, thebetween basic attributes and CSI-C, we

negative group was n = 457, the false-positive

considered having one cutoff value coveringgroup was n = 15, and the true-positive groupelementary to high school as age group.

was n = 28.

For the purpose of the ROC analysis, theIn an ROC analysis, a larger area under the

sample was divided into positive and negative

curve

(AUC)

indicates

more

accurategroups based on the applicable measure’s cutoff

identification of true-positives. According tovalue.

Swets (1988), an AUC value of .60 to .75 may

Subjects who scored less than 16 points on

be considered as moderate accuracy, .75 to .90

the DSRS-C were assigned to the negative

as good accuracy, .90 to .97 as excellent

group (n = 394), and subjects who scored ataccuracy, and .97 to 1.00 as ideal accuracy. To

least 16 points were assigned to the positive

determine the ideal cutoff point, we employedgroup (n = 106). For the PTSSC-15, subjects

the Youden Index.

who scored less than 19 points wereassigned to the negative group

The average general stress response score for(n = 457), andpositives on the DSRS-C was 26.49 (SD =those who scored at least 19 points were

9.07), and M ± SD was thus 17 to 36 points.

assigned to the positive group (n = 43).

The area under the curve (AUC = .79) indicatedBecause there are few items related to memory

good identification accuracy. Analysis using theon the PTSSC-15, which is a central element of

ROC curve and Youden Index revealed the

PTSD

ideal

symptoms(relivingtheevent,

cutoff

value

to

be

21

pointsflashbacks), we anticipated the possibility of a(sensitivity .623, specificity .827). Based on

false-positive

thethis cutoff point, the “low general stressfalse-positives from true-positives, we used the

response” group scoring under 21 points was nsame procedure as described by Wakashima,= 366 (73.2%) and the “high general stressHiraizumi, Kobayashi, Asai, and Noguchi

response” group scoring at least 21 points was(2015); items on the PTSSC-15 which mightn = 134 (26.8%).

group.

To

discernsuggest the reliving of a traumatic event or

The average disaster stress response score forflashbacks were identified. These were item 8

the true-positive group on the PTSSC-15 was(“I avoid people, places, or things that might

14.68 (SD = 5.98), and M ± SD was thus 8 tocause me to remember something painful”),

21 points. Here too, the area under the curve

item 10 (“I blame myself; I think bad things(AUC = .77) indicated good identification

happened because of me”), and item 11 (“Iaccuracy. Analysis with the ROC curve andthink about painful things even though I don’t

Youden Index indicated an ideal cutoff value ofwant to”). The total for these three items (from12 points (sensitivity .643, specificity .841).

0 to 15 points) was considered independently,

Based on this cutoff point, the “low disaster30

Hiraizumi et al.

stress response” group scoring less than 12

displayed similar moderate correlations withpoints was n = 407 (81.4%), and the “highthese criteria. Because of this demonstrated

disaster stress response” group scoring at least

correlation with depression and PTSD, we can

12 points was n = 93 (18.6%).

say that the CSI-C

possesses sufficientconcurrent validity.
Review of cutoff values

Discussion

The target of thisThis research developed the CSI-C, astudy was children, which are assumed to differ

comprehensive measure of stress response infrom adults. Therefore, we chose external

children. We adjusted expressions used in thecriteria specific to children, the DSRS-C andCSI to be easier for children to respond to, andPTSSC-15, when considering cutoff values.

confirmed the four-factor structure of the

Our determined values were 21 points formeasure. This discussion will consider thegeneral stress response and 12 points for

relationships between the CSI-C’s factorial

disaster stress response. Cutoff values for the

structure,

concurrent

CSI as shown in Wakashima et al (2015) were,validity and cutoff values. It will also debate

for screening purposes, 25 points for general

the reliability and validity of the CSI-C as a

stress response (in research, 33 points ismeasurement of stress response in children.

recommended when sampling a clinical group

The

with higher stress), and 13 points for disasterinternal

consistency,

Review of factorial structure

results of the confirmatory factor analysis

stress response. Wakashima et al.’s (2016)

demonstrateofadditional survey of university students in“anxiety and tension,” “temper and anger,”absence of trauma did not contradict these“autonomic symptoms,” and “disaster stressvalues. This suggests that the CSI’s cutoff

symptoms” to be valid. Additionally, as thevalues for both types of stress response arealpha reliability coefficient was greater than .80,

stable. Our results in regards to stress response

we can conclude that the CSI-C has sufficientin children following a disaster did notreliability as well. These results correspondcontradict the cutoff values shown in thiswith the four-factor structure observed in adults

earlier research focusing on adults.

thefour-factor

structure

following a disaster and with Wakashima et al

However, our cutoff values for general stress(2016) study of university students who had not

response were significantly lower than thosebeen subjected to a disaster event. Accordingly,

suggested for adults. This may indicate higher

we can say that the CSI-C is a measure

responsiveness in children to items testing forpossessing sufficient factorial validity.

general stress response. In a survey of 395

Review of concurrent validity
CSI-C

demonstrated

moderateThe

students from three elementary schools and one

positive

juniorhighschoollocatedinFukuokacorrelation with the PTSSC-15 and DSRS-C.

Prefecture, the DSRS-C, which was ourFurthermore, the subfactors of the CSI-C

external criteria for general stress response,Comprehensive Stress Response Inventory for Children

31

yielded a positive rate of 9.6% (Murata et al,on adults with language ability as a way to1996). In contrast, our research, which sampledverify the accuracy of CSI-C.

from among children who were in the Tohoku

Moreover, this study is significant in that weor Kanto regions at the time of the Great East

set a cutoff value to discern between high- andJapan Earthquake, yielded a positive rate of

low-stress individuals. Our external criteria

21.2%. In light of this difference between stresswere different from those in Wakashima et alobserved in students within one particular(2015) as our study involved children, but our

school district (Murata et al, 1996) and in

results were in line with previous findings insubjects present in Tohoku or Kanto during theterms of the cutoff value for disaster stressGreat East Japan Earthquake, we must bear in

response.

mind the possibility of difference in our survey

examined using corresponding data from an

and the survey conducted 20 years ago in

actual clinical group.

These

results

shouldalsoberegards to results yielded by the DSRS-C’s

The instructions for the CSI-C disaster stressmeasurements (e.g. “I feel like I want to cry,”,measure take the format of listing disaster“I feel all alone”).

contents relating to stress response. The disaster
contents include not only natural disaster but
man-made disasters (experiences of abuse andConclusions and Challenges
The significance of this research is its
substantiation

of

the

CSI-C’sbullying, traffic accidents, and other specificfour-factor

traumatic experiences) as well. As such, CSI-C

structure. The CSI-C employs a four-factor

can be applied in classrooms where an

structure in accordance with prior research, andemergency has taken place and to assess

it demonstrates sufficient validity and reliability

children’s

as a measure of stress in children. It is capable

Moreover, in cases where there is no specificof gauging both general stress response anddisaster content, the general stress response

disaster stress response. The fact that we could

measure can be used by itself by separating

confirm that CSI-C has the same factor

disaster stress response from that measure, as

structure as CSI for adults suggests that it is awith CSI.

specific

traumatic

experiences.

measure that can be applied to a broad range ofage groups, ranging from children to adults.

Acknowledgements

However, in this study, we do not consider how

This research was funded by the 51st

assessments are affected by the simplification(2015) Meiji Yasuda Mental Health Foundationof CSI items (the possibility that the capacity of

Research Grant. We express our gratitude for

CSI questions to discern different symptoms isthe cooperation of the subjects and staff

reduced). In future studies, it will be necessary

associated with this research.

to conduct examinations using item response
theory or comparisons between CSI-C and CSI

Reference

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Hiraizumi et al.

Asai, K., Morikawa, N., Hiraizumi, T., Usami,T., Wakashima, K. (2013). Development ofComprehensive Stress Response Inventory.
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CounselingStressScienceResearch, 28, 66-73. [in Japanese]

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AssessingComprehensive Stress Response Inventory for Children

33

Appendix 1. Japanese version of Table 1
Results of the CSI-C confirmatory factor analysis (standardized estimate)
F 1

F 2

F 3

F 4

不安・緊張 (a =.92)
1. 前よりも，不安になる.56

2. 前よりも，びくびくしている.62

5. 前よりも，落ち込んでいる.85

6. 前よりも，さみしく感じる.83

9. 前よりも，悲しいと感じる.81

10. 前よりも，自分のことが嫌になる.84

13. 前よりも，焦っている.77

14. 前よりも，考えがまとまらない.82

17. 前よりも，緊張している.81

不機嫌・怒り (a =.90)
3. 前よりも，不機嫌になる.81

7. 前よりも，怒りと感じる.85

11. 前よりも，いらいらする.80

15. 前よりも，不愉快な気分になる.91

自律神経症状 (a =.82)
4. 前よりも，頭痛がする.72

8. 前よりも，めまいがする.76

12. 前よりも，お腹が痛くなる.64

16. 前よりも，ドキドキする.81

災害時特殊ストレス症状 (a =.94)
18. そのことを思い出すものには近寄らないようにしている.77

19. そのことには触れないようにしている（考えない、そう思わない、話さないなど）.78

20. そのことを思い出すとそのときの思いが強くなってくる.79

21. そのことを思い出すと、身体が反応する （ドキドキしたり、呼吸が苦しくなったり、汗が出るなど）.86

22. 考えるつもりはないのに、そのことがいきなり頭に浮かんでくる.86

23. そのことについてよくない夢をみる.84

24. そのことの重要な部分をうまく思い出せない.80

25. 気がつくと、そのときに戻ったように感じたり、ふるまっている

.75
因子間相関
F1
F2
F3
F4

数値は標準化推定値
GFI =.90，AGFI =.86，CFI =.96，RMSEA =.06

F1

F2

F3

F4

―

.83

.85

.69

―

.76

.53

―

.64
―

International Journal of Brief Therapy and Family Science
2018 Vol. 8, No.1, 34-48< Original Paper: Case Report >Advantage of empty-chair dialogue over emotion-focused couples therapy for a Japanese
couple with marital infidelity: A case study
Kenji Yokotani1)
1) Niigata Seiryo University, Graduate School of Clinical Psychology

ABSTRACT. Couples with marital infidelity have received many therapies, but the effective therapies for them were still unclear.
The present case study utilized Emotion-Focused Couples Therapy (EFCT) and Empty-Chair Dialogue Intervention (ECDI) for acouple with marital infidelity and aimed to show advantages of ECDI over EFCT. Our case was a Japanese heterosexual couple withhusband’s infidelity. The husband also had alcohol abuse and bipolar disorder, whereas the wife assaulted him physically. During thefirst 6 monthly sessions, they were peaceful but wife’s physical assault suddenly occurred and interrupted the therapy. During thenext 5 monthly sessions, EFCT was applied for them, but his hypomanic episode and her physical assault disturbed theiremotionally responsive communication during the sessions. During the last 5 biweekly sessions, ECDI was applied for the wife. She
imaginary dialogued with the husband’s extramarital lovers, rather than the husband. During the ECDI sessions, she had been able
to fall asleep during night and her physical assault on him had been disappeared. Even after the three-year follow up since the ECDI
session, her physical assault and his marital infidelity had not occurred. Comparative advantages of ECDI over EFCT werediscussed.
KEY WORDS: Marital infidelity, Empty-Chair Dialogue Intervention, Wife’s Physical Assault against husband, Bipolar disorder,
Emotion-focused Couples Therapy

Advantage of empty-chair dialogue overwere still unclear (Blow & Hartnett, 2005).

emotion-focused

Most of them received the Empty-Chair

couplestherapyforaDialogue Intervention (ECDI) (Paivio, 1999;

Japanese couple with infidelity: A case study
Marital infidelity is a social problem. One

Paivio&Greenberg,

1995)

or

partner’s infidelity injured the other partner’s

Emotion-Focused Couples Therapy (EFCT)

feeling (Halchuk, Makinen, & Johnson, 2010),(Greenberg & Foerster, 1996; McKinnon &increased the injured partner’s risk of major

Greenberg, 2017). However, direct comparison

depression (Cano & O’leary, 2002), and finallyof them was still rare. The present study

ended their marital relationships (Previti &compared the effects of them for a Japanese

Amato, 2004). Couples with infidelity received

couple with infidelity.

many therapies, but effective therapies for them
CORRESPONDENCE

TO:

Yokotani

Niigata Seiryo

Empty-Chair Dialogue Intervention (ECDI)

University, Graduate School of Clinical Psychology, 1-5939,

andEmotion-Focused

Couples

Suidocho, Chuo-ku, Niigata-shi, Niigata, 951-8121, Japan(EFCT) for a couple with infidelity

Therapy

The ECDI, in which a client engages in an

e-mail: yokotani@n-seiryo.ac.jp

34

35

Advantage of empty-chair dialogue over emotion-focused couples therapy

imaginary dialogue with the person sitting in(Narkiss-Guez, Zichor, Guez, & Diamond,the empty chair (Paivio, 1999), was originally2015). Another quasi-controlled study also

from Gestalt therapy (Perls, Hefferline, &found that 7-week group ECDI sessions were

Goodman, 1951) and has been utilized andeffective in reducing traumatic experience andvalidated in many therapies (Pugh, 2016).

avoidant behaviors for wives whose husbands

ECDI encourages clients to access theirwere either killed or missing during the war

previously avoidant memories/thoughts and to(Hagl, Powell, Rosner, & Butollo, 2015).

reconstruct them in the therapy-provided safety

Another longitudinal study indicated the effects

environment (Timulak & Pascual-Leone, 2015).

of ECDI in reduction of depressive symptoms

The ECDI exposes clients to their intense

for individuals who experienced the death ofemotion, which has been avoided for long term

their spouse (Field & Horowitz, 1998). These(Greenberg & Foerster, 1996), so that ECDI isfindings indicated that ECDI could be useful

useful for clients who avoid specific emotions

for the unresolved issues with significant other.

for long term, such as those with posttraumatic

Marital infidelity can cause an unresolved

stress disorders (Steenkamp et al., 2011).

issue

with

significant

other

in

marital

ECDI is especially effective for people who

relationship. One partner’s marital infidelity

had unresolved issues with significant other,

injured partner’s feeling (Halchuk et al., 2010)

because they had continued to avoid theirand increased the injured partner’s risk of major

primary emotions about the issues (Steinmann,depression (Cano & O’leary, 2002). These

Gat, Nir-gottlieb, Shahar, & Diamond, 2017).

findings indicated that the injured partner couldOne

reported

have lingering unresolved negative feeling,

comparative efficacy of ECDI for community

such as anger, with their partner (Johnson,

sample who had lingering unresolved negative

Makinen, & Millikin, 2001). Actually, several

feeling with the significant other, such asindividuals reported unresolved issues with

ex-partner, from the past (Paivio & Greenberg,

their romantic partner who did infidelity1995). Those who received 12-week ECDI

(Narkiss-Guez et al., 2015; Paivio & Greenberg,

sessions

randomly

controlled

reducedtheir1995). One case study also utilized the ECDI

resolved

theirfor a husband whose wife had extramaritalunresolved issues than those who received

affairs (Paivio, 1999). These findings indicate

12-week psychoeducation sessions about thethe applicability of ECDI for marital infidelity.

interpersonal

unresolved

significantly

trial

distressissues.

andAnother

randomized

Based on the ECDI findings, EFCT wascontrolled trial also found that single ECDI

developed for couples with infidelity, where thesession was more effective in reducing theoffending partner repetitively apologizes about

anger for university students who had persistent

one’s misconduct and the injured partner finallyanger toward their significant other than single

forgives his misconduct (Greenberg, Warwar, &emphatic listening session regarding their anger

Malcolm, 2010). The EFCT is effective if

36

Yokotani.

couples meet following two conditions: (1)2017) studies: The applicability of EFCT and

offending partner expresses their vulnerable

ECDI for couples with these severe problems isemotion&unclear. Clarification of these three points

Greenberg, 2017; Meneses & Greenberg, 2011,

could extend the clinical scope of EFCT and2014): (2) the injured partner also forgives the

ECDI to an East Asian couple with multiple

partner’s misconduct (Halchuk et al., 2010). Yet,severe problems. Hence, our research question

satisfaction of these two conditions is not easyis that Are ECDI and EFCT effective for a

for many couples (Greenberg & Foerster, 1996).

Japanese couple with marital infidelity, alcohol

Forgiving extramarital affair was still the mostabuse, marital violence, and bipolar disorders?

difficult task for couples(Kluwer & Karremans,

To answer this research question, we utilized2009). Hence, therapy effects of EFCT oncase study for a detailed description of ECDI

marital infidelity are still limited (Blow &and EFCT on the Japanese couple with these

Hartnett, 2005; Wiebe & Johnson, 2016).

problems. ECDI findings were more robust

to

their

partner(McKinnon

regardingexperimental

designsthan

EFCT(Paivio & Greenberg, 1995), so we

Aims of the present study
Previous study showed the effectiveness ofhypothesized that ECDI would be more

ECDI and EFCT for couples with maritaleffective for a Japanese couple with theseinfidelity (Greenberg et al., 2010; Paivio &problems than EFCT. Our case study involves

Greenberg, 1995). However, direct comparison

four stages. The first stage aims to build coupleofsoalliance and therapeutic alliance as foundation(dis)advantages of ECDI over EFCT are stillof couple therapy (Timulak & Pascual-Leone,

unclear. Further, the effectiveness of ECDI and2015). The second stage applied EFCT. The

EFCT were mainly confirmed in Caucasian

third stage applied ECDI. Although previous

couples (Greenberg & Foerster, 1996; Hagl etstudy of ECDI focused on actual injuredal., 2015). Marital infidelity patterns werepartner (Paivio, 1999), we focused the partner’sreportedly different from European to East

extramarital lovers, rather than the partner. This

Asian couples(Moore, 2010; Schmitt David P.,

is because physical violence from her to him

2004). Hence, the applicability of ECDI and

was severe so that we need to divert the target

EFCT for East Asian couples is also unclear.

of her anger from him to other individuals. The

Moreover, couples with alcohol abuse, marital

final fourth stage is follow-up sessions for 3

violence and bipolar disorders were excluded

years.

ECDI

and

EFCT

was

rare,

from the sample in EFCT (Greenberg &Foerster, 1996; McKinnon & Greenberg, 2017;

Case Description

Meneses & Greenberg, 2011) and ECDI (Field

Basic information& Horowitz, 1998; Narkiss-Guez et al., 2015;

Identified patient and client (January X

Paivio & Greenberg, 1995; Steinmann et al.,year): Identified Patient was a husband who

37

Advantage of empty-chair dialogue over emotion-focused couples therapy

was 31 years old and worked for a sake brewer.

uterine fibroids but gave birth to her son.

Client was his wife who was 43 years old andDuring her second pregnancy (August X-1

housewife. They had a son aged 5 years oldyear), she became anemia and decided towith Autism spectrum disorder. They lived inabortion. She had never been pointed out any

the P city of Hokuriku district in Japan since

special problem so far.

their marriage (X-9 year). The wife’s parents

Problem history: In X-4 year, the husband

had a large house and land so that their house

had an affair with the married woman (referred

was in the garden of the parents’ house.

to as C) in his neighborhood. He repetitively

Main agenda: The wife wanted to talk aboutcame back to home at early morning so his

her husband’s extramarital affair, whereas theneighborhood rumored about him. Finally, his

husbandhiswife detected his extramarital affair with thealcohol-related problem. During initial session,

woman. She smashed the husband several times.

main agenda was inconsistent between the wife

In June X -1 year, the husband failed the examand husband.

in the brewery company. In September X-1 year,

wanted

to

talk

about

he suddenly yelled at his child, which had
Case history

never been occurred. He also drank daily until

Family history: The husband’s mother was

3 o’clock in the morning. In November X-1

the last stage of stomach cancer (died in July X

year, the husband and wife received oneyear). His father also had extramarital affairs

therapy session in a local Q hospital. He waswhen the father was young. Both of theirdiagnosed as bipolar disorder type II withparents and sibling lived in the P city so they

hypomanic episodes. During the therapy, hefrequently met with each other. For example,

said to her wife that "I do not like you!" and "I

the wife’s sister visited a hospital to see the

do not need you!" After the therapy, theyhusband's mother.

decided not to visit the hospital again because

Life history: The husband lived in the P city

his friend worked in the same hospital despite

until his high school days and lived alone inof their positive attitudes to the therapy. After a

Kanto area during his college days. After hewhile, the wife found that the husband bought a

had graduated from his university, he returnedring to give to his extramarital lover andto the P city, worked at the sake brewing

pointed out it to him. He stopped giving thecompany, and got married. He had never been

ring to the lover but presented the same ring topointed out any particular problem so far. The

the wife. When she had not used the ring, hewife also lived in the P city and had never leftgot

the P city. After graduating from her university,

recommended by a local health nurse who

she was doing a few jobs. After marriage, shemainly care about their son, they visited an R

quitted her job and became a housewife. Duringhospital. A psychiatrist said that the husband

her first pregnancy (X-6 years), she became

had no problem and would recover in short. Yet,

angry.

In

December

X-1

year,

38

Yokotani.

in December X-1 year (before New Year's Day),use”. Wife said that “If he returns to thethe husband's brother, the wife's brother, andprevious status, I like to continue mythe husband's friend witnessed a scene whererelationship with him”. The husband said thatthe husband goes to a hotel with another“I do not know how to return to the previous

woman (referred to as B) by chance. With thisstatus. I am nearly forgiving up relationshipincident trigger, his friend also reported thewith her”. Although they fought every day, theywife about his extramarital affair with anotherconfirmed that they cooperated to come here

woman (referred to as A). The wife could notwithout fight. The therapists asked them tocontrol her anger and had continued to smashcome here again, because their communication

the husband for several hours. He had been

to come here was cooperative without fight.

receiving her punch without any counterattack
for the hours. Since then, he frequently reported

Therapy Process

lots of things to her. In January X year, the wife

Stage 1: Building Couple Alliancealone visited author’s therapy center and

The first case formulation: Any topic could

another therapist met her. Although her friends

produce their fight except for the topic about

and family members recommend her to divorce,

couple therapy. Hence, first stage tried toshe did not want to divorce because of her childdecrease their fight, to increase cooperativeand money. She knew the days when her

communication, and to build couple alliancehusband was good, so she wanted to continue

between them (Bodenmann, Hilpert, Nussbeck,her marital relationship with him as far as she& Bradbury, 2014). After the couple built

could. Her husband was also positive aboutalliance, the therapy can set their main agenda

couple therapy. Then they started to receive

consistent between the husband and wife. In

monthly couple joint therapy in charge of theaddition,

author. The husband has received medication

therapeutic alliance with them, which was(lithium carbonate and Olanzapine) for his

foundation of many psychotherapies (Paivio

hypomanic episode from the S hospital since& Greenberg, 1995; Timulak & Pascual-Leone,

March X, but the wife did not receive any2015).

medication.

thetherapists

aimed

to

build

#2(February X year): Compared to previous

Initial session [#1] (February X year):session, the wife and husband had eye contact

During couple joint session, they had no eyewith each other. Actually, they went out in thiscontact with each other so that they had a longweekend with their son. Still, the husband

silence to change their turn. The wife liked tosometime said at home that "I am working hardtalk about his extramarital affair in the therapy.

for the child, but not for you." She also said

However, the husband said "I did an affair, but Ithat she could not trust him because he was

do not feel any guilty. The extramarital affair is

nice to her in the therapy room but arrogant tolike a game." ”I like to talk about my alcohol

her in their house. The couple communication

39

Advantage of empty-chair dialogue over emotion-focused couples therapy

seems to be better than the initial session.

can take time for extramarital sex!" Then, she# 3(March X year): The husband said that

asked about how he cheated up until 3 and 4

marital relationship became peaceful. The wife

o’clock in the morning. The husband tried toacknowledged her peaceful marital relationshipanswer at the beginning of discussion, but hewith him, but she was anxious about how longcannot see the end of the discussion, his

this peaceful relationship continued. Both ofsleepiness won, and finally he said "I do notthem liked to talk about “peaceful life in theirknow" "I forgot" and ignored her questions

family (including the husband, wife and son)”suddenly. Then, the wife’s frustration had morein following session. Their main agenda

accumulated. The husband also did little work

consistent between them was decided as “theduepeaceful family life”.

communication was too much in the couple so

to

lack

of

sleep.

Destructive#4(April X year): Couple was mostly

the therapists intervened in the communication

peaceful, but they had a fight one time and she

and proposed to restrict their time forsmashed him during driving. The therapists

discussion within an hour per day. Further, theirnormalized their fight.

intervention is necessary to prevent escalating#5(April X year): The husband drank alcohol

their fight to severe physical violence. The

even though he pledged to quit alcohol in front

husband accepted their proposal, but the wifeof her. During his drunk, he made a pass at a

got angry. The wife’s anger exploded suddenly

woman. Even after he became sober, he did not

and damaged their marital communication.

stop making pass at the woman, because he did
not want to miss the opportunity to have a sex
with her. The wife said “I cannot understand themeaningof

youropportunity!”

Interruption period
After the sixth session, they had madeHis

appointment monthly, but they cancelled thealcohol-related relapse triggered his fainting,appointment the day before the therapy. Theirrough attitudes, and their fight.

cancels continued from July to August X year.

#6(May X year): The first half in the April

During these months, husband’s mother andwas peaceful, but the second half got worse foruncle passed away one after another so theyboth husband and wife. During the second half,

were actually busy preparing for funerals andthe husband started to counterattack to his

could not come to the therapy. Still, theirwife’s smash. When their son fell asleep aroundcancellation was also repeated in middle of the

11 o'clock, the wife every day started to ask the

September. Hence, the therapists supposed thatreason why he made marital infidelity. He

the wife had hostility toward the therapists who

responded to her for an hour and tried to go to

did not understand her anger. Therapists madebed because of the next day's work. Then, she

appointment with her via telephone andbecame angry and said "Why you cannot takereported that they felt sorry that they did nottime for our communication even though you

help her nicely. Then, they revisited the therapy

40

Yokotani.

center.

Greenberg, 2017). When the wife satisfied withemotionally responsive couple communication

Stage 2: Emotion-focused couples therapy

about the husband’s infidelity, the number of(EFCT)

her unresolved issue about the infidelity would

The second case formulation: The first stage

decrease and finally resolve (Figure 1)

focused cooperative couple communication, but#7-#8(November X year): The wife's anger

not wife’s unresolved issues caused by her

exploded again because she recalled thehusband’s infidelity. To treat her unresolved

November X-1 year where his marital infidelity

issue, we utilized EFCT (Figure 1). The second

was repeated. When her heart felt rough, she

stage aimed to increase husband’s expression of

kept hitting her husband for 1-2 hours. Her

vulnerable emotion and to produce her

hitting and rough feeling lasted 3 days and one
week, respectively. She said “My husband does

forgiveness on his infidelity in the context of

not understand anything though I feel such aemotionally responsive couple communication

suffering.” He said that he liked to be patient(Greenberg

for her smash because the smash was caused by

et

al.,

2010;

McKinnon&Note: Y and N represent Yes and No, respectively
Figure 1 Wife’s unresolved issues with her husband’s marital infidelity and emotion-focusedcouple therapy approach

Advantage of empty-chair dialogue over emotion-focused couples therapy

41

his infidelity. He also appreciated her every

intervene in her aggression directly. Therapists

day’s work in house. The husband tried to keep

empathetically listened to her emotion to calm

calm, but the wife did not. Her anger on his

down her aggression and to stop her physicalmarital infidelity was under-regulated again.

violence indirectly.

Although therapists noticed her aggression#9(December X year): Their fight occurredagainst him was severe physical violence,in front of their son so that the son had started

therapist intervention on her aggression failed

to suffer nightmare since the fight. The husband

in the last session (#6), so therapists did nottried to select his word before he spoke

Note: Y and N represent Yes and No, respectively
Figure 2 Wife’s unresolved issues with her husband’s marital infidelity andempty-chair dialogue intervention

42

Yokotani.

especially when he was angry. He said “Thethem.

past is the past. We like to live peacefully infuture.” Still, the wife did not forgive his past

Stage 3: Empty-chair dialogue intervention

and could not imagine peaceful future. The(ECDI)

husband and wife had a big gap in their

The third case formulation: We thought thatrecognition about his infidelity. Although

EFCT did not fit well with this couple because

therapists noticed their fight in front of theirof two reasons. First, the husband had beensontherapist

received physical and psychological violenceintervention on her aggression failed in thefrom his wife, so he had difficulty to express

previous session (#6), so therapists did not

his weakness in front of her, since his weakness

intervene in their fight directly. Therapists

might be a target of her attack. Second, whenempathetically listened to their emotion to calm

he became hypomanic, he said “All what I said

down their aggressions and to stop their fightin the therapy is a lie” so that the wife cannot

indirectly.

trust his words in the therapy and could be

ispsychologicalviolence,#10(February X+1 year): The wife remindeddifficult to forgive him in the therapy.

that the husband concentrated on TV andTo overcome these limitations, we utilized

comics too much to care his son, so she started

ECDI for the wife and encouraged her

to attack him in the therapy room. When she

imaginaryheated up, he turned to pale. Her repetitive

extramarital lovers, rather than the husband

violence to him might shrink his feelings. His(Figure 2). During her imaginary talk with thehonest expression of his feelings in front of her

lovers, her anger could focus on the lovers,

might be difficult.

which could reduce the risk of her violence on

dialogue

with

her

husband’s#11(May X+1 year): The wife became

him. Furthermore, she could express her

anxious about her son’s school life, because his

uncontrollable anger as she liked (Paivio, 1999)

classmates might tease him because of his

regardless of his hypomanic mood. When thefather’s marital infidelity. When she thoughtwife is satisfied with aggressive

about the son’s future, she thought “Everythingcommunication with her husband’s extramarital

had no value”. On the other hand, the husband

lovers, the number of her unresolved issue

said that he could enjoy weekends so he did notabout the husband’s infidelity would decrease

feel any problem. After the last session, heand finally resolve (Figure 2). For ECDI

became hypomanic and said “I tell a lie in thesession, therapy structure was changed. The

couple therapy. All what I said in the therapy is

first 40 minutes was for wife’s individual ECDI.

a lie”. The wife’s and husband’s expectation

The last 10 minutes was for couple joint session

about their family was different from each other,to confirm the effects of ECDI and to keep theso that the therapy needed to reset another main

husband to be cooperative with her. The

agenda, which would be consistent between

therapy also held biweekly.

Advantage of empty-chair dialogue over emotion-focused couples therapy

First picture (3-1)

Second picture (3-2)

43

Third picture (3-3)

Figure 3 Wife’s drawing pictures regarding her husband’s extramarital lover#12(July X+1 year): During ECDI, shemarital affairs to your ex-partner. I will show

started to attack the woman A verbally. Whenhim your affairs." Then, she would ask the wife

she stopped her verbal attack on A, theto forgive her for paying, but the wife would

therapists said “Your anger is not such a small

not forgive her. "I will never forgive yourdegree. Please show your anger more.” andmisconducts. I will inform your husband about

encouraged her to continue to attack her inyour affairs. You will be receiving domesticorder to treat her unresolved issues with A. She

violence from him. Then you have been kicked

said "Yankee who lives in the town" "I feel likeout from his house and you will die on the

I've been caught for a long time by you" "Istreet. Die!" She also expressed her anger

want you to avoid us" "I do not want you to see

toward B.

us even for one second" "You cannot#13(August X+1 year): The wife had a goodunderstand us because you are stupid." "Idiot issleep after a long time. The husbands alsopoor thing. Can you understand the meaning ofregarded that she calmed down. Her expression

idiot? This idiot (lol)" She expressed her strongof anger in ECDI could work in this couple.

anger toward A. She also started to attack the

She was satisfied with her expression toward A

woman B who aged 20’s. She had 5 or 6

and B so she started to imagine the woman C.

extramarital affairs even though she had a child.

She was the wife’s sister's colleague. She had

The B would say "Marital infidelity is notdone bad things always and been familiar withalways from me. Your husband is also bad".

extramarital affair since her school days. The

Then, the wife said “You are always flipping”

wife asked her to stop approaching her husband,"You are absolutely wrong regardless of otherbut she did not quit. Even though therapists

men’s behavior." "You seem to be hiding

asked the wife to have imaginary dialogue with

44

Yokotani.

her, she did not.

picture on C (Figure 3-3). The attack on C was#14(August X+1 year): The wife could sleep

going well. The attack was also translated into

well. The frequency of couple fight was also

language, such as "die”, “dirty”, “stupid”,

decreasing. During ECDI targeting the woman“your Japanese language is strange”, “sick”,

C, the wife talked to the therapists rather than C.

“crazy”, and “hell" (Figure 3-3). After she“She has children, so I cannot get angry withfinished drawing, she said “my angers on A, B,

her.” “I am not good at her. So I cannot get

and C were completed.” After this session, theangry.” Then, finally, she said “Perhaps, I wastherapy structure was restructured as to be abad (rather than her).” The therapists intervened

monthly joint couple therapy.

in the imaginary dialogue and said “It is
impossible that you are bad. This case is 100%

Stage 4: Three-year follow up

bad for C, so please be angry with C”. Still, she#17-21(from October X+1 year to March

did not express her anger toward her, andX+2 year): The husband tried not to meet A

finally told “It is difficult." ECDI targeting C(Yankee). The B’s house was his commuting

might not work for her.

road, so he decided not to use the road. When

#15(September X+1 year): The frequency of

the wife got to meet C by chance, she recalled

their couple fight on marital infidelity became

the bad memory and asked the husband about

only one time per month. The fight also lasted

his past extramarital affair. Then he answered it

only 10 minutes. She continued to have good

calmly. Therefore, they discuss recently, but thesleep during night. During the wife’s individual

discussion never developed into a fight. The

session, we asked her to draw picture about thetherapists proposed the end of couple therapy,

Woman C, instead of ECDI. The first picture

but they liked to continue the therapy. Hencewas simply painted with black crayon (Figure

follow-up sessions were conducted around3-1). We asked again to draw C. Then, she drewbimonthly.

a colorful figure. Then, we asked her to attack#Follow-up sessions (from September X+2

C. When she stopped the attack, we asked heryear to September X+4 year): The therapists

to continue to attack the woman until there ishave been following up the couple for three

no space in the paper. Figure 3-2 shows theyears and have not confirmed any special

final version of the second picture. The C’s

problems since the ECDI sessions. The agenda

neck was cut by her favorite son. She alsoof their couple therapy is mainly about school

entered in a tomb. The tomb had graffiti andsupport for their son with Autism spectrum

bird droppings. The tomb smelled around. After

disorders. During follow-up, couple requested

she finished drawing, she made a smile andcompensation

said "It's funny." The therapists told "This is ahusband's extramarital sex partner. Even thoughvery tasty picture" and laughed together.

the sex partner and her lawyer took a#16(October X+1 year): She drew the thirdfordamagesagainstthehigh-pressure attitude to them, the couple

45

Advantage of empty-chair dialogue over emotion-focused couples therapy

successfully responded and succeeded in

especially expressed less vulnerable emotions

receiving the consolation fee.

(such as fear and sadness) to their wives thantheir wives expressed to them (Safdar et al.,2009). When therapist implements EFCT for

Discussion
The present study compared the effect of

this couple, husband’s expression of his

ECDI and EFCT for a Japanese couple withvulnerable emotion is essential (Field &maritalHorowitz,

infidelity,

alcohol

abuse,

marital

1998;

Hagl

et

al.,

2015;

violence, and bipolar disorders through a caseNarkiss-Guez et al., 2015; Paivio & Greenberg,

study. As hypothesized, ECDI were more

1995): His emotional expression is a key in

effective for the Japanese couple with marital

many couple therapy (Snyder, Mangrum, &infidelity and multiple severe problems thanWills, 1993). However, Japanese husband’s

EFCT.

different

expression of his vulnerable emotion isrequirements during therapy sessions between

culturally restricted (Safdar et al., 2009). Hence,

EFCT and ECDI. EFCT in this case requires

Japanese couple with husband’s extramarital

the husband to express his vulnerable emotion

sex might be difficult to apply EFCT, eventoward her and the wife to be patience tothough the couples with husband’s extramaritalforgivesex were dominant in Japan (Moore, 2010).

This

his

might

be

maritalfrominfidelity

duringsession(Halchuk et al., 2010; McKinnon &The ECDI also could be useful for distressed

Greenberg, 2017; Meneses & Greenberg, 2011,

couples2014). In contrast, ECDI only requires the wife

disorders were significantly correlated withto imagine her husband’s extramarital lover

marital distress (Whisman, 2007). Spousal(Paivio & Greenberg, 1995). Comparison of

hypomanic episodes sometime ruins whatthese requirements between EFCT and ECDI

couple has built up until then. In our case, thesuggest that couple feel easy to receive ECDI

husband said to his wife “All what I said in therather than EFCT (Greenberg et al., 2010;

therapy is a lie”. After listening to these words,

McKinnon & Greenberg, 2017; Meneses &she could not trust his words in the couple-joint

Greenberg, 2014). Hence, ECDI’s applicability

therapy and the impact of the therapy on theirfor couples might be greater than EFCT. In

coupleother words, couples who are not applicable toEffective therapies for family with bipolar

EFCT could be applicable to ECDI, but not thedisorders frequently separated the family

other way around.

members from the patients with bipolar

Further,Japanese

cultures

might

have

disorder,withbipolarrelationshipalthoughdisorders.

could

the

be

Bipolarminimized.

patient

receive

negative effects on implementation of EFCT.

medication individually (Geddes & Miklowitz,

This is because Japanese couples reportedly2013). In line with these therapies, ECDI

showed less emotion than Caucasian couples

separate the wife from the husband with bipolar(Safdar et al., 2009). Japanese husbands

disorder. ECDI might be effective for spouses

46

Yokotani.

who suffered from both their partners’ bipolar

their partner’s lover also could treat theirepisodes and marital infidelity.

uncontrollable anger and reduce the risk of

However, our study has limitations regarding

their physical assault on their partner. Actually,

academic and clinical methodology. First, ourafter the ECDI in our case, wife’s violence

study

the

against her husband was disappeared. Previous

generalizability of our findings was limited.

study reported effectiveness of ECDI with a

Further, we did not control the effects of order.

few

The order of session (ECDI first or EFCT first)

Greenberg, 1995; Pugh, 2016). Accumulation

might have different treatment effects on ourof ECDI evidence for couples with marital

couple. Future study needs more couples andinfidelity could propose an effective therapy

randomized research design. Second, our caseplan for couples with marital infidelity andalso missed risk management of family

contribute to reduce their suffering.

wassinglecase

designso

evidence(Paivio,

1999;

Paivio&violence during EFCT sessions. Actually, wife’s
physical violence against her husband andAcknowledgement

couple’s psychological violence against their

We would like to express our deepestsons frequently occurred during the sessions 7,

gratitude to the couple who accepted this case

8 and 9. To stop these kinds of violence,

presentation. We also would like to thanktherapists needed an earlier decision to change

Professor Keizo Hasegawa and Doctor Tai

theirinterventions.

Kurosawa for their clinical and academic

Incidence of family violence should becomments on our case. Part of our study wasconsidered more severely in future case studies.

orally presented in the Japan Association of

Despite these limitations, this study is the

Family therapy 34th Annual meeting in Tsukuba,

first approach, at least our knowledge, toand the National Foundation of Brief Therapy

compare the effect of ECDI and EFCT for a

9th Annual meeting in Fukuoka.

caseformulation andJapanese couple with marital infidelity andmultiple problems including bipolar disorder,

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