INTERNATIONAL JOURNAL OF STRUCTURED ASSOCIATION TECHNIQUEAn Electronic Journal of Social Skill, Counseling and Imagery Therapy

NUMBER

3 − DECEMBER 2009

CONTENTS

1.

Long-term prognosis of psychogenic visual disturbances (PVD) in children
following SAT therapy
Noriko Higuchi and Tsunetsugu Munakata ・・・・・・・・・・ 1

2.

Reconstructing Life and Society with SAT Therapy:Foundations of the New

Generation CBTTsunetsugu Munakata ・・・・・・・・・・ 35

3.

Comparative examination of the effects of the SAT-DVD Learning Program
Therapy and the Qigong (the traditional Chinese breathing exercise) Therapy to
alleviate stress in cancer survivors
Noriko Higuchi, Kazue Nakashima, Kiriko Murakami,Ryoichi Obitsu,
and Tsunetsugu Munakata ・・・・・・・・・・ 61

International Journal of Structured Association Technique No.3

Long-term prognosis of psychogenic visual disturbances (PVD) in children
following SAT therapy

Noriko Higuchi and Tsunetsugu Munakata
Department of Human Care Science, Graduate School of Comprehensive Human
Sciences, University of Tsukuba
Correspondence: n.higuchi@jcom.home.ne.jp, munakata@hcs.tsukuba.ac.jp

Abstract
OBJECTIVE:

This paper aims to (i) evaluate long-term prognosis of PVD after

Structured Association Technique therapy based on recurrence rate and changes inbehavioral characteristics, and(ii) elucidate the factors that play a role in therecurrence of PVD.
METHOD:

The targets of this study were 17 cases diagnosed with PVD. Tenchildren who recovered under SAT therapy (SAT) and 7 children who recovered underconventional therapy (C.T.) Their parents agreed to participate in the study andcompleted the self–administered questionnaire. The follow up survey for the medium-term
prognosis study was conducted in July 2002, while the long-term prognosis study was
implemented in July 2004.
RESULTS:The following findings were obtained. 1）Recurrent numbers for eachmethod of therapy was 2 out of 7 patients (28.6％ ) in the conventional-type therapy
group at the medium-term prognosis observation time point, whereas it was one case outof the 10 subjects (10.0%) in the SAT therapy group.
significant difference noted.

There was no statisticallyAt the long-term prognosis observation time point, visualInternational Journal of Structured Association Technique No.3

1

disturbance recurrence was seen in 1 out of 5 patients in the conventional-type therapy
group, whereas recurrence was not seen in the SAT therapy group.

Therefore, in bothgroups a significant difference in visual disturbance recurrence was not seen even at thelong-term prognosis observation time point.

In the SAT therapy intervention group,scores of self-repression, emotional dependency, and trait anxiety that improved soonafter intervention remained low even though there was a slight increase at the long-term
prognosis observation time-point. Similarly, scores of self value and degree of awarenessof mother’s emotional support similarly remained high, though there was a slight drop.
On the other hand, scores of self-repression, self-esteem, trait anxiety, and perceived
emotional support hardly changed in the conventional-therapy group. In the PVD
recurrent cases, it was confirmed that anxiety,self-repression, and emotional

dependency were high though an improvement was temporarily seen, and self-value anddegree of awareness of mother’s emotional support were low, thus accompanying achange in psychological characteristics.
These results suggest that since psychological conflicts were behind the outset of
PVD, therapy should not focus on resolving superficial issues such as visual disturbance,but should involve psychological interventions to find solutions to observed psychologicalconflicts.

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1. Introduction
1.1

Aim
Psychogenic visual disturbances (PVDs) cause abnormal visual performance. For

many years its cause was unknown, as was the explanation for the resulting poor vision.
The incidence in pediatric ophthalmology patients is reported to be approximately 1%(Yokoyama, 1999) 1) .

Recent development of imaging diagnostic technology has enabled

the identification of reduced blood flow to the visual association area as a cause of PVD(Okuyama, Kawakatsu, Wada & Komatani, 2002) 2)
Somatization disorders such as those seen in children with PVD, arise as a result ofstress revealing itself as a functional disorder of the body or a transformation of the
conscious mind, without the patient being aware of it.

Such disorders are often seen inchildren whose body and mind have not properly differentiated 3) .

These children aresaid to have the tendency to relieve stress by converting it to a physical symptom rather
than finding a solution psychologically, perceiving stress as stress 4) .
The present authors have so far reported that children with PVD have stressful
psychological characteristics such as a low self-esteem, high anxiety, and show
self-repressive and emotional dependency characteristics 5) .

It is widely known that such

psychological characteristics accumulate stress, easily cause worry and anxiety, andtrigger psychobiological reactions (interactive reactions involving the autonomous
nervous system, endocrine system and the immune system) 6) due to suppression offeelings and desires without expressing them.

Therefore it was thought that thephysiological characteristic of building up stress influences the onset of PVD throughsuch mechanisms.
Research reports relating to long-term prognosis of PVD are scarce, with only a few
that center on eyesight observations 7-9) and extremely few case reports 10) .

International Journal of Structured Association Technique No.3

There are3

hardly any reports on detailed long-term observation through active psychologicalintervention.

The various therapeutic approaches to PVD are mostly psychologicaleducation and advice 11)-12) .

Conventionally, psychotherapies for PVD used approaches

that tried to reach memories and experiences of psychological trauma in early childhood.
However, many evidences which memories of latent psychological trauma experienced in
the fetal stage are recently being revealed. Then,in the present study, a prognosis
evaluation will be conducted using a new psychological intervention that tries to approach
memories of latent psychological trauma experienced in the fetal stage.

This paper

aims to (i) evaluate long-term prognosis of PVD following Structured Association
Technique therapy (SAT) 13) based on recurrence rate and changes in behavioral
characteristics, and (ii) elucidate the factors that play a role in the recurrence of PVD.

2. Method
2.1 Subjects
The targets of this study were 23 cases diagnosed with PVD at A University Hospitalfrom April 1999 to March 2003; subjects with organic symptoms were excluded.

The

chosen subjects did not show improvement of eyesight during the observation period of atleast two months or more prior to intervention and included cases with psychogenic
abnormal visual fields and abnormal color vision. The subjects who finished theirtreatments

at least one year

before were recruited for this study. Informed consent

was obtained from patients and parents prior to participation in the study.

2.2

The method of intervention and treatment termination criterion

2.2.1 Intervention by SAT therapy
Conventional psychotherapy focuses on unresolved issues from early childhood andInternational Journal of Structured Association Technique No.3

4

tries to raise awareness of the issues that reconstitute the mental attitude 14) .

Recently

Van den Bergh et al. 15), in their fetal programming hypothesis, reported that the degree ofanxiety of the mother in the early gestation period is likely to hinder brain development of
the baby and that this degree of anxiety correlates with childhood ADHD and height ofanxiety 16) .

They described that when the mother’s degree of anxiety is high during thisperiod, the mother’s cortisol has an effect on the baby through the placenta and may
affect development of the HPA system, limbic system, and prefrontal cortex 17) .

In SAT

theory, it thought that the presence of such pre-birth trauma makes it easy to draw out
image memories accompanying aversion system affects, and that these mutual influences
cause misinterpretations in reality perception.

Thus SAT tries to work on memories offetal life and infancy using emotions and body sensations as clues.

Image memories ofthe fetal period that are unperceivable during normal consciousness are aroused using
hypnosis-mediated fetal stage image induction from fetal sensations while expressing theemotions.
The main technique used in SAT therapy is to modify the self-image script.
Hypothesizing first that through flashback on past problems the client is currently awareof, SAT tries to identify those negative experiences of the past.

Then, in order to findpositive meaning within the associated negative images, image script formation is done
through re-learning, re-talking, re-imaging, re-acting and physical contact.

As a resultof these, SAT aims to secure a new self-image. These are several reports that a brain
activation

which is related to imagery

similar to actual experiences

was evident .

Therefore, a similar consequence is obtained when imaging and when actuallyexperiencing the same experience 18) .

Thus SAT therapy considers the formation of adetailed and vivid image to be highly important.
In order to achieve this, SAT therapy centers on approaching latent,

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unconscious traumatic memories in the child, changing the images associated with thenegative feelings, and forming a reassuring image.

Specifically, SAT (i) grasps strong

traumatic feelings (terror of being abandoned, self-denial, sadness and sorrow) that thechild is currently aware of, elucidates the voice within that expresses those feelings,
clarifies the key circumstances that are common to these situations, and promotes thechild to image such that the emotions of traumatic scenes of the past are temporarily
awakened; (ii) during the emotion awakening, the child is made to recall images of the
fetal period and infancy, including physical sensations; (iii) from the drawn out sensations,the child is helped to realize latent emotions and wants, and a desired scenario such as“what he/she really wanted” is created. Based on this scenario, a role-play is performed
to change the images to parental images that the child considers to be soothing, andimages of parents welcoming the pregnancy and delivery. At this time the therapist
creates an image that satisfies the desire and craving for affection and employs thesomatic communication method (physical contact method) with the child.
The method implemented in this study sets specific action goals for finding
solutions to actual problems the child faces at the moment, conducts a rehearsal taking
practical use of social skills, and assists the mental and physical growth of the childhimself by actively supporting the solution of the real issues behind.

This is done byenhancing the feelings of efficacy attained through solving problems by oneself.
duration of intervention per session was 30-40 minutes.

The

At commencement, art therapy

was done, making efforts to enhance the expression of inner feelings and rapport building.
SAT therapy was then performed in 2-3 sessions.

These interventions were performedby the authors who are qualified Orthoptists with adequate knowledge and experience intesting and treating patients in the fields of Ophthalmology and Orthoptic Correction, and
who are also qualified image therapists approved by the Heath Counseling Society.

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2.2.2

Conventional-type therapy
This is a treatment practiced by University A which mainly involves hypnotic

eyeglass prescription, placebo eye-drop prescription, advice giving to parents to improvethe environment, and so on, conducted by the 0phthalmologist in charge of the patient.
This is a general method widely used in Clinical Ophthalmology.

Environment

improvement involves advising the young patients to stop attending several after-school
cram schools(a habit which has become a burden), requesting the mother to stop

over-possessiveness or excessive meddling, and such.

The patient is not informed thatthe visual dysfunction is the result of stress.

2.2.3

The intervention and completion of treatment
Completion of SAT therapy intervention was done after conducting one to several

interventions and confirming improvements in each of disappearance of verbal complaints,
evaluationofpsychologicalcharacteristics,

andvisualfunctionassessment.

Finally ,healing judgment was done by doctors for both groups, and treatment wascompleted when the subject was judged to be healed based on improvement of visualfunctions including corrected vision.

2.3

Method of investigation
A survey was conducted to the patients and their guardians using a self-reportquestionnaire.

In follow-up studies, subjects who were periodically visiting hospitals fornear-sightedness and similar problems even after treatment were given questionnaires
directly at the hospitals.

To the other subjects, the questionnaires were posted by mail.

The follow up survey for the medium-term prognosis study was conducted in July 2002,

International Journal of Structured Association Technique No.3

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and that for the long-term prognosis study was implemented in July 2004.

In the current

study, “medium-term prognosis” was defined as prognosis at a time point of one year or
more after treatment, whereas “long-term prognosis” was defined as prognosis at a time
point of three years or more following treatment. The questionnaire items for patients andtheir guardians are as follows:＜ For the patients＞(1) Subjective symptoms: Higuchi (2000) and Higuchi & Munakata (2002) createdthis scale. Questionnaire items were collected from the data provided by the patients
after which an item pool was created. After consulting with two ophthalmologists andthree Orthoptists, 14 items were set after correcting inappropriate expressions. The 14
items included “Characters on the blackboard are difficult to see” and “Textbook
characters are difficult to read.” The scores ranged from: 3 (Strongly Agree), 2 (Agree); 1(Slightly Agree) and 0 (Disagree) with the total scale score ranging from 0 to 42 points.
Cronbach's α coefficient was 0.95.
(2) State-trait anxiety inventory for children (STAIC; Soga, 1983): Assuming that astate anxiety indicated a “temporary emotional state that may change depending on theconditions being experienced by the subject” and a trait anxiety a “temporary emotional
state that reflected a reaction inclination of the subject relative to the anxious stateexperience,” Spielberger (1966) created STAI and then a “State-transition anxiety
inventory for children” (STAIC). This scale is a Japanese version standardized by Soga
(1983). It consists of 20 items such as state and trait anxiety. Each item is scoredbetween one and three with three being the highest level of anxiety. Anxiety points are
distributed between 20 and 60. Only the trait anxiety scale was used this time to checkthe tendency of anxiety. Cronbach’s α coefficient was 0.90.

International Journal of Structured Association Technique No.3

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(3) Self-esteem for children (same as above): This scale is used to measure thedegree of self-satisfaction or how highly the subject regards him- or herself. It was
created by Yoshiba & Munakata (1997) and consists of ten items with values of 0 to 10
assigned to each item. A higher score indicated higher self-esteem. Cronbach’s αcoefficient was 0.83.
(4) Self-repression for children (Yoshiba & Munakata, 1997) (same as above): The
self-repression scale is used to measure the behavioral trait indicating the patient’s
tendency to suppress his or her feelings or thoughts to avoid being disliked by others, orto avoid making things worse. This scale for children was revised by Yoshiba from thatdeveloped originally by Munakata. This scale consists of 10 items with point values
assigned to each item of two points for “Always yes,” one point for “Often yes,” and nopoints for “No” with the total score ranging from 0 to 20 points. Cronbach’s α coefficient
was 0.83. This time, a value of 0.79 was obtained.
(5)Emotional dependency for children (Yoshiba & Munakata, 1997) (same asabove): This scale is used to measure how much the relevant child expects others to takecare of him or her and level of emotional dependency. This scale measures the trait
whereby those behaviors that allow the subject to cope with the expectations of others
are adopted according to other’s evaluations, as well as that trait whereby unrealistic
expectations continue to be held, even for an unreliable person. This scale consists of ten
items with the total score between 0 and 10 points. Cronbach’s α coefficient, from whichinternal consistency was confirmed by Yoshiba, was 0.74. This time, a value of 0.71 was
obtained.
(6) Perceived Emotional Support (Yoshiba & Munakata, 1997) (same as above):This scale focuses on the perceived emotional support provided by the various social
support networks. It measures how much a child is aware that there are “people around

International Journal of Structured Association Technique No.3

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you who support you emotionally and mentally.” This scale, originally developed by
Munakata, has been revised for children and its validity and reliability have been
confirmed. This scale consists of ten items with a total score of ten points. Four
categories include “Father”, “Mother”, “Brother” and “Friend” and the children identify
which of these they have as supporters. Each individual counts for one point. The
Cronbach’s α coefficient for children, as confirmed by Yoshiba & Munakata (1997), is
between 0.83 and 0.89. The α coefficients obtained for this sample were 0.91 for Father,
0.88 for Mother, 0.84 for Brother, and 0.81 for Friend.

＜ For the guardians＞(i) Results of eye tests done in school physical examinations(ii) Complaints of vision difficulties(iii) Causes behind the visual impairment of the child, the child’s personality, behavior,child-parent relationship, family relationships.
（ 4 items, open-ended）

For subjects who recurrence was suspected,

a visual function test

were executed.

Additionally, an interview survey of the guardians as to the causes of recurrence was
executed after verifying the guardians’ wish to consult the therapists.

2.4

Method of Analysis
The Friedmann test was used for data of three or more time points.

When awithin-group comparison showed a difference, a multiple comparison test (Wilcoxon

International Journal of Structured Association Technique No.3

10

signed-rank test with Bonferroni correction) was used, and the evaluation was done bymodifying the assessment criteria of the P value following Bonferroni correction.
Differences between groups were tested with the Mann-Whitney U test.

Furthermore,qualitative data such as verbatim records of the counseling process and verbatim recordsof the interview data were analyzed together with quantitative data.

3.

Results

3.1

Demographic Characteristics of Intervention Participants (Table 1)
In the medium-term prognosis study, 23 subjects who had been healed for one year

or more were asked to participate in the study out of which 17 subjects responded,making the valid response rate as 73.9%.

In the long-term prognosis study, 14 out of 20

subjects responded, making the response rate as 70.0% -- Table 1.
The follow-up period for the medium-term prognosis study was 21.82 ± 7.6 months
after healing, whereas that for the long-term prognosis study was 48.14 ± 7.72 months.

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3.2

Recurrence frequency of psychogenic visual disturbance depending on themethod of treatment
A comparison of psychogenic visual disturbance recurrence depending on themethod of treatment was conducted.

At the medium-term prognosis observation time

point, results revealed recurrence in 2 out of 7 patients (28.6％ ) in the group that
underwent conventional-type treatment.

On the other hand, in the group that received

SAT therapy, recurrence was contained to just one case out of the 10 subjects treated(10%).

However, no statistically significant difference (Pearson’s χ 2 ＝ 0.977.00, df=1,

p=0.323) was noted as the studied cases were few in number.
At the long-term prognosis observation time point, results revealed recurrence in 1
out of 5 patients of the conventional-type treatment group, and in one case, thepsychological symptoms had deteriorated and were diagnosed as symptoms ofdepression.

On the other hand, in the group that received SAT therapy, there were nocases that showed recurrence of visual disturbance, but there was one patient who was
refusing to attend school.

Again, no significant statistical difference was found as to thenumber of visual disturbance recurrence cases between the two groups (Pearson’s χ 2 ＝0.733, df=1, p=0.188).

3.3

Changes in psychological characteristics and psychotic symptoms before andafter therapeutic intervention depending on the method of treatment

1) Baseline ValueFirst, baseline values of various scale scores in the SAT intervention group andconventional-type treatment group before and after treatment were compared.

There

was no significant difference in the two groups (Table 2).

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Table 2.
Comparison of baseline data (before intervention) between SAT and conventional
therapy groups

Mean Score ±SD
Conventional
Therapy
SAT group

group

Scale(Min-Max)(n=10)(n=7)

Z

difference

SATIC

41.0±5.938.0±4.4

-0.64

n.s.

8.7±4.7

8.0±4.1

-0.16

n.s.

6.7±1.8

6.9±1.6

-0.11

n.s.

4.4±2.1

4.0±1.6

-0.70

n.s.

4.3±1.7

4.1±1.3

-0.16

n.s.

5.8±2.6

6.9±2.0

-0.20

n.s.

(20-60)Self-repression

Statistically(0-20)
Emotional dependency(0-10)
Self-esteem (0-10)
Percived emotional
support from Father (0-10)
Percived emotional
support from Mother (0-10)
Mann-Whitney U test

International Journal of Structured Association Technique No.3

132) Changes in psychological characteristics and psychotic symptoms before and after
therapeutic intervention depending on the method of treatment.
(i)Trait anxiety (STAIC)
Before commencing SAT treatment the score was on average 41.0±5.9 points, soonafter SAT therapy it was on average 31.9±4.1 points, at the medium-term prognosis study
time point, it was on average 32.1±9.0 points, and at the long-term prognosis study time
point, it was on average 28.3±6.3 points, showing a significant difference at the 4observation time points (Friedman, p=0.022).

Compared to before intervention, asignificant drop was seen soon after intervention (p<0.05) and at the long-term prognosis
study time point (p<0.05), and the drop of scores at the medium-term prognosis study
time point had a significant tendency (p<0.10) (Table 3-1).
Meanwhile in the conventional-type therapy cases, the score prior to treatment wason average 38.0±4.4 points, after therapy it was on average 36.7±3.1 points, at themedium-term prognosis study time point, it was on average 39.7±3.9 points, and at thelong-term prognosis study time point, it was on average 37.2±7.1 points, showing no
significant statistical difference at the 4 observation time points (Friedman, p=0.267 n.s)
(Table 3-2).

(ii)

Self repression
Before commencing SAT treatment the score was on average 8.7±4.7 points, soonafter SAT therapy it was on average 4.2±2.1 points, at the medium-term prognosis study
time point, it was on average 4.6±4.9 points, and at the long-term prognosis time point, it
was on average 3.0±2.3 points, showing a significant difference at the 4 observation time
points (Friedman, p=0.015).

Compared to before intervention, a significant drop wasseen soon after intervention (p<0.05) and at the long-term prognosis study time point

International Journal of Structured Association Technique No.3

14

(p<0.05)(Table 3-1).
In the conventional-type therapy, the score prior to treatment wason average 8.0±4.1 points, after therapy it was on average 7.6±3.9 points, at themedium-term prognosis study time point, it was on average 9.3±3.9 points, and at thelong-term prognosis study time point, it was on average 5.6±2.0 points, showing no
significant statistical difference at the 4 time points ( Friedman, p=0.3916, n.s.) (Table
3-2).

(iii)

Emotional dependency
Before commencing SAT treatment the score was on average 6.7±1.8 points, soonafter SAT therapy it was on average 4.2±1.2 points, at the medium-term prognosis study
time point, it was on average 5.2±1.9 points, and at the long-term prognosis study time
point, it was on average 4.4±2.3 points, showing a significant difference at the 4observation time points (Friedman, p=0.0415).

Compared to before intervention, asignificant drop was seen soon after intervention (p<0.05).

In medium-term prognosis

and long-term prognosis, even though there was a drop of the average scores comparedto that before intervention, there was no significant statistical difference (Table 3-1).
In the conventional-type therapy, the score prior to treatment was on average
6.9±1.6 points, after therapy it was on average 6.3±1.7 points, at the medium-term
prognosis study time point, it was on average 7.4±1.4 points, and at the long-term
prognosis study time point, it was on average 7.4±2.7 points, showing no significant
statistical difference (Friedman, p=0.3033 n.s) (Table 3-2).

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Table ３-1

SATIC
Self repressioninterpersonal dependency

Longitudinal observation on psychological characteristics in SAT
therapy group
beforeintervention

afterFriedma Statisticall
interventio 2 years
4 years n χ2＝ynfollow-up follow-up(df)
difference

41.0(5.9)a31.9(4.1)b8.7(4.7)a6.7(1.8)a4.2(2.1)b4.2(1.2)b

14.6
(3)

a>b, a>d*a>b†3.0(2.3)d

10.5
(3)

a>b,d*

4.4(2.3)d

8.2
(3)

a>b*
a>b* a>d†32.1(9.0)c 28.3(6.3)d4.6(4.9)c
5.2(1.9)c

Self esteem

4.4(2.1)a8.9(1.2)b6.4(2.7)c

6.9(1.1)d

14.2
(3)

perceived emotional support from
Father4.3(1.7)a8.3(1.1)b5.2(4.1)c

6.0(2.8)d

7.3
(3)

a>b*

9.1(1.5)d9.6(3)a>b* ,a>c†

perceived emotional support fromMother5.8(2.6)a9.6(0.5)b9.0(2.1)cFriedman rank sum test
† Significant at P<.08 Wilcoxon paired signed rank testwith Bonferroni adjustment ( Post hoc test)* Significant at P<.05 Wilcoxon paired signed rank test with Bonferroni adjustment ( Post hoc test)** Significant at P<.01 Wilcoxon paired signed rank test with Bonferroni adjustment ( Post hoc test)

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Table 3-2

Longitudinal observation on psychological characteristics inconventional therapy group

beforeintervin
tion

After
intervention

2 yearsfollo
w-up

4 years
follo
w-up

Friedman
χ2
＝
(df)
4.8

SATIC

38.0(4.4)

36.7(3.1)

39.7(3.9)

37.2(7.1)
4.0

Self repression

8.0(4.1)

7.6(3.9)9.3(3.9)

5.6(2.0)
3.6

Emotional dependency

6.9(1.6)

6.3(1.7)

7.4(1.4)

7.4(2.7)

Self esteem

4.0(1.6)

4.4(2.0)

3.7(3.4)

4.8(3.4)

Perceived emotional support from
Father4.1(1.3)

4.9(1.8)

6.3(3.8)

3.8(3.2)

0.6

Perceived emotional support fromMother1.6
1.3
6.9(2.0)

6.5(2.1)

6.5(4.0)

7.8(3.9)

Statisticallydiffere
nce

(3)

n.s.

(3)

n.s.

(3)

n.s.

(3)

n.s.

(3)

n.s.

(3)

n.s.

Friedman rank sum test(iv)

Self‐esteem
Before commencing SAT treatment the score was on average 4. 4±2.1 points, soonafter SAT therapy it was on average 8. 9±1.2 points, at the medium-term prognosis study
time point, it was on average 6. 4±2.7 points, and at the long-term prognosis study time
point, it was on average 6.9±1.1 points, showing a significant difference at the 4observation time points (Friedman, p=0.027).

Compared to before intervention, asignificant rise was seen soon after intervention (p<0.05).

International Journal of Structured Association Technique No.3

In long-term prognosis

17

(p<0.07), a rise with a significant statistical tendency was seen (Table 3-1).
In the conventional-type therapy, the score prior to treatment was on average
4.0±1.6 points, after therapy it was on average 4.4±2.0 points, at the medium-term
prognosis study time point, it was on average 3.7±3.4 points, and at the long-term
prognosis study time point, it was on average 4.8±3.4 points, showing no significant
statistical difference (Friedman, p=0.8866, n.s) (Table 3-2).

(v) Perceived Emotional Support from father
Perceived Emotional Support was on average 4.3±1.7 points before commencing
SAT treatment, soon after SAT therapy it was on average 8.3±1.1 points, at themedium-term prognosis study time point, it was on average 5.2±4.1 points, and at thelong-term prognosis study time point, it was on average 6.0±2.8 points, with a significant
tendency at the 4 observation time points (Friedman, p=0.0638).

Compared to before

intervention, the score following intervention was significantly high (p<0.05) (Table 3-1).
In the conventional-type therapy, the score prior to treatment was on average 4.1±1.3
points, after therapy it was on average 4.9±1.8 points, at the medium-term prognosis
study time point, it was on average 6.3±3.8 points, and at the long-term prognosis study
time point, it was on average 3.8±3.2 points, showing no significant statistical difference(Friedman, p=0.6525) (Table 3-2).

(vi)

Perceived Emotional Support from mother
Perceived Emotional Support from mother was on average 5.8±2.6 points before

commencing SAT treatment, soon after SAT therapy it was on average 9.6±0.5 points, atthe medium-term prognosis study time point, it was on average 9.0±2.1 points, and at thelong-term prognosis study time point, it was on average 9.1±1.5 points, showing aInternational Journal of Structured Association Technique No.3

18

significant change at the 4 observation time points (Friedman, p=0.0222).

Compared tobefore intervention, the score following intervention was significantly high (p<0.05).
Even at medium-term prognosis, a rise was seen although with a significant tendency(p<0.10）（ Table 3-1） .
In the conventional-type therapy, the score prior to treatment was on average
6.9±2.0 points, after therapy it was on average 6.5±2.1 points, at the medium-term
prognosis study time point, it was on average 6.5±4.0points, and at the long-term
prognosis study time point, it was on average 7.8±3.9points, showing no significant
statistical difference at the 4 observation time points (Friedman, p=0.7379) (Table 3-2).

4.3.5

Analysis of causes behind recurrence in recurrent cases (Table 4)
Features of changes in psychological characteristics in the 3 recurrent cases seenat the medium-term prognosis study time point were analyzed.

Case A and B had

received conventional therapy, and Case C had received SAT therapy.

Recurrence wasconfirmed in Case A even at the time long-term prognosis study time point.
(i) Recurrent cases in the SAT-therapy group (C) – Table 4-1
After intervention, the scores of SATIC, self-suppressive behavioral characteristics
and interpersonal-dependent behavioral characteristics showed a drop, but there was asignificant rise in the scores at the time of recurrence (medium-term prognosis study time
point).

After that, vision improved by SAT intervention and at the long-term prognosis

study time point all the scores had remarkably improved.
The degree of awareness of emotional support from father and mother showed an
improvement following intervention, but at the time of recurrence (medium-term prognosis
study time point), a significant drop in scores was observed.

The scores then improvedat the long-term prognosis study time point.

International Journal of Structured Association Technique No.3

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International Journal of Structured Association Technique No.3

20

Table 4-1. Features of psychological characteristics in the recurrent cases in the SAT-therapy group

Scale(Min-Max)

Case

SATIC(20-60)

C

Self repression (0-20)

CInterpersonal dependency (0-10)

C

Self esteem (0-10)

C

Perceived emotional support from Father (0-10)

Perceived emotional support from Mother (0-10)

beforeintervention

Afterintervention

2 years
follow-up

4 years
follow-up

36

32

49↑

34

6

4

16↑

6

8

5

8↑

4

2

8

2↓

8

3

10

4↓

7

4

9

4↓

9

C

C

International Journal of Structured Association Technique No.3

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Table 4-2. Features of psychological characteristics in the recurrent cases in Conventional therapy group

Scale(Min-Max)

Case

SATIC(20-60)

A
B

Self repression(0-20)

A
B

Interpersonal dependency (0-10)

A
B

Self esteem (0-10)

A
B

Perceived emotional support from Father (0-10)

A
B

Perceived emotional support from Mother (0-10)

AB

beforeinterve
ntion

After
intervention

2 years
followup

4 years
followup

42

40→

41→

34↓

32

31→

42↑

48↑

3

3→

11↑

9↑

7

7→

5↓

6

6

5→

9↑

7

6

5→

7↑

10

4

4→

7↑

5

3

3→

0↓

0↓

3

3→

0↓

0

5

5→

10↓

1

6

8↑

3↓

2↓

5

6→

0↓

10↑

(ii) Recurrent cases in the conventional-therapy group – Table 4-2
In the 2 recurrent cases of the conventional-therapy group, there was no change inscores, and a high degree of anxiety continued until the time of recurrence (medium-term
prognosis study time point).

In Case A where recurrence was confirmed at the time

long-term prognosis study time point, the anxiety had become even stronger.

International Journal of Structured Association Technique No.3

Degree of22self-repression showed no change in Case B from before treatment to long-term
prognosis study time point, whereas a rise in the score was seen for Case A at time ofrecurrence.
Scores of interpersonal dependence-type behavioral characteristics hardly changed
in both cases even after therapy, a rise was seen at the time of recurrence (medium-term
prognosis study time point), which continued to be high even at the long-term prognosis
study time point.
Self-esteem scores showed no change before and after therapy, and continued to be
low, showing a further decline at the follow-up study time point.
Perceived Emotional Support from father showed no change following therapy, andalthough a drop was seen in one case at the follow-up study time point, in the other case,there was a rise in the score.

As for the Perceived Emotional Support from mother, aslight rise in scores was observed in both cases, but at the time of recurrence(medium-term prognosis study time point), the scores had sharply declined.

In Case A

where a further decline in vision was seen at long-term prognosis, this score showed anincrease, but in Case B, there was a further decline.

3)

Narrative evaluation of recurrence causes recognized by the patient himself andparents in recurrent cases
Inquiries were made as to causes that influenced recurrence in the 3 recurrent
cases.

There were important causes such as the way love was expressed, lack ofcommunication within the family, etc.
4.

Discussion
In the present study, recurrence was seen in 2 out of 7 patients (28.6％ ) in thegroup that underwent conventional therapy, and in 1 out of 10 patients (10.0％ ) in theInternational Journal of Structured Association Technique No.3

23

group that underwent SAT therapy, at the medium-term prognosis observation time point.
At the long-term prognosis observation time point, recurrence was seen in 1 out of 5
patients (20%) in the conventional-type treatment group, whereas in the SAT therapy
group, no visual disturbance recurrence was found in any of the patients (0 out of 9, 0%).
Up to now, reports on PVD prognosis following therapy have described non-healing or
recurrence in 7 out of 15 patients (46.7%) as reported by Rada et al. 22) from the field ofclinical psychiatry; in 8 out of 19 patients (43.1%) as reported by Abe et al. from the fieldof ophthalmology; in 4 out of 14 patients (28.6%)) as reported by Sletterberg et al. 7) ; andin 1 out of 23 patients (4.3%) as reported by Catalano et al. 23) . Even when these pastreports and the present study’s results for conventional therapy are compared, thelong-term prognosis following SAT therapy was the best after the Catalano report.
Catalano et al. 23) report that 35% of the cases showed an improvement within 24 hours
and 61% showed an improvement within a month by merely a guarantee that the patient
will be “definitely cured”.

In contrast, the subjects of present study’s SAT therapy

included many cases that had showed no response even to treatment spanning a few
months to one year or more after being diagnosed with PVD.

Even though a simple

comparison is not possible, SAT therapy effects are thought to be good considering thesedifferences in severity of the cases studied.
Mochizuki et al. 24) divided into two groups 42 patients who has been diagnosed ashaving conversion disorders by DSM-III-R based on decreased vision as the main
complaint.

The two groups were improved group and protracted group.

Mochizuki etal. 24) reported that children who refused to attend school were significantly higher in the
improved group.

In the present study, although there was one child who refused goingto school after SAT therapy, going to school became possible shortly after the childhimself chose to undergo SAT therapy and when the problems were solved after theInternational Journal of Structured Association Technique No.3

24

intervention.

This showed that symptom shifts to other somatizations and behavioral

symptoms is hardly seen in SAT therapy intervention, and that resolution of underlying
issues is urged.
There are extremely few reports relating to long-term prognosis of PVD.
Yokoyama 10) observed long-term prognosis for 2 PVD cases and reported a psychologicalmechanism that mental swings of adolescence, namely sibling conflicts was the cause.
The present study elucidated a long-term prognosis of PVD (4 years in average after
healing) for the first time in a positive study with a control group and based on detailed
data on visual functions and psychological characteristics following active intervention.
This

study

revealed

that

(i)

trait

anxiety,

self-suppression,andinterpersonal-dependence that decreased following SAT therapy remained low even at thelong-term prognosis observation time-point, and (ii) self value and degree of awarenessof mother’s emotional support that improved following SAT therapy remained high even at
the long-term prognosis observation time-point, although there was a slight drop.
Detailed evaluation of each psychological characteristic showed that, first, PVD has acharacteristic low self-value, which is improved after SAT intervention.

Self-assessmentand feelings of self-respect which are similar to self-value are said to arise from the ageof eight 25) .

This is the stage around which self-consciousness develops, enhancing aninterest in internal matters.

Incidentally, this period around 8 years of age overlaps withtime when symptoms of psychogenic visual disturbances peak.

Self-assessment at thisstage depends on the assessment of others by significant others (generally, the mother).
C. Rogers describes that children perceive themselves through clarification ofself-concepts within interactions with significant others, and require positive assessment
from significant others 26) .

It is thought that self-images and self-concepts getdetermined by assessments of those around from early childhood, and self-confidence isInternational Journal of Structured Association Technique No.3

25

created and acted out via having a positive image of oneself.

Having a low self-value ata time when the foundation of self- assessment is being completed, is thought to create
defects in self-confidence and increase uneasiness when taking various actions, because
the child always worries about other people’s opinions.

Therefore, psychologicalinterventions at this stage that focus on self-image enhancement are extremely important.
In SAT therapy, latent traumatic memories such as sensation images in the fetal stage
or early childhood were approached from problems recognized at the present time, andimage conversion was conducted to satisfy unfulfilled internal demands of the mind andunresolved emotions associated with the trauma.

To mention, re-learning of perception

and behavior based on positive images was encouraged.

Munakata has described that“dangers to survival experienced in infancy and birth are unconsciously played back 27)”.
There are also reports that causes of certain mental and physical problems may lie in the
fetal period, and experiences made during this fetal period and at birth have a huge
influence on the life thereafter 28) .

By trying to approach traumatic memories that thepatient is not aware of, SAT intervention is thought to have made it possible to transform
various images of oneself and one’s surroundings.
The following may explain the low self-suppression and interpersonal-dependence.
What is behind strong interpersonal dependence are non-fulfillment of needs and desires
to feel affection such as “not being understood”, “not being able to emotionally depend on
someone”. High -suppression has the tendency to suppress ones thoughts and feelings tosuit the expectations of those around.

Negative latescent image memories such as fearof being abandoned, self denial, and loneliness are behind the patient being forced to
become independent, giving up the need to emotionally depend on others.

In SAT

therapy intervention, real desires within the heart may be fulfilled due to the formation of
the self-image that the patient is treasured by his/her parents, thus decreasing theInternational Journal of Structured Association Technique No.3

26

dependence and self-suppression.
Although a rise in the degree of awareness of the mother’s emotional support wasseen the SAT therapy group, this degree was low in all recurrent cases at the recurrence
point.

Deterioration of relationships with family and parents is thought to deteriorate theself-image along with the decrease of the feeling of having emotional support.

This isthought to lead to stronger stress responses, and cause, as a physical response, theonset of visual disturbance recurrence.

Wynick et al. 29) showed by analyzing PVD

children’s assessments of their mothers, that these children thought that while the motherwas very loving and receptive towards him or herself, she was also dominating andmeddlesome.

The improvement of the degree of awareness of the mother’s emotional

support through SAT therapy can be presumed to have been the result of an improvementin the awareness of support from a significant other due to the decrease of the child’s
degree of dependence.

However, in future, it would be necessary to conduct SAT

therapy taking the influence of the family environment surrounding the PVD child into
consideration.
Causes of PVD recurrence had, as intrapersonal factors, the features of (i) highanxiety, (ii) high self suppression and interpersonal dependency, and (iii) low self-value
and low degree of awareness of the parents’ emotional support.

In cases in whom an

improvement was seen after SAT intervention, the state of psychological characteristics
were more or less maintained from the time soon after intervention, whereas recurrent
cases showed a deterioration of psychological characteristics that once improved at thetime of intervention. Taking into view situations where the gap between image scenarios
created for SAT therapy and the actual images are too big, in order for the patient toconvert the parental image and for that image to become established, SAT therapy
currently considers it vital that (i) the parents themselves grow and accept psychologicalInternational Journal of Structured Association Technique No.3

27

interventions to change the personality so that they would become able to unconditionallyaccept the child, and(ii) the child lives separated from the parents for a while 30) .

Even in the present recurrence, the improved parental image may have become bad
again because the improved image was considerably different to the actual.
Turgay 31) gives the following as factors that correlate with good therapeuticachievements for conversion disorders in childhood and adolescence: (i) being a juvenile,(ii) having a healthy personality, (iii) having healthy family functions, and (iv) the family
understanding the psychological features of the disorder.

The present result alsosuggests that even in the PVD healing process, healthy psychological characteristics
equivalent to Turgey’s “healthy personality”, in other words personality development, andthe surrounding environment that “the family understanding the psychological features ofthe disorder” are highly important.
The present study reveals that to treat PVD, counseling of the patient and providing
guidance for the mother are effective in most of the cases.

However, analysis ofrecurrent cases teaches the necessity for the following improvements.

Likelihood ofrecurrence is highly increased when the mother’s level of anxiety is high, and theaffection of “unconditionally accepting the child” is low.

In such cases, it is vital thatfirst the mother herself becomes emotionally stable to accept the child under any
circumstance.

Therefore, the authors believe that simultaneous SAT therapy

intervention for the mother would lead to the prevention of recurrence and even solutionof family issues that are appearing as a physical reaction in the child.
The sorting into each of the intervention groups done in the current study is nothomogeneous.

For example, the SAT group included cases in whom healing could not

be seen even after several months, and too few cases were studied.

Therefore, there

still issues remaining for strict evaluation of SAT intervention group and conventional

International Journal of Structured Association Technique No.3

28

therapy intervention group.

4.2

Conclusion
Effects of psychological intervention by SAT therapy were observed for a long

duration assessing recurrence rate, behavioral characteristics
psychological symptoms.
(i)and changes in

As a result, the following findings were obtained:

Recurrent numbers for each method of therapy was 2 out of 7 patients (28.6％ ) in
the conventional-type therapy group at the medium-term prognosis observation
time point, whereas it was one case out of the 10 subjects (10.0%) in the SAT
therapy group, although there was no statistically significant difference.

At thelong-term prognosis observation time point, visual disturbance recurrence wasseen in 1 out of 5 patients in the conventional-type therapy group, whereas
recurrence was not seen in the SAT therapy group.

Therefore, in both groups asignificant difference in visual disturbance recurrence was not seen even at thelong-term prognosis observation time point.
(ii)

In the SAT therapy intervention group, scores of self-repression, emotional
dependency and trait anxiety that improved soon after intervention remained loweven though there was a slight increase at the long-term prognosis observation
time-point. Similarly, scores of self value and degree of awareness of mother’semotional support similarly remained high, even though there was a slight drop.
On the other hand, scores of self-repression, self-esteem, trait anxiety, andperceived emotional support were hardly changed in the conventional-therapy
group.

(iii)

In PVD recurrent cases, it was confirmed that anxiety, self- Self-repression, andInternational Journal of Structured Association Technique No.3

29

emotional dependency are high even though an improvement is temporarily seen,and self-value and degree of awareness of mother’s emotional support are low,
thus accompanying a change in psychological characteristics.

The above results suggest that since psychological conflicts are behind the onset of PVD,
therapy should not focus on resolving superficial issues such as visual disturbance, butshould involve psychological interventions that encourage finding solutions to those
psychological conflicts.

International Journal of Structured Association Technique No.3

30

References
1） Yokoyama, H. (1999). Psychogenic visual disturbance. Ophthalmology in Japan, 70(10), 1227-1231.
2) Okuyama N, Kawakatsu S, Wada T, Komatani A et al: Occipital hypo-perfusion in apatient with psychogenic visual disturbance.

Psychiatry Research Neuroimaging

114:163-168,2002
3) Hisako Watanabe: Hysteria（ dissociative disorder）. Journal of pediatric practice63（ 10） :1508-1514,2000
4） Bass C and Benjamin S: The management of chronic somatization. British Journal of
Psychiatry 162: 472-480,1993
5 ） Noriko Higuchi, Tsunetsugu Munakata, Sayuri Hashimoto and Hirohiko Higuchi:
Psychological Characteristics of Children with Psychogenic Visual Disturbance.
Journal of the eye.21:999-1004,2004.
6） Masatoshi Tanaka: Perspectives of Stress-From a biological standpoint. Shinryonaika
2:93-99,1998.
7) Sletterberg O, Berteisen T, Hovding G: The prognosis of patients with hysterical visual
impairment. Acta Ophthalmol 67(2):159-163,1989
8) Kazuhiko Abe: Treatment of psychogenic vision impairment in children. Rinsho Seishin
Igaku 16(10):1443-1448， 1987
9) Minoru Okamoto, Masayasu Watanabe, Hidetomi Watanabe et al.:disorders in adolescence. Ganka

Psychogenic eye

26： 147-152， 1984

10) Naohiro Yokoyama: Psychogenic visual disturbances understood by long-term
observation cases. Gannka rinsho ihou 93(5):790-793,1999
11) Yoshihisa Oguchi: Psychogenic visual disturbances in school-age children. Ganka
26:139-145,1984.

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3112) Junko Tozawa and Hideyuki Unuma: Pathology and treatment strategies in
Psychogenic visual disturbances- focusing on the mother-child relationship.
Ganrini2（ 5）： 658−664， 1998

13) Tsunetsugu Munakata: Chapter 1, Practice counseling based on structuralized
association technique.

Counselling Therapy and Health, Editorial Supervisor:

Tsunetsugu Munakata: Kaneko Shobo, Tokyo. 3-26， 2004
14) Clinical psychology handbook for mental clinicians- edited by Keigo Okonogi, Chikako
Fukatsu, and Yu Ohno, revised edition 42, Sogensha, Tokyo 2005
15) Van den Bergh BR, Mennes M, Oosterlaan J, Stevens V, Stiers P, Marcoen A and
Lagae L.:High antenatal maternal anxiety is related to impulsivity duringperformance of cognitive tasks in 14- and 15-year-olds.Neurosci Biobehav Rev.
29(2):259-69,2005
16) Van den Bergh BR and Marcoen A.:High antenatal maternal anxiety is related to
ADHD symptoms, externalizing problems, and anxiety in 8- and 9-year-olds. Child
Dev. 75(4):1085-97, 200417) Van den Bergh BR, Mulder EJ, Mennes M, and Glover V:Antenatal maternal anxiety
and stress and the neurobehavioural development of the fetus and child: links andpossible mechanisms. A review. Neurosci Biobehav Rev. 29(2):237-58,2005
18) Sheikh AA: Imagination and healing.

Amityville, NY ,Baywood,1984

19) Noriko Higuchi ： Research on SAT image therapy for psychogenic visual
disturbances-centered on a follow up study spanning more than a year. 2002 Masterthesis collection of the University of Tsukuba School of Comprehensive Human
Sciences， 2003.
20) Soga, S. (1983): Study of STAIC standardization Japanese edition. PsychologicalResearch, 54, 215-221.

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3221) Yoshiba, K., & Munakata, K. Development of psychological health-related scales forchildren. The Japan Association of Mental Health Sociology Annual Report, 7： 29− 35， 199722) Rada RT, Meyer GG, and Kellner R: Visual conversion reaction in children and adults.
J of Nerv & Ment Dis 166 (8):580-587,1978
23) Catalano RA, Simon JW, Krohel GB, Rosenberg PN: Functional Visual loss in children.
Ophthalmology 93(2):385-390,1986
24) Hiromi Mochizuki， et al： Pathological Images of psychogenic visual disturbances- acomparative analysis of an improved group and persisting group.

Abstracts of the

38 th Annual Meeting of The Japanese Society for Child and Adolescent Psychiatry,
157， 1997
25） Christoph Andre and Francois Lelord: Psychology of Self Assesment; 4th Edition,
Kinokuniya Shoten, Tokyo, 94， 2001.
26) Morio Saji and Kiichiro Iinaga: Rogers client oriented therapy, yuhikakushinsho, 1stedition, 15th print， 1998
27) Tsunetsugu Munetaka: Health Counselling Evolution Theory, 3 rd Self-care support
viewed from a stress-management standpoint.

Health Councelling 5（ 3）: 49-54,

200228) Michael G and Marie G，translated by Yoko Huey: The Fetus Speaks- The womb is thecradle of the soul: cyoubunnsya， 1999
29) Wynick S, et al: Psychogenic visual disorders in children-Perspectives fromadolescence. Journal of Child psychology & Psychiatry & Allied Disciplines 38(3):375-379,1997
30) Tsunetsugu

Munakata： SAT Image Therapy for the family with seclusive young

people. Psychosomatic Medicine 42(1)： 37-46， 2002

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3331) Turgay, A: Treatment outcome of children and adolescents with conversion disorder.
Can J Psychiatry 35 :585-589,1990

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Reconstructing Life and Society with SAT Therapy:

Foundations of the New Generation CBT

Munakata, Tsunetsugu, Dr H Sc

President, Academy for Health Counseling
Professor & Chair, Department of Human Care Science, University of Tsukuba, D511,
1-1-1 Tennoudai, Tsukuba, Japan 305-8577 e-mail: munakata@hcs.tsukuba.ac.jp

Summary
All mammals, including humans, instinctively control through attachment behaviors their fear of
not being able to subsist. Under normal circumstances, a child’s principal care provider is his or
her parents or guardians. However, if the latter are emotionally unstable, the child, who is
supposed to be the care recipient, unwittingly becomes the one that provides the emotional carethe parents or guardians covet. As a consequence, even after the child becomes an adult, he/shewill unconsciously seek out an emotionally unstable family member or colleague at work and builda codependent attachment relationship replacing the former parent-child relationship in which one
relies on the other and vice a versa. Such relationships, however, create a whirlpool of unduestress accompanied by “insecurity, distrust and exploitation.” To be able to overcome subsistence
fear and build a stable attachment relationship marked by “ease, respect and gratitude,” theindividual needs to change the facial expressions and images of “tension and irritability” he/sheremembers of their parents or guardians to those of “smile and serenity.”
SAT is a structured imagery therapy used to promote reconstruction of stable attachment
International Journal of Structured Association Technique No.3

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relations through the application of a subjunctive mood that takes clients back throughevolutionary time to their ancestors and ultimately to their particles. A certified SAT therapist uses
a retrospective image projection technique, including pictures, paintings, religious paintings, andcomic books, to help clients discover their parental surrogate representations. By having clientsobserve these parental surrogate representations instead of the expressions and images of theiractual parents or guardians, the SAT therapist helps clients reduce their negative emotions,
thereby helping them to break up their codependent attachment relationships. SAT therapy isthus a new-generation CBT (cognitive behavioral therapy) that promotes rational thinking
compatible with the client’s genetic disposition.

Keywords:
attachment, codependency, parental surrogate representation, cognitive behavioral therapy,
SAT therapy

International Journal of Structured Association Technique No.3

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Introduction
Since ancient times, society has been organized in such a way that people have to rely on others
to gain access to scarce rewards. In such a society (hereinafter referred to as“other-reward-seeking society), people have to compete or fight with each other to gain access to
scarce rewards such as evaluation, praise, honor, income and status. In another-reward-seeking society, people cannot help but be stressed out. But what if we could build
a society where people help each other to gain access to unlimited rewards such as self-growth,
self-satisfaction, gratitude, empathy, inspiration, pleasure and sense of accomplishment. Even insuch a society (hereinafter referred to as “self-reward-seeking society”) people will still be understress, but stress here would be benign enough to allow people to learn from their mistakes anddevelop a genuine sense of well-being. According to surveys conducted by the Cabinet Office,since the 1980s, the tendency of Japanese to seek richness of mind, such as spiritual growth,
gratitude and inspiration, rather than material affluence has increased significantly over thepassed 30 years. Indeed, expectations have heightened for the creation of a self-reward-seeking
society.
However, in a traditional other-reward-seeking society, where people have to rely on others
to gain access to limited resources, top priority is put on social adaptation. Consequently, fromour early childhood, parents and guardians, in the name of discipline, refuse to let us “just be
ourselves,” and subject us, to a greater or lesser extent, to emotional and physical abuse thatconditions us to physical fear. Thus we are afraid to express “our true selves,” which inherently lie
deep in our hearts. We are unable to change, even if we wanted to. As our self-conflict deepens
and our malignant stress intensifies, our stress disorder continues to expand. However, it canInternational Journal of Structured Association Technique No.337

also be said that as our stress disorder continues to expand, we are actually accumulating energy
for self-growth. In order to realize a self-reward-seeking society where people can universallyexperience a sense of well-being by realizing their “true selves,” in this paper I would like to takeup the theory of SAT therapy, along with its methodology, as a form of cognitive behavioral
therapy that will help clients solve their unresolved issues over codependency attachment
relations, which will enable them to survive in an other-reward-seeking society.
In recent years, cognitive behavioral therapy (CBT) has been applied to help peoplechange their thinking habits from those that cause them to suffer malignant stress to those thatare more adaptive to their situation. However, while it is true that CBT has helped people change
their thinking habits in the short-term by making changes that, on paper, appear rational, CBT
may also lead to somatization and acting out of stress. This is because, when the forebrain,(which is involved with reasoning) and the limbic brain (which is involved with emotions) are in
opposition, the latter trumps the former. This is why a new generation of cognitive behavioral
therapy is needed that will not only change our thinking habits but also directly alters ouremotions.

1. Attachment is indispensable for life
Attachment runting syndrome
A runt – the smallest and weakest animal of a litter – will die a few weeks after birth even when nochange has occurred in the environment. This is because the runt is too weak to stimulate themother’s nipple for milk and induce her to engage in the attachment behavior associated with

International Journal of Structured Association Technique No.3

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grooming. A form of human bonding called attachment is formed between a mother and a childvia oxytocin secretion not only at the time of delivery but when there is physical contact including
when the baby suckles. Unless this attachment bond is formed, the mother will be less and lessinclined to give the runt physical care such as grooming. As a result of this neglect, the runt will
experience so much stress that it becomes difficult for its body to secrete growth hormones. The
same thing occurs in human offspring as evidenced by the fact thatmany children inorphanages have been reported to suffer from a low level of a growth hormone known as
nonorganic hypogenesis (Stanhope et al., 1994; Albanese et al., 1994). These runting syndrome
cases demonstrate the importance of getting parents and guardians to engage in attachment
behavior to control subsistence stress and ensure survival.
That said, I think forming a stable attachment relationship after birth requires almost a
miracle. Of course, trying to make that miracle happen may be admirable, but it is better to takethe view that each client has an attachment relationship suited for him or her situation.
Nevertheless, depending on the nature of the attachment relationship formed, the client will insome cases end up leading an unexpectedly complicated life.

What Is Attachment？
Johan Bowlby (1969) named the “emotional bond” formed between mother and child“attachment,” arguing that even infants inherently seek to form proximity relationships withselected targets. In other words, to gain their affection, infants behave in a way that will bringthem closer to their caregivers. There are a number of attachment behavioral patterns that are

International Journal of Structured Association Technique No.3

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formed in this process. According to the famous technique for measuring the quality of
attachment that Mary Ainsworth (1978) developed by applying her Strange Situation method,
there are four types of attachment patterns: “avoidant attachment,” “secure attachment,”
ambivalent attachment” and “disorganized attachment.” Attachment behavior is “behavior thatseeks to gain a sense of security in time of fear by drawing the caregiver’s attention and seeking
proximity. By repeating this behavior, the infant is assured that the caregiver will provide
protection, thereby enhancing its ability to cope with stress.

Roundabout way of forming attachments
What happens to children when their parents or guardians mentally and physically reject them byrefusing to accept them “as they are” and are thus subjected to such severe emotional andphysical abuse that they are unable to form safe and secure attachment relations with theirparents or guardians?
First of all, they will show behavioral patterns in which they personally try to void
attachments out of feeling of dread. Being suspicious of caregivers they encounter, they mightshow self--repressive behaviors, that is, behavior patterns in which they try to suppress theirlonging to be looked after by their parents or guardians. They do this because they havedeveloped a sense of caution in their past relationships with their parents or guardians, and havetransplanted these unstable attachment relationships to their other relationships. In extreme
cases of avoidant attachment, fearful of being rejected by their caregivers, and out of a sense of
caution, children develop a belief that they should not turn to their caregivers for help and soInternational Journal of Structured Association Technique No.3

40

unconsciously begin to suppress their longing for care. These children then begin to show
alexithymia behaviors in which they try not to show any emotions and work very hard to do things
by themselves.
When parents or guardians refuse to accept children as they are, the latter may also show
problem-avoidance behaviors that cause them to act independently and become insensitive totheir own problems. They may also show problem-avoidance behaviors that compel them to act
as if their problems were not really theirs, and show depersonalized behaviors in which, insteadof relying on their parents or guardians to give them care, they turn to themselves. Because of
these behaviors, children become insensitive to tensions associated with stress and continue toaccumulate such more stress that they manifest physical disorders, which in turn lead to stressdisorders and diseases associated with adult lifestyle (Munakata, 2004, 2006; Munakata,
Kobayashi, 2007). But these can be regarded as illness behaviors that seek attachments in aroundabout way by drawing the attention of caregivers and promoting formation of proximity
relationships.
Children who fail to form legitimate attachment relationships not only distrust others but
also become more inclined to deepen their sense of self-denial, thus driving them to seek carefrom caregivers in a distorted manner known as parasuicide, which includes cutting one’s wrist,
planning to commit suicide, and increasing accident proneness. Or, because of their inability totrust others, they refuse to rely on people’s kindness and end up developing substancedependence on alcohol, drugs and the like that affect their psychoneurotic system.

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2.

Trauma dependency syndrome and codependency bondTrauma dependency
I’m sure most of you have heard the term “runner’s high.” Human beings possess a stress
reaction system that discharges a chemical substance called endorphin in the brain to relieve
pain and bring comfort when they find themselves in a highly stressful, life-threatening situation(Perry & Szalavitz, 2006). Those with a traumatic experience of being powerless in the face oflife-threatening danger to themselves or to others have experienced being in a highly stressful
situation where a chemical substance is discharged in the brain to relieve pain and bring comfort.
This is why when those with serious traumatic experiences are delivered from their high levels ofstress, they develop a sense of irritability, fear, excess arousal and feeling of helplessness notunlike the symptoms addicts experience when they stop taking morphemes or heroine. However,
because trauma patients do not suffer the same withdrawal symptoms as drug addicts do, they
compulsively seek even higher levels of stress. Consequently, they become more inclined to
become addicted to trauma (Van der Kolk & Greenberg, 1987).
Children with serious traumatic experiences can’t bear being in a quiet place. They areprone to risk-taking behaviors like fighting, bullying, gang warfare, delinquency, wrist cutting,accident proneness, depression and suicide attempts, as well as tobacco, alcohol and drug
dependency. They avoid quiet atmospheres, draw the attention of caregivers by acting
precariously, and try to stay attached to them by forming proximity relationships. In addition, atleast physiologically, they maintain the highly stressful condition they’re in and retain the highInternational Journal of Structured Association Technique No.3

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level of endorphin secretion in their brain in order to overcome their irritability, sense of fear, andfeeling of helplessness.

Trauma-bonding
Out of fear or disgust, children who have been sexually abused by their fathers may be expected
to be completely repulsed by sex. But contrary to such expectation, sexual abused trauma
survivors tend to engage in promiscuous sexual behavior even with complete strangers (e.g.,
fellatio). They engage in such acts not as an expression of affection, but rather as an “act ofsubmission.” By acting this way, survivors of childhood sexual abuse learn that adults who arepotentially dangerous may not turn out to be their worst enemy.
The following behavioral pattern is generally observed among many Japanese. Trauma
survivors raised by physically abusive fathers and mothers who refused to come to their rescue
tend to engage in self--repressive behavior known as “act of submission” in which they send
strong authority figures expressive messages in the form of facial, voice, and bodily movements
to let them know how harmless and submissive they are, thereby leaving a favorable impression
on the other party.
Because they experienced relationships based on fear, survivors of childhood traumatic
experiences such as sexual abuse, abusive upbringing, and neglect are unable to form stableattachment relationships based on an original sense of reassurance. As a result, they form
distorted codependency relationships (both dependency they want for themselves anddependency they want to force on others) known as trauma-bonding that goes beyond social

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convention. Trauma victims tend to form codependency relationships with other trauma victims.
Perhaps, they do this because, on a gut level, they feel they cannot form such relationships withanyone who does not have similar traumatic experiences. In other words, based on theexpressive messages of caregivers conveyed in the form of facial expression, voice and bodily
movement, trauma victims, as members of the disadvantaged, on a gut level, foresee receiving
care from caregivers who are themselves trauma victims. They feel in their bones that suchcaregivers will without a doubt rescue the disadvantaged, and in the process they come to know
intuitively how to exploit their caregivers to their advantage. Since caregivers who are themselves
trauma victims can gain self--satisfaction or be rewarded in the form of being healed by having
the underdog trauma victims become depended on them, the latter anticipate that caregivers will
come to rescue them, just as drug addicts seek relief by turning to drug dealers.
Although the act of one trauma victim rescuing another trauma victim may appear altruistic,
the former is actually rescuing himself. His is a narcissistic behavior. When a rescuer rescues aperson who is disadvantaged in order to rescue himself, he is doing this only to satisfy himself.
Thus, when such a rescuer is unable to get satisfaction, the person who is supposed to be
rescued is not rescued; instead, he is more likely to be betrayed. Regardless whether
relationships are based on social functions – such as those between husband and wife, parent
and child, and master and pupil – or therapeutic relationships, as long as they are codependency
relationships, those with traumatic experiences, because they are disadvantaged, may, uponseeing the expression of the disadvantaged, react by trying to rescue the disadvantaged.
However, caregivers who are supposed to rescue trauma victims from their sufferings, because

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they cannot get satisfaction themselves, are apt to turn into trauma caregivers who are apt to bea source of fear and sufferings for trauma survivors.
If trauma survivors are able to form only distorted attachment relationships dominated byfear, they may develop Münchausen syndrome, which forces patients to draw attention ofcaregivers to themselves in the hope of forming proximity relationships with them by engaging inparasuicidal behaviors, or they may develop Münchausen syndrome by proxy, a variant of
Münchausen syndrome, that forces them to draw attention of those around them and form
proximity relationships with them by caring for children or adults who have experienced tragedy. A
person affected with Münchausen syndrome in proxy ensures that her child will become ill,thereby forcing the child to take tests and undergo treatments that are not really necessary. While
the affected person takes care of the child, those around her direct their concerned look toward
her and begin to hug her as a sign of encouragement. This response is precisely what theaffected person seeks.
According to past studies of Münchausen syndrome in proxy, patients with serious
symptoms may experience tragic consequences. In one study, the researchers recorded on video
the behaviors of 39 mothers apparently afflicted with this disorder. When the video was shown,one of the mothers actually confessed to killing her child (Southall et al., 1997). In Japan, Europe
and the U.S., there are cases where nurses and other caregivers, possibly with Münchausen
syndrome in proxy, have driven patients to tragic ends.
While those afflicted with codependency pathology may commit the most heinous acts oftyranny imaginable, it is also true that, as they wander astray, they may be observed performingInternational Journal of Structured Association Technique No.3

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the most beautiful acts of kindness humans are capable of performing (Perry & Szalavitz, 2006).
In my view, trauma victims can only be rescued by trauma victims. Only those who haveexperienced traumatic events themselves will stay around those with trauma dependency
syndrome. Whether they are husband and wife, parent and child, master and pupil, or intherapeutic relationships, they are expected to overcome their anxiety, distrust and exploitation of
the codependency type of attachment relationships and in the process establish stableattachment relationships of reassurances, respect and gratitude. Toward this end, it is necessary
for both parties to become aware of their mutual longing for codependency.

3.

How to overcome codependency

Other-reward-seeking behavior and self-reward-seeking behavior
Although there are individual differences, children are usually motivated to act in ways that willreinforce the reward responses in which the expressions and images of the faces, voice andbodily movements of their parents or guardians express “happiness.” Or they may be motivated
to avoid responses of revulsion that express the doubt, anger and sadness of their parents or
guardians. In other words, children choose behaviors that reinforce the formation of attachments.
Even when they become parents or guardians, themselves, they are motivated by the reward
responses of their significant others in social groups like school, society, and post-marriage
families, resulting in the formation of other-reward-seeking behaviors that help reinforce
attachments
On the other hand, from our childhood days, it is through self-reward-seeking responses,

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such as solitary play, playing with friends, adventure, art and sports activities, and caring forplants and animals, that we can enjoy ourselves and become motivated to act in ways that willreinforce these responses These responses help increase our sense of self- trust and enable us
to develop into mature individuals capable of controlling the countless stressors we encounter inlife. These motivations enable us to form self--reward-seeking behaviors after we mature into
adults.
Since other-reward-seeking behaviors conform to the evaluation of others for forming
attachments, it is easy to avail oneself to the resources of others. That said, it is others who
possess positive resources – e.g., praise, favorable impression, repayment, honor, status, income– and negative resources – e.g., threat, punishment, restraint, disregard, discrimination,indifference. Consequently, with other-reward-seeking behavior one is easily swayed by theevaluation of others, which is often accompanied by tension and insecure feeling, resulting inaccumulation of even more stress. Also, since other-reward-seeking behaviors require theevaluation of others, those who engage in them are apt to suppress their true feelings, thus
resulting in self- denial and further aggravation of their depression.
By contrast, in the case of self-reward-seeking behaviors, it is difficult to get rewards fromothers but easy to give rewards to oneself – rewards like pleasure, interest, inspiration, resolve,
sense of accomplishment, growth, self-satisfaction, gratitude and empathy. Since you yourself
possess the resources involved in self-reward-seeking behaviors, self-rewards are easy to get,provided you are able to learn from your mistakes. This is why self-reward-seeking behaviors do
not lead to accumulation of stress as with other-reward-seeking behaviors.

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People cannot tell between Self and Others – Mirror Neurons
If you have experienced physical trauma in the form of emotional and physical abuse, you will be
too afraid to take up self-reward-seeking behaviors, and will likely be frightened, anxious, harbora sense of guilt, resignation, and so on, and as a result, you will not be able to act appropriately.
You need to become aware that emotions such as fear, anxiety and sense of guilt are conditionedby the fear written on the expressions of your parents or guardians constituting the trauma they
have experienced.
The areas of the brain that are activated differ in accordance with the difference in theexpression of revulsion people make. In either case, it is now clear that, through the mediation of
mirror neurons, the same location of the brain is activated in both the person making theexpression and the person looking at the expression (Carter, 1998). In other words, when we lookat the expression of revulsion in the faces of others, we end up having the same feeling of
revulsion. If the relationship with parents or guardians is such that if we are always looking at theexpression of revulsion on the face of others, the expression on our face will also become
expression of revulsion. This is why children who grow up looking at expressions of revulsion on
the faces of their parents or guardians find themselves making similar expressions.
How will your body react when you look at the picture below of a woman with an
expression of revulsion (Fig. 1)? You might feel stiff in the shoulder. Your heart might start
pounding. You might have difficulty breathing. Your hands and feet might start feeling cold. YourInternational Journal of Structured Association Technique No.3

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whole body might stiffen. How will you react if the person in Figure 1 were living next to you? How
would you feel? What kind of body sensation will you have? What about your facial expression?

Fig. 1 Woman with an expression

Fig 2. Family with a smile on their facesof revulsion
How about when you look at smiling faces those in Figure 2? What about your body sensation?
And what kind of expression will you have on your face? For no apparent reason, you can feelyourself beginning to smile, can’t you? This is the effect mirror neurons may have. In other words,
your self-image is created by the image you have of your parents or guardians.
When your mother has a fight with her mother-in-law or with your father and mother is
attacked by father, and mother looks sad like the woman in Figure 1, the mirror neurons of theirchildren will show the same kind of excitement as their mother’s emotions. From then on, for thechildren, the mother becomes someone they have to protect. The only way they can now form
attachments with their mother is by protecting her. And the mother ceases to be a “parent” withwhom they can form attachment relationships and a “parent” who will give them comfort andsense of stability. In a word, they can no longer expect their mother to look after them. This is aform of emotional neglect. To remain attached to such a mother, the children are compelled toform a self- image that seeks rewards from others. Unable to seek help from others, they haveInternational Journal of Structured Association Technique No.3

49difficulty recognizing other people’s feelings. Excessive positive thinking makes them avoid facing
problems. They show a sympathetic nervous tone characterized by self- dissociation, which
compels them to constantly watch over themselves.
When boys mature into adults and find codependent partners who resemble theirmothers, they find them endearing and develop an illusion that they are in love with them. By
contrast, girls grow up to become mothers closely resembling their own mothers and findcodependent partners who are apt to act violently toward them.
On the other hand, how do children relate to their fathers? If they’re the type who seek
attachments with their father even as they revolt against him for reproaching their mother, theirmirror neurons, empathizing with the father, will try to develop an other-reward-seeking type ofself with whom their father will feel comfortable and safe. From then on, for the children, thefather becomes someone they have to protect. The only way they can form attachments with theirfather is by protecting him, and from that moment, the father ceases to be a “parent” with whom
the children can form attachment relationships that provide comfort and sense of stability, and thechildren can no longer expect their father to look after them. This too is a form of emotional
neglect. Moreover, if a boy tries to protect his mother, the father will verbally or physically attack
him. By being emotionally and physically abused in this manner, the boy will grow up not having
formed any other father image than that of his abusive father, with the result that he will end up
being just like his father, or find a partner who is obedient just like his mother. This is how thecodependent attachment relationships are handed down from generation to generation.

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Self-image can be changed by a proxy image of parents or guardians
Those who have a positive self-image with a strong sense of self-affirmation tend to be selfconfident and are likely to anticipate that their future will open up for them. Thus they are free ofanxiety and full of hope. They are proud of their past and filled with gratitude. Also, they have noregrets, are patient, free of uncertainty and depression. They have excellent mental health.
By contrast, those who have a negative self-image with a strong sense of self-denial
always tend to expect the worst about their future. They easily harbor fear, anger and sadness,and therefore are unable to gain a sense of well-being. Individuals like this have a self-image
marked by self-repressiveness that can be thought of as attachment relationships that bringneither comfort nor sense of stability (repressing the self to gain recognition of those around you),difficulty with emotion recognition (working hard without relying on the help of those around you),self-disassociation (maintaining composure by regarding your problem as somebody else’s
problem), and problem avoidance (coping with a particular situation ignoring the underlying
problem and with undue positive thinking). It has become clear that, in all cases, the more
pronounced these traits characterize the self-image of an individual, the more severe his or her
depression gets (Munakata, 2003: 2004).
As noted above, the self-image of a client is likely to correlate with the image of his or her
parents or guardians. That is to say, those who have a bad image of their father or mother also
have a bad self-image and lack a sense of well-being. For example, it is now clear that those who
remember their parents having an expression of revulsion like the facial expression on the
woman in Figure 1 tend to have such physical symptoms as headache, stiff shoulder, lower-backInternational Journal of Structured Association Technique No.351

pain and allergy, and have a deeply repulsive self-image, and lack a sense of well-being(Munakata, 2009).

SAT therapy
In SAT therapy, the counselor applies a subjunctive mood* to determine what would happen if aclient is taken back through evolutionary time to their ancestors and ultimately to his or her
particles, and as a result, the client’s past is changed in a way that improves the client’s own life
situation. A retrospective image projection technique is applied to help the client visualize his or
her parents or guardians as people who provide care unconditionally. On the basis of this image,the client discovers his or her parental surrogate representation in photographs, paintings,
religious (Buddhist) paintings and bronze statues that resemble the image the client originally hadof his or her parents or guardians. The client is instructed to continue looking at the parental
surrogate representation so that the brain will receive visual stimulations frequently enough thatthey will become firmly fixed in his or her brain. Instead of looking at the facial expressions of hisor her actual parents or guardians, everyday the client looks at the parental surrogate
representation in photographs, paintings, religious icons, comics and the like that have the same
facial expressions as the ones the client imagines his or her true parents or guardians have.
Forming an attachment relationship with the improved parental surrogate representation helps theclient feel better and more refreshed, which in turn enables his or her body to relax. The brain iseasily affected by mirror neurons, and this is especially prominent in facial expressions. By
imagining the facial expressions of his or her parents or guardians to be like those of persons

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who provide care unconditionally, the client is able to improve his or her self-image to resemble
the smiling faces shown in Figure 2. In this way, the client learns to fix in his or her mind thosesmiling facial expressions as the self-reward-seeking type of self-imaging script (Munakata, 2009).
Of course, together with raising his or her expectations for self-growth, the client seeks further
improvement of his or her self-image, which in turn may inspire the client to come up with an
upgraded version of the substitution expressions and images that he or she had already decidedon.
*Note:The retrospective journey through time covers the entire evolutionary process ranging from the Big Bang toparticles to atomic nuclei to atomic elements to molecules to proteins to living organisms, and to humans. In thisjourney, the client is guided to recall up to the time of his or her ancestors, and through his or her parents or
guidance, to his or her own births and growth. The client is then taken back to any one of the earlier evolutionary
stages, where he or she improves the image of his or her parents or guardians, and in turn improves his own
self-image script. Below are four ways of rewriting one’s self-image script:
1.

Re-resolving imagery therapy: This is a technique for supporting clients’ efforts to change their present
self-image script by counseling them to re-learn how to solve

unresolved problems dating back to theirchildhood days and thereby also changing the self-image script of their parents or guardians.
2.

Three-generation script imagery therapy (formerly, rebirth and re-rearing therapy): This is a technique forsupporting clients’ efforts to change their present self-image script by altering the image script they have
had of their parents or guardians by urging them to go back three generations to re-resolve the crisis in thewomb recalled during the womb-regression therapy.

3.

Pre-generation retrospective imagery therapy: This is a technique for guiding clients to change theirpresent self-image script by altering the image script of their parents and guardians by urging them to go
back in time to re-resolve the survival crisis of previous generations recalled during the womb
retrogression therapy.

4.

Retrospective evolution imagery therapy: This is a technique for guiding clients to change their present
self-image script by urging them to go back through time to re-revolve the crisis of their particles or
biological existence recalled during the womb regression therapy.

_____________________________________________________________________________
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Controlling the fear of human relationships
We alternate between hope and fear as we watch television and movies. It’s as though we weretalking with our past. We project and fear those characters in stories we ourselves haveexperienced in our past, and relive the anxiety, sadness and other emotions that we experienced
then. Similarly, among those we have encountered since infancy, most of the others who make us
feel stressed have some of the same expressions that our parents or guardians who made us feelstressed in the past had. This is why we relive the same stress. We respond to some of thoseexpressions in the same emotional way. To explain this phenomenon, it will be useful to giveyourself the test described below.
Picture in your mind the good expressions and expressions of revulsion of either yourfather or mother, and see how your body reacts to the expressions and images you’ve recalled. If
the parent you recall has a good expression, of course, your body will relax, but if the parent has
an expression of revulsion, your body will respond in a variety of ways: I feel tense in some partsof your body. I feel a knot of pain in my head; I feel stiff in the shoulders; I have a pain in mychest; my heart starts pounding; my stomach feels funny; my hands and feet feel cold; and mywhole body becomes rigid.
Now, consider how a client’s body might react if the counselor asked him or her to recall
the expression on the face of a person who made him or her feel stressed. If the client were
properly guided in this, you would be surprised at the expression of revulsion on the face of either
the aforementioned father or that of the mother, or at the similarity of the body’s responses when
the client looked at the expression of both the father and the mother (Munakata, 2009).
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Until the client becomes self-reliant, it is understandable that the therapist should try tocontrol the client’s survival fears by controlling the attachment relationship between the client andhis or her parents or guardians. But there is no reason to fear one’s parents or guardians or to besaddened after becoming independent. If you can control this fear by applying the proxyexpressions and images of your parents or guardians, by all means, use them to your advantage.

Cutting the umbilical cord of codependency with SKP surrogate representation
However, there are cases where you cannot reduce your own stress merely with the parental
surrogate representation. Many symptoms, like suicide attempt, alcohol/substance abuse,
personality disorder, and mental illness that you cannot control acting on your own will, cannot be
explained by what psychoanalytic theories (including Bowlby’s theory) refer to as the way youwere conditioned by your parents or guardians in your infancy. This is because there are manycases where people find happiness despite their parents’ or guardians’ failure to raise or condition
them properly in their infancy. This is why treatment strategies (attachment therapy, play therapy)
that focus only on conditioning rarely lead to cure. Such treatment strategies are more likely tolead to a pathological condition of codependency of care providers. I believe the reason these
symptomatic behaviors cannot be controlled by you acting on your own is that they have their
origin in the fear that conditions you during the period between the embryo and the fetus.
The first factor to consider in analyzing the period when you are still in your mother’s womb
is the significant effect emissions of various chemical substances (e.g., noradrenalin, stresshormones) have on the embryo and fetus that reflects the relation nature of your mother andInternational Journal of Structured Association Technique No.3

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father.
Another factor is the possibility of embryonic and fetal deaths in multiple births. Medical
research has shown that only one in three zygotes test positive when urinalyses are administeredon pregnant women, the rest (i.e., two-thirds) die and disappear. Although most miscarriages arecaused by abnormality of chromosome, since other causes of miscarriages (i.e., half of thegenetic material contained in the blastocyst) are inherited from the father, the mother’s immune
system regards them as viruses and attacks them, thus resulting in fetal deaths - The chemicalmaterial that remains after the remains of the dead fetuses is reabsorbed by the mother. The
information carried by the reabsorbed chemical material may be stored in the cell membranes ofmore than 50,000 uterine cell receptors.
In the case of unborn babies of multiple conceptions, it may be that fear, anger, sense ofgrief and other emotions felt by the “siblings that died” are transmitted to the “siblings thatsurvived” via their mirror neurons. This is why may be there is the possession of emotional
information of our other siblings. Even if a client strongly desires to live, if the death wish, fear andsense of grief of his or her siblings have been transmitted to the client, then the client will bear ababy with contradictory emotions and personalities.
Clinical cases using SAT imagery therapy make it clear that patients with thesecontradictory personalities engage in destructive behaviors like attempted suicide andalcohol/substance abuse and suffer from personality disorders and mental illness. These
disorders are considered to be purely diseases of the body. However, our research demonstrates
that even those suffering from autoimmune diseases have similar backgrounds (Munakata, 2005;

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Munakata, 2007; Munakata, Kobayashi, 2007).
This is why it is necessary to devise a treatment program that will cut off the transmissionof emotions afflicting the client’s deceased siblings. In SAT therapy, a three-generation retro
narrative imagery technique is used to trace the crisis that have fallen on the client’s three
generations – parents, siblings and children – by having him or her go back three generations
and re-resolve the crisis in the womb recalled during the womb-regression therapy, thereby
liberating itself- from his or her subconscious control by turning his or her facial expression intoproxy expressions and images.
Of the three-generation family, including those “siblings that died an absurd death(miscarriage, still birth, death by accident, death by disease, etc.), “those who protect us, or thosewith whom we wish to form codependency relationships” are referred to as spiritual key persons(SKP). By consciously visualizing the surrogate representation of the expressions on the faces of
SKPs, clients undergoing the womb-regression therapy are clearly able to feel at ease and form atension-free self-image.
If a client does not have the necessary SKP surrogate representation, the counselor will
guide him or her to seek “a person who will protect him or her, or a person he or she would like toprotect” and form a codependency relationship in which the client plays the role of the underdog
or the caregiver. The client is guided this way because the codependency relationship will
reproduce a whirlpool of malignant stress that in turn will produce stress-ridden patients andcreate intractable problems. Consequently, if the client continues to look at his or her parental or
SKP surrogate representation, he/she will be able to proceed to form a secure attachment

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relationship based on sense of ease, respect and gratitude. And if the client’s parents or
guardians are still alive, the latter will now be able to change his or her relationship with his or her
real parents or guardians.

Conclusion
Other-reward-seeking society where people fight over limited resources, which generate a lot of
malignant stress that systematically batters the very social fiber, is about to outlive its usefulness.
The time has come to build a self-reward-seeking society marked by a highly-organized structure
where people cooperate with each other to gain unlimited self-rewards such as self-growth,
self-satisfaction and gratitude. To build such a society, we must move beyond conventional
codependency relationships and form secure attachment relationships based on sense of ease,respect and gratitude.

References
Ainsworth, M (1979). Infant-mother attachment.

American Psychology 34, 932-937.

Albanese, A, Hamill, G, Jones, J, Skuse, D, Matthew, D R, Stanhope, R (1994). Reversity ofphysiological growth hormone secretion with psychosocial dwarfism. Clinical Endocrinology
40(5), 687-692.
Bowlby, J (1998). A secure base: parent-child attachment and healthy human development. Basic
Books, NY.
Bowlby, J (1982).

Attachment. Basic Books Inc, NY.

Carter, R (1998). Mapping the mind. The Orion Publishing Group Ltd.
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Munakata, T (2003). Depression as human professionals. Journal of Psychiatric and Consultation
Liaison Nursing 4(1)，7-13 (in Japanese).
Munakata, T (ed.) ( 2004). Counseling Health Care, 1-272. Tokyo: Kaneko publishing company，(in Japanese).
Munakata, T (2006). SAT Therapy, 1-24. Tokyo: Kaneko publishing company, (in Japanese).
Munakata, T & Kobayashi, K (2007). SAT therapy for treating cancer, 1-226. Tokyo: Sinjusha, (inJapanese)
Munakata, T (2008). Does SAT re-scripting expression imagery enable us to overcome
unendurable hardships toward true life career? Journal of Health Counseling 15, 75-92 (inJapanese).
Perry, B, Szalavitz, M (2006). The boy who was raised as a dog and other stories from a childpsychiatrist’s notebook.

Perseus Books, Inc., Cambridge, Massachusetts.

Rizzolatti, G, Craighero, L (2004). The mirror-neuron system.

Annual Review of neuroscience27, 169-92.
Stanhope, R, Wilks, Z, Hamill, G (1994).

Failure to grow: lack of food or lack of love?

Professional Care of the Mother and Child, 4(8), 234–237.
Southall, D P, Plunkett, M C, Banks, M W, Falkov, AF, Samuels, M P (1997). Covert video
recordings of life- threatening child abuse: lesions for child protection. Pediatrics 100(5),735-760.
Van der Kolk, B A (ed.) (1987). Psychological trauma. Washington DC.
Van der Kolk, B A (1989). The compulsion to repeat the trauma: repeat the trauma: reenactment,International Journal of Structured Association Technique No.3

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revictimization and masochism. Psychiatric Clinics of North America, Vol 12. Treatment ofVictims of Sexual Abuse, W B Saunders, Philadelphia.

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Comparative examination of the effects of the SAT-DVD Learning Program Therapy and the
Qigong (the traditional Chinese breathing exercise) Therapy to alleviate stress in cancer
survivors

Noriko Higuchi1), Kazue Nakashima2), Kiriko Murakami2),
Ryoichi Obitsu3), Tsunetsugu Munakata2)
1) Meikai University, Research Building, 1Meikai, Urayasu city, JAPAN
Faculty of Languages and Cultures Department of English
2)Division of Health Counseling Science, Department of Human Care Science, Graduate
School of Comprehensive Human Sciences, University of Tsukuba3) Obitsu Sankeijyuku Clinic

Summary〔Purpose〕 This study aimed to examine the stress-alleviative effects of the self-learning
SAT Imagery Therapy recorded on DVD (hereinafter called as SAT-DVD)in cancer survivors.

With the qigong therapy, a representative alternative medicine that makes use of images, as thecontrol group, various changes before and after the intervention were examined to alleviate
depression, psychological traits and biochemical indexes of salivary immunity.
〔Methods〕 The subjects were 17 cancer survivors (aged 52.2±8.7).
Prospective, pre/post-test intervention, single-arm trial
therapy, SAT-DVD watching therapy.

The study design:

Intervention Methods: the qigong

Psychological indexes were measured by means ofself-report questionnaire before, immediately after and one week after each intervention of theqigong practice and SAT-DVD watching.

Saliva for test was collected before and after each

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intervention and was analyzed statistically.

Measured items: Distinction of sex, age, andpsychological indexes (scales of depression, self-control, difficulty of emotional recognition,
problem solving, dissociative identity, and trauma syndrome).
〔Results and Discussions〕As to the biochemical indexes, significant decline of theadrenocortical hormone level after the qigong intervention and significant rise of salivary
secretory immunoglobulin level after SAT-DVD watching were observed.

As to thepsychological indicators on the other hand, no significant change was observed in the scores ofany psychological characteristics after the qigong intervention while significant decline wasobserved in the scales of depression, self-control, difficulty of emotional recognition and thescores of trauma syndrome after the SAT-DVD watching.
It was presumed that improvement of self-image and alleviation of depression was the possiblemeans that SAT-DVD watching therapy improved immunity responses (the increase of salivary
secretory immunoglobulin) in the cancer survivors.

Keyword: cancer survivor

SAT stress management

depression

salivary SIgA

salivary cortizol

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1.

Introduction

The number of cancer survivors in Japan is estimated to have reached 3,650,000 at the year-end
of 2004 and is forecasted to increase to as many as 5,000,000.1)

According to the study by

Hoffman et al on cancer survivors in the US, long-term cancer survivors are at increased risk ofexperiencing serious psychological distress compared with people who have never been
diagnosed with cancer.2) Also in Japan there are indications of problems of mental health for
rapidly increasing cancer survivors, and particularly problems of their living with fears ofrecurrence and metastasis of cancer.3)

The measure from the view point of mental health is anurgent need for the cancer survivors since the very fear has indirect effects to intensify stress andprevent spontaneous cure.

When it comes to a relation between cancer and psychosocial

factors, studies on the relation between cancer and personality have been known for a long time.
Suppression and denial of emotional expression, failure in coping with stress, and Type C
personality4) characteristically with such resigned reactions as hopelessness and helplessness
have been reportedly related to outset and progression of cancer.

According to Maeda et al4),

the self-suppression type (self-suppression aiming to be appreciated by the people around) andthe type of difficulty in recognizing emotion (having difficulty in recognizing own emotion andinclination to keep going to the end without seeking assistance from the people around) areremarkable as the character traits of the patients after gastric cancer resection. To be more
precise, they have difficulty in recognizing their own senses and emotions and they have little
inclination to express themselves but they are very much persevering.
International Journal of Structured Association Technique No.3

In addition to the above,63

Munakata5) indicated that the dissociative identity type (to see one’s own matter as if it were
somebody else’s in order to remain calm), the problem avoidance type (to avoid facing a mattersquarely and tackle anything with a super-positive attitude of mind) and the self-pity type (to lookat oneself with pity) are also remarkable as the character traits of the patients after gastric cancer
resection.

By all accounts, they have difficulty in recognizing their own senses and emotions,seeking help from the people around and facing up the reality.

Also, they are apt to take asuper-positive attitude of mind and keep going to the end tenaciously alone.

Some people

explain that the immunity against tumor cells gets lowered because they cannot openly express
their displeasure, try to carry out all the way through their duties over-seriously and thus keep
stress chronically in.

Many a prospective cohort study on a causal relation between

cancer-prone personality and outset of cancer reports the relationship between outset of cancer
and depression and emotional suppression.6)-8)

On the other hand, there are some reports

indicating no clear relationship between them.8)-11)

Thus academic opinion is still divided on

this question.
Personality is made up in the core of temperament that is subject to genes and self-image scriptthat creates the behavioral traits based on the temperament.

As to the characters related tostress, there are in the core some hereditary temperament such as anxiety-prone temperament
and tenacious temperament that is highly sensitive to stress.

When people have experiences ofbirth trauma and infancy trauma, the self-image of the others-reward oriented type which easily
over-reacts to stress remains in their memory, the scripts for their behavioral traits are finished,
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and as a result the stress-prone temperament such as self-suppressive, difficult to recognize
emotion, and problem avoidant are believed to be formed.
A person with the stress-prone temperament easily stretches his/her sympathetic nerve and isforced to continuously secrete adrenaline.

Consequently, it easily leads to the decrease oflymphocytes in a leukocyte and the increase of granulocyte due to the continuous secretion ofadrenaline.

The active oxygen released from granulocyte serves to exclude foreign mattersentered into the body.

It is suggested at the same time that it may possibly cause the outset ofcancer by damaging cells and nucleuses and genes in cells.12)
According to some previous reports, cancer patients are so aspiring having strong tenacious
temperament, so thick-skinned that they would not recognize their own emotions and senses, andso solitary without trying to seek help from others.

They try to keep going to the end with theother-reward oriented behavior so that they may be appreciated by other people.

They tend tolack in communications with their families and their family relationship is weakened.13)14) If welook at it from a different angle, the disease called in the name of cancer has some truth to help
the patients find the original way they feel in accordance with their inherited genes, and also findthe necessity of enjoying themselves, of mentally communicating with families, and of theself-reward oriented behavior with which they may seek self-satisfaction and appreciation.15)
On the hypothesis that stress has an influence on the outset of cancer, lots of psychotherapy
have been conducted for cancer patients both domestically and abroad.

Making the survey ofstudies on psychological interventions with the study design of randomized clinical trials, we learn,International Journal of Structured Association Technique No.3

65

from a study on the intervention to breast cancer patients with symptoms of metastasis, life
prolonging effect of the intervention for those in the intervention group.16)
Although longer survival was denied in the follow-up trials, the intervention has proved to haveeffects to decrease psychological stress and ease pains.17) Post operative patients of malignant
melanoma in the short-term cognitive behavioral intervention group reportedly showed moreincrease in the ratio of NK cells compared with those in the control group.18)19) It is reported byRehse et al20) that psychological intervention is valid for improving QOL based on the results ofmeta-analysis concerning the effects of psychosocial intervention for adult cancer patients.
While on the other hand, we see, among studies on randomized socio-psychological intervention,some negative reports that psychological intervention is not effective for longer survival.21)22)
Notwithstanding accumulated researches and studies as seen above, It is hard to say that
evidences for the effects of psychological intervention have been amply provided.
The SAT imagery therapy helps the patient become aware how the self-image is changed withthe changes in other past images as if he/she were brought up by an unconditional caretakerunder improved conditions for his/her own growth. According to our clinical research, it confirms
the weakened behavioral traits of others-reward oriented type such as self-suppression anddifficulty in emotional recognition, as well as the significant effect to enhance the immunity
responses (to increase lymphocyte count and degree of activation) and the rate of tumor
suppressor gene expression.23)24)25)

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In practice, a hypothetical way is used in the SAT imagery therapy: The patients, with themeditative imaging technique to go backwards to the past in the evolutionary process (self - a
fosterer - an ancestor - a biological being - a particulate

being), experiences time regression.

And in the newly created image, their past are changed as if their growing background were
improved and as if they were brought up by those who offered unconditional care.
self-image is also changed in some way or another.

Then, theIn order for them to form their futureself-image, we help the patients become aware of the self-image script that they were brought up
under natural growing background with unconditional care although it has not been transmitted
from their ancestors over generations.

And we encourage them to become aware of the actionplans (major, middle, and minor objectives) for realizing the improved self-image script.

It is theThird Generation Cognitive Behavioral Therapies with which emotional change, cognitive change
and behavioral change are promoted.

We, on the basis of the SAT Imagery Therapy, have beendeveloping the stress management system with resources available for cancer patients forincreasing their mental health, immunity and expression of tumor suppressor genes.
The purpose of this study is to examine the effects of the SAT self-learning program recorded on
DVD with a control group as a basic study for developing a stress management e-learning
program for cancer survivors utilizing web-technique and the SAT Imagery Therapy.

We

adopted the qigong therapy and set it as a control group, partly because it is utilized by many
cancer survivors though it is different from this program in utilizing physical exercise, and partly
because it, utilizing various images, shares common feature of imagery therapy with this program.
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It is hypothesized that watching the SAT-DVD self-learning program for cancer survivors with thecontrol group of the qigong therapy may alleviate depression, change psychological traits,
improve immunity responses/salivary corticosteroid index.

2. Method
Theoretical Background

The Qigong Therapy:

The basic elements of the qigong are said to be the control of body,breathing and mind.

The autonomic nervous system gets stabilized by moving the body,

catching the breath and relaxing.

By exercising the so-called “space time method” centered on

the solar plexus breathing, the effects to prevent recurrence and metastasis of individual diseaseby site are expected for cancer patients.28)
SAT-DVD self-learning program: With this approach to let cancer survivors watch SAT-DVD, weaimed to let them weaken the image of expected death and alleviate the fears by having a senseof gratitude for being alive and change their behavior from the self-reward oriented type to theothers-reward oriented.

A couple of learning assistants sat in company with the subjects of one

to four in number each time and supported their learning through watching the SAT-DVD
including PC operations.

It took 90 minutes only each time for watching the SAT-DVD.

of the support are shown in Table1.

Details

The SAT-DVD watching was executed with interval of 2 to 3

weeks after the qigong intervention.

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To promote their self-understanding the temperament coaching therapy and psychological trait
checking were utilized.

Hereditary temperament, nucleus of one’s nature consisting ofhereditary factors and biological factors related to neurotransmitter, does not change throughout
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69

one’s lifetime.

Among them all, those who have either “the Persistence Type of Temperament”

observed in perfectionists or “the Anxiety Type of Temperament” represented by pessimism andtendency to be opinionated are inclined to become fearful, solitary and stressful.

So theyneeded to be coached for their self-care activities.
Furthermore, in order to help them change their self-image of suppressing the self andaccumulating it in the soul, blunting the emotion, and staying the course at the sacrifice of the self,
to the new one of enjoying the own life, and exchanging heartfelt communications with theirfamilies and friends, we let them experience the two kinds of imaging works used in the SAT
imagery therapy as shown in Table 1.

We helped them notice the necessity to change their

behavioral trait to the one of the self-reward oriented type that is hard to accumulate stress by
way of letting them know the gap between the innate self obtained through these exercised
self-image trainings (the self protected and brought up at will) and the actual one.

Research Collaborators

A meeting for explaining the study was held for participants to the qigong class sponsored by aclinic specialized in cancer treatment in the Tokyo metropolitan area, and research volunteers
were collected among them.

On explaining the objectives and meaning of the research, close

attention was paid by the researchers including one in charge of practicing qigong to keep
neutrality so that any biased information might not be inputted.

There were 34 prospective

research volunteers: 17 cancer survivors and 17 healthy individuals including families of cancer
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survivors. The intervention period lasted about one year: December, 2007 ~ February, 2008.

Participants

The 17 cancer survivors who had agreed to the explanations on the intended and meaning of theresearch were set as the analysis subject.

Healthy individuals were excluded from the analysis

for the purpose of the study was to examine the stress management therapy for the cancer
survivors.

As to the changes in the psychological indexes, analyzed were the 15 subjects (2males and 13 females) excluding 2 who were not available at the time of research conducted 1
week after the intervention.

Attributes of the study participants are shown in Table 2.

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Ethical Considerations

Approval was obtained for this study from the Board of Examination of Epidemiological Study, theUniversity of Tsukuba.

Explanation on the intended meaning of this research was made inwriting and orally to the subjects and the research was conducted after obtaining the agreementof the subjects.

Study measures
Psychological traits

1.

Self-rating depression scale (SDS, Zung)23)[20 items, maximum of 80 points]:

SDS is ameasures of depression. The higher the points are, the higher the depression.

2.

Scale of self-suppressive behavioral trait (Munakata, 1996)24)25)[10 items, maximum of 20

points]: The scale measures the expectations of favour from those people around by suppressing
own emotions to satisfy those around.

The scale comprises of 10 items; 2 points is given to“always so”, 1 point “usually so” and 0 point “not so”, with total scores of minimum 0 to maximum
20 points.

3.

The scale of problem solving behavioral trait (Munakata, 2001)25) [10 items, maximum of 20

points]: This is the scale to measure the behavioral trait to try to positively, effectively andInternational Journal of Structured Association Technique No.3

72

realistically deal with the tasks and problems standing in front.

The scale comprises of 10 items

including “In anything I rather make judgment while confirming the fact”.

The higher the points

are, the more remarkable is the trait to try realistically dealing with the problem for solution.
Lower points in this item suggest the tendency to repeat the same kind of failures and errors forpostponing the solving of problems without facing up to the reality.

It is also believed that there

exist some stressful memories with aversive emotions behind the low points in this item.

4.

The scale of difficulty in recognizing emotions (Munakata, 2001)25)[10 items, maximum of

20 points]: This is to measure the tendency of difficulty in recognizing emotions that is to endure
the hardship without getting emotional and to easily somaticize stress.

5.

The scale of the dissociative identity (Munakata, 2001)25) [10 items, maximum of 20 points]:

This is to measure the scale of dissociative identity, that is the split self, one being embarrassedwith a serious problem and the other calmly watching the former.

The higher the points for thisitem are, the stronger is the emotion of dissociative identity such as fear, impatience and panic.

6.

The scale of the post-traumatic stress syndrome (Munakata, 2001)25) [10 items, maximum of

10 points]: This is to measure the seriousness of traumatic stress symptom.

The higher the

points for this item are, the stronger is the emotional reactions under a specific key situation withthe recognition of trauma.
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Biochemical Indexes

In order to examine the stress management effects of practicing the qigong program and
SAT-DVD electronic self-learning program for the participants, saliva was collected before andafter the qigong class and SAT-DVD watching, and then the changes in the salivary corticosteroid
and salivary SIgA were measured.

1. Salivary corticosteroid (Cortisol): Steroid hormone secreted from adrenal cortex is discharged
into the blood and then is carried to saliva. It is said that stress can be quantitated to some extent
by them.26)

It is known that there is a time lag of about 20 to 30 minutes between stressor andresponse.

2.

Salivary Secretory Immunoglobulin A (salivary SIgA): Salivary SIgA has a major function in

mucosal immunity.

It is said that under stressful conditions the concentration of SIgA, a

complement component of immunity in saliva, is lowered.27)

Analysis

Responses to the questionnaire were collected 5 times in total, namely, before the intervention,
immediately after the qigong class, one week after the qigong class, immediately after watching
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SAT-DVD self-learning program, and finally one week after watching SAT-DVD self-learning
program.
Psychological indexes of the 15 subjects were measured before, immediately after and one week
after intervention.

Their biochemical data, measured before and immediately after intervention,

were statistically analyzed.

Normality of psychological indexes was checked, and the two way

repeated measures (within subjects × within subjects) analysis of variance (ANOVA ) was
conducted.

As to the changes in biochemical data, the Wilcoxon Test, which is a

non-parametric statistical hypothesis test, was used due to the large scale individual variation ofdata.

3. Results

The changes in biochemical indexes between pre- and post- intervention (Table 3)

Before and after each intervention of the qigong practice and the SAT-DVD watching examined
was how the secretion levels of salivary corticosteroid and salivary SIgA immediately after and 1
week after intervention were changed in comparison with those before intervention.
International Journal of Structured Association Technique No.3

Significant
75decline of corticosteroid was observed after the qigong intervention (Z=−2.23, p=0.03).

Alsosignificant was the observed rise of salivary SIgA after the SAT-DVD watching (Z= -2.27, p=0.02).

The changes in psychological traits before and after the intervention (Figure 1)

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Scores for the qigong therapy and the SAT-DVD e-learning program before, immediately and 1
week after intervention were analyzed with the repeated measures (corresponding ×
corresponding) two way analysis of variance (ANOVA). As a result, the interaction effects
between time and intervention were observed in the self-rating depression scale (F(2,24)=4.45,
p= .023).

Now after the examination of simple main effect by the intervention method, thedecline of the self-rating depression scale was observed in the SAT-DVD watching group while nosuch change was confirmed in the qigong group.

As the result of examination by multiple

comparison, improvement of the self-rating depression scale was observed by the fact that itturned out to be significantly lowered immediately and 1 week after watching compared with theone before watching (before intervention ― immediately after intervention; p＜.05, before
intervention ― 1 week after intervention; p＜.05).
Then, the interaction effect of time by intervention was confirmed in the scale of self-repression(F(2,26)=13.94, p< .001).

Now after the examination of simple main effect, significant decline ofscale of self-suppression was confirmed in the SAT-DVD watching group (F(2,26)=21.5, p=.001)
while no significant change was observed in the qigong group either at three points of time of theqigong intervention(F(2,29)=1.219, p=.310, n.s.).

With the fact that in multiple comparison thescores were significantly lowered at both points of time, immediately and 1 week after intervention
compared with those before intervention (before intervention − immediately after intervention;p ＜ 0.5, before intervention − 1 week after intervention; p ＜ .05), the weakened
self-suppression and promoted self-expression were observed.
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Significant change was seen in the scale of problem solving behavioral trait neither as theinteraction effect of time by intervention nor as the simple main effect of respective time andintervention(interaction effect:

F(2,24)=.279, p=.61, simple main effect (time): F(2,24)=1.338,

p=.281, simple main effect (intervention method) : F(1,12)=.915, p=.36).
The interaction effect of time by intervention was not confirmed in the scale of difficulty inemotional recognition (F(2,26)=1.762, p=.192, n.s.), but the simple main effect was confirmed
both at the time of intervention and in the intervention method (intervention method: F(1,13)=18.41, p=.001;

time of intervention: F(2,26)=8.5, p=.002).

Significant changes in scoresby the timing of intervention were confirmed between the two groups.

With the fact that in

multiple comparison the scores were significantly lowered for the SAT-DVD watching group at
both points of time immediately and 1 week after intervention compared with those before
intervention (before intervention − immediately after intervention; p＜0.5, before intervention− 1 week after intervention; p＜.05), blunting of emotion was confirmed to be alleviated.
The interaction effect of time by intervention was confirmed in the scale of the dissociative identity(F(2,24)=3.33, p=.033).

Now after the examination of simple main effect by the intervention

method, significant decline of scale of the dissociative identity was confirmed in the SAT・DVD
watching group while no significant change was confirmed in the qigong group (simple main
effect; at the time of intervention for SAT-DVD watching group: F(2,22)=4.003, p=.003
time of intervention for the qigong group: F(2,29)=0.062, p=.94).

at theAfter the examination withmultiple comparison, significant changes in scores were confirmed by the timing of intervention.
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With the fact that in multiple comparison the scores were significantly lowered for each group 1
week after intervention compared with those before intervention (before intervention −immediately after intervention; p＜0.5, before intervention − 1 week after intervention; p＜.05),
tendency of the dissociative identity was confirmed to be weakened.
The interaction effect of time by intervention was observed in the scale of the post-traumaticstress syndrome (F(2,26)=4.64, p=.019).

Now after the examination of simple main effect by

the intervention method, significant changes in scale of the post-traumatic stress syndrome wereobserved in the SAT-DVD watching group, and after the examination with multiple comparison,
the scores were significantly lowered for the SAT-DVD watching group at both points of time,
immediately and 1 week after intervention, compared with those before intervention (before
intervention − immediately after intervention; p＜0.5, before intervention − 1 week after
intervention; p＜.05),

As to the contents of the program, many of the participants looked to have enjoyed their imaging
experiences in both programs as seen in the following opinions; “It was an enjoyable work to
image the space and the interior of the womb.
linked with the space.

I heard in the practice of qigong that we were

I was excited with the sense of going to and from the space.” “I was

entranced as if I had been in a dream.”
As to the SAT-DVD watching, many of the participants looked to have realized the necessity tolive in a relaxed manner as seen in the following opinions; “I suffer from trifling matters in myInternational Journal of Structured Association Technique No.3

79

everyday life.

I wanted to live in an easy state.” “I thought I had improved fairly successfully myways of thinking and living in my own way, but I was awoken to the fact that actually I had beenleading conventional life with an idea that it must be so and so.

Now I want to explore thepossibility to realize myself in accordance with my visualized self-image by relaxing a bit more
and trusting myself.”
As to the innate self-image and behavioral objectives for living with it, many of the participants
looked to consciously practice the self-reward oriented way of living as seen in the following
opinions; “From time to time I remember and image my inner self.” “I practice to live inaccordance with my innate self-image.” “I practice looking at the displayed memo.”

4. Discussion

Changes in the biochemical indexes

In this study we examined changes in immunity responses for cancer survivors, taking the
SAT-DVD watching and the qigong, one of the alternative medicines, as control groups.

Theqigong reportedly enhances spontaneous cure28), and also reported is that it is effective fordecreasing leukopenia in case it is used in combination with chemotherapies for cancer
patients.29)

Density of salivary corticosteroid showed a significant decline immediately after theqigong class, which suggested its effectiveness for alleviating stress.
International Journal of Structured Association Technique No.3

Corticosteroids increase80when human bodies are exposed to stress and tension while they decrease when human bodies
are in the state of relaxation.26)

Accordingly, the decline in corticosteroid was thought to be

attributable to the acquirement of the state of physical relaxation by participation to the qigong
class.

However, it is known that the level of corticosteroid is subject to diurnal variation with its

peak at 8 o’clock in the morning and gradual decline thereafter until noon.30)

Since the qigong

class was conducted from 9 o’clock until 10 in the morning, effect of diurnal variation on thedecrease of corticosteroid cannot be denied, and therefore, there is a limit to insisting theunmixed effect of the qigong.
The decrease of corticosteroid in the blood was reported by Van der Pompe G et al as the resultof 13 week short-term psychotherapy program for breast cancer patients, but no such significant
change was seen in the density of corticosteroid by the comparison of the levels before and after
our 90 minute SAT-DVD intervention.

However, significant increase was observed in SIgA.

is known that SIgA reflects the psychosomatic stress.

It

SIgA secretion is decreased by placing aburden of stress on the body or bearing negative emotions in mind.27)

It was suggested as aresult of this study that SAT-DVD watching, immediately after carrying it out, had stress alleviating
effect.
It is said that salivary SIgA easily reflects psychosomatic stress27) while salivary corticosteroid
rather physical stress.

When the contents of the intervention program of this time are taken into

consideration, the effect to alleviate psychological stress may have been reflected in the
SAT-DVD watching and the effect to alleviate somatic stress in the qigong class.
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Changes in Psychological Indexes

By the qigong intervention, no change was confirmed in any psychological indexes.

By theSAT-DVD watching on the other hand, improvement was confirmed in all the psychologicalindexes except for the behavioral trait of problem solving type.

After all, those who participatedin the SAT-DVD watching intervention program were promoted to change their self-image to theone in which negative events were hard to be grasped as mental damages, self-expression waseasy and support from the people around was easily sought when necessary.
Surveying the interventions conducted in the past, reported was a case showing the effectivenessto alleviate depression with the combined use of Simonton’s image control method for cancer
care and biofeedback.32) In it, the correlation is studied between alleviation of depression andrecovering “the identity” that can control disease by creating the image of own lymphocytes
attacking and eating cancer cells.

Reported also by Fawzy et al33) was that as the result of thepsychological intervention by the supporting group (tackling the cancer problems with colleagues)
the mortality rate of the subject group showed one third of the control group 5 years after
intervention.

Based on the past reports, the identity of the subject patient and the mutual

supporting have been discussed as the factors of great importance to overcome cancer.
In the SAT-DVD program, unlike other conventional psychological interventions including
cognitive behavioral therapies, the method without depending on the information based on theInternational Journal of Structured Association Technique No.3

82

memory of past experiences is used for promoting the patients to recognize their “innate self”.
To give a full account, if a behavioral change is resolved with the past self-image intact, it isnothing but an extension of the present way of living.
one’s character demonstrated by behavioral trait.

Therefore, it is impossible to change

Human cognition and behavior are fixed by

the self-image obtained from the information based on the memory of past experiences.

We

come to understand how we should better lead the life with the figure of innate self only when we
recognize the difference between “the actual self” and the visualized image of “the innate self” inwhich we were protected unconditionally and lived at will.

That we adopted an imaging work forreconstructing the inner self based on a certain hypothetical way seemed to be an importantfactor for the obtained result.

If we give a thought to descriptive data including opinions together

with changes in the psychological indexes, the followings seem to have been influential; thesubjects realized their innate self, andthey set the concrete and clear-cut behavioral plan

which looked satisfactory and enjoyable for them and they themselves were able to realize thatthey were actually carrying out the plan.

Among the measured behavioral traits, however, nosignificant change of score was observed in the behavioral trait of problem solving type.

Toenhance the ability of problem solving, additional approaches seemed necessary including
showing the subjects a competent role model.

Also, it was considered as one of the major

causes that other latent psychological problems might remain unsolved and disturb enhancementof problem solving ability.
The qigong therapy was confirmed effective for relaxation by the decrease of salivary
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83

corticosteroid, but at the same time it showed changes neither in scale of depression nor in
psychological traits.

With the qigong therapy alone it seemed impossible to help the patients torealize, much less to change, the self-image script (the scenario by which behavioral traits werecreated) that caused stress disorders including cancer.

If the qigong practice is used together

with other programs including the reconstruction of the self-image script, however, it may possibly
become an effective stress management therapy.
The SAT-DVD self-learning system has possibilities to provide many cancer survivors with carefor stress compensating for the weakness of other individual intervention therapies in which thesubject is limited to a small number of people.

The Limits of the Study and Future Tasks

We tried conducting the SAT-DVD watching program with the support by an intervention assistantas one part of the basic study for developing the SAT self-learning system utilizing DVD, but
cancer survivors might not necessarily be familiar with PC operation.

Therefore, the effects ofthe program conducted with the assistant’s support in research of this time may be different fromthose of the program to be individually practiced by a patient alone.

It is required henceforth toclosely examine the effects of the program under the circumstances where a cancer survivor,
operating PC alone, practices this program to be distributed through Web network.

Furthermore,

only short-term effectiveness before, immediately after and 1 week after the program intervention
International Journal of Structured Association Technique No.3

84was examined in this study.

It has been untouched and remains therefore as a future task to

examine if the improvements of immunity response and depression are sustainable in the longrun. s the research design this time, we adopted the methods conforming to the single-grouptime-series design and the crossover design.

However, there was a limit to the study that

influence of carryover effects cannot be eliminated since two different kinds of intervention wereconducted to all the subjects in the same order.

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Yoshimura K: A study of the cancer survivor statistics in Japan. Annual report of the cancer

research. Ministry of Health, Labor and Welfare, 2003.

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Takaharu K: Palliative care and psychosomatic medicine. Japanese Society ofPsychosomatic Medicine, 48(3):173,2008

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Temoshok L.: Personality, coping style, emotion and cancer: towards an integrative model.

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Shekelle RB, Raynor WJ Jr, Ostfeld AM, et al:Psychological depression and 17-year risk ofdeath from cancer. Psychosom Med. 43(2):117-25, 1981

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Takako Maeda, Francis N. Onuoha, Tsunetsugu Munakata: The Effect of Postoperative

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