Original article

Structured Association Technique (SAT) Imagery Work Preventing Depression throughFocusing on Self-Image among Japanese Female University Students

Toshiko Ueda1), Wen-Yan Hu2), Tsunetsugu Munakata3)

1) Faculty of Education, Ehime University, 3,Bunkyo-cho, Matsuyama, Ehime 790-8577,
Japan2) Mental Health Counseling Center, Zhejiang Gongshang University, Hangzhou, China
3) Institute of Emotive Cognitive Behavior Therapy
Professor Emeritus of University of Tsukuba, Japan・Email addresses: tohsiko6617@hotmail.com
Abstract

The purpose of the present study was to evaluate the effectiveness of structured association
technique (SAT) imagery work on preventing depression among Japanese female university
students through improving self-image. Subjects were divided into two groups; an intervention
group and control group. The intervention group participated in SAT imagery work approach
which aims to improve the people’s self-image. The control group was given a lecture about
mental health by a physical education teacher. In the intervention group, the scores on the
self-esteem and problem solving behavioral trait scales significantly increased, while the scoreson the self-repression behavioral trait scale and the SDS scale significantly decreased afterInternational Journal of Structured Association Technique No.61

intervention. In the control group, none of these scores showed significant change. One possible
interpretation for the current results is that because of the self-image of the participants amongintervention group changed positively, changes their feelings and thoughts for the futurechanged to positive ones, which result in ameliorate depression. Moreover, the students amongintervention group could perceive more emotional support from fellow students, which might becontribute to the increase in the measures score.

Keywords: SAT imagery work
Depression
Prevention
Self-image
Female university students
1. Introduction
The mental disorder of university students has been well documented in the literature. For
example, the rate of neurotics of students was higher than that of other life stage groups [1].
Another study reported that mental health problems have become long-term problems andalthough students with probable mental disorders are aware of the need for treatment, they do
not receive treatment [2]. The preventive treatments are required also because of the symptoms
of depression in adolescences are considered to predict an episode of major depression in
adulthood [3]. Recently, David et al. has reported that subthreshold depression in adolescence
may increase the risks of later depression and suicidal behaviors [4]. Lewinsohn et al. carriedInternational Journal of Structured Association Technique No.6

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out a family study and reported that subthreshold depression has a considerable effect on thecontinuity of major depressive disorder [5]. Recently, school-based cognitive behavioral
therapy(CBT) programs on preventing depression and anxiety have been designed, implemented
and evaluated [6] [7] [8]. For example, Peden et al. reported that female students participated in
a 6-week cognitive behavioral intervention that targeted identification and reduction of negative
thinking, using thought stopping and affirmations [9]. As a result, participators experienced
greater decreases in depressive symptoms and negative thinking in addition to a greater increase
in self-esteem than those in the control group.
CBT has been focusing primarily to change the irrational cognition to adaptive cognition
through activating the function of the frontal cortex. However, when the amygdala related to theevaluation of emotion is overly activated, emotions cannot be controlled, making the change toan adaptive cognition difficult. This is due to nondeclarative memory attention or implicit
memory, which is one of the two memory systems described by LeDoux [10], and is formed byfear conditioning with unconscious. Thus, the application of the conventional CBT is limited,and it is necessary to develop new methods focusing on changing nondeclarative memory.
It has been pointed out that as one of influential factors, parenting style is associated withdepression. For example, self-esteem of adolescents and parenting style has been reported asrisk factors for depression. [11]. Another study also been reported that the most potent

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predictors of major depression onset for adolescent girls included subthreshold depressive
symptoms, poor family function, low parental support, bulimic symptoms, and delinquency [12].
Moreover, parenting style is highly associated with physical and mental symptoms of children[13], and some studies with university students as the samples showed that parent’s image havestrong impact on the self-image [14] [15]. All of those past studies, parent’s image was
examined with the Parent Bonding Instrument (PBI) [16].
However, the representation of parent’s facial expression is important to form parent’s image
because humans can obtain a lot of information from facial expression in a moment, and thefacial expressions are very important element of non-verbal communication. Ueda et al. focusedon the representation of parent’s expression of disgust (tension and nervousness) for university
students [17]. The group with high scores on the disgusted parent’s expression showed higherscores on self-denial, trait anxiety and depression than the low-score group. Moreover, theparent’s image script, which is formed based on the recognized support from their parents andthe representation of parent’s facial expression, positively affects the self-image script andameliorate depression and trait anxiety [18]. Hence, in the current study we considered it
necessary for supporting students to improve the self-image script through changing therepresentation of parent’s facial expressions and focused on imagery work by structured
association technique (SAT therapy). SAT therapy is used to support people finding problem

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solving methods using intuition in the state of consciousness or altered state of consciousness(meditation) [19]. It is such kind of method that can change the past image memory to a positive
image in the state of meditation, and change the ways of feeling and thinking. It focuses on thefact that the most of the brain system almost has a neural plasticity and aims to modify the past
negative memory to positive one by creating a new image in the brain. Moreover, Munakata
proposed the concept of image-script, which consists of sensory and emotional information.
Sensory information is input from the senses of sight, hearing, smell, and taste as well as
somatic sense [19]. Emotional information is memorized in the amygdala such as sadness, fun
and fear. SAT imagery work aims to modify the image script to new one. In a SAT-based
intervention research for Chinese college students, the score on the perceived emotional support
increased and their self-image was improved by SAT therapy [20]. For cancer survivors, a study
showed that the cortisol level decreased, the S-IgA level increased, and the scores on the trait
anxiety, depression and self-repression behavioral trait scales decreased after the intervention[21].
The purpose of this study is to examine the use of SAT imagery work for the prevention ofdepression of Japanese female university students on the basis of the following hypotheses: 1)
The scores on the self-esteem and problem solving behavioral trait scales will increase after
intervention. 2) The scores on the self-repression behavioral trait scale and the self-rating

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depression scale will decrease after intervention.

2. Methods
2.1 Participants
The intervention group consists of 42 female nursing students in Japan, who attended the“Theory of health behavior” class. The control group consists of 12 female students in Japan.
We used a single – blind technique for internal validity.

Ethical Considerations
We explained to the participants orally and in writing that they would not be personallyidentified, and that the participation will be based on free will. Approval was obtained from the
Ethical Committee of Graduate School of Comprehensive Human Sciences, University ofTsukuba.（No. 22-169）

2.2 Measures
We distributed self-rating questionnaires for both groups before and after the intervention.
(1)Scale of self-esteem (10 items; score range, 0-10 points). The scale was developed by
Rosenberg [22] . We used the scale translated by Munakata et al. [23].
(2) Scale of self-repression behavioral trait (10 items; score range, 0-20 points]. The scale wasdeveloped by Munakata [24]. The scale measures the degree of tendency to suppress his or her
feelings to avoid being disliked by others.
(3) Scale of problem problem solving behavioral trait (10 items; score range, 0-20 points]. The

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scale was developed by Munakata [23]. The scale measures the degree of tendency to actively
and effectively cope with a problem.
(4) Scale of the self-rating depression (SDS) (20 items; score range, 20- 80 points]. The scale
was developed by Zung [25]. We used a Japanese version [26]. The higher the score are thehigher the depressive tendency.

2.3 Procedures
The duration of the program was approximately one hour for both the intervention group andthe control group. For the intervention group, the program was carried out during the “Theory ofhealth behavior” class and the instruction was given by Dr. Munakata, who developed SAT
imagery work. After the guidance about imagery work, the subjects participated in peer training.
During the imagery work, the subjects were basically in the state of mediation. Following acounseling sheet, Step1 they were asked whether they wish to have brothers and sisters, which
are called spiritual key person (SKP) in the imagery work. “SKP imagery method (Munakata,2011)” and “3-generation imagery therapy” (brief version, Munakata, 2011) were used for the
SAT imagery work [27]. Munakata assumes that SKP is based on knowledge of microchimerism,
which meant the presence of cells from another individual in the body system. For example, Yanet al. reported that male microchimerism in women without sons includes pregnancies,
unrecognized spontaneous abortion, vanished male twin, and an older brother transferred by theInternational Journal of Structured Association Technique No.6

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maternal circulation, or sexual intercourse [28]. Fetal cells are present long after birth in thematernal body and usually fetal microchimerism is beneficial for mothers [29]. In imagery work,
such other’s cells are embodied as SKP to imagine positive expressions (e.g., smile and calm).
Step2, we change the representation of parent’s facial expressions to positive expressions. The
parent’s facial expression was measured by the objective scale of parent’s facial expression
assessment. SKP and Parents were different concepts. In SAT imagery work, we hypothesized that
we exist brothers and sisters who wish to born on image. We called it SKP (Spiritual Key Person).
This mean is to assume that the life was supposed to birth. The purpose of this method was to change
SKP and parent’s facial expression into positive expressions.

The subjects were asked to select a drawing or a religious image (images related to Buddhism)that they thought represented a surrogate similar to SKP and parent’s facial expressions.
Moreover, the subjects were instructed look repeatedly of the picture so that the image was built
in the brain thought frequent stimuli on the basis of long-term potentiation (LTP) in neuralactivity pattern [30].
The control group received a lecture on mental health by a physical education teacher. This
concept was so far method to preventing depression. We examined this concept in both the twogroup. The contents of the lecture included mental health (major depression disorder),psychological stress, effective stress coping techniques, and the importance of sleep. These

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topics were a part of enlightenment activities related to mental health currently proposed andreferred to the mental support site for the younger presented by the Ministry of Health, Labourand Welfare in Japan.

2.4 Data analysis method
Two-way analysis of variance (ANOVA) was conducted using two groups the intervention andcontrol groups as a between-subjects factor and survey time (before and after the program) as awithin-subjects factor. SPSS 12.0J for Windows, a statistical software package, was used forstatistic analysis in this study.

3. Results
3.1 Comparison of baseline values between intervention and control groups
By comparing the baseline values, the demographics of age showed a significant difference
between the intervention group (N=42) and the control group (N=12). The other scales showedno significant difference (Table 1).

Table 1Baseline values between intervention and control groups
Intervention Group (N=49)

Control Group (N=12)

25

50

75

25

50

75

p value

age

19

19

20

18

18

19

z=-3.257**

self-esteem

2.3

4.0

6.0

2.0

5.0

6.0

z=-.531n.s.

self-expression behavioral trait

9.0

12.0

13.0

8.3

10.5

14.8

z=-.021n.s.

problem solving behavioral trait

6.8

9.0

11.3

8.0

10.0

13.0

z=-1.437n.s.

self-rating depression (SDS)

36.8

40.0

47.3

33.3

41.5

50.3

z=-.063n.s.

Mann-Whitney test ** p<.01

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3.2 Change in scale value after intervention
Two-way ANOVA (mixture design) was performed and the following results were obtained.
The time×group interaction effect for the self-esteem score was statistically significant (F=（1,51）=10.65, p<.05). Sub-effect test showed significant changes in the intervention group after
intervention(F=（1, 103）=58.05, p<.001). However, in the control group, no significant changes
were observed. Analysis of the self-repression behavioral trait score showed a statisticallysignificant time×group interaction effect (F=（1, 52）=17.99, p<.001). Sub-effect test showedsignificant changes in the intervention group after intervention (F=（1, 104）=24.42, p<.001).
However, in the control group, no significant changes were observed. When considering the
problem solving behavioral trait score, a statistically significant time×group interaction effectwas observed (F=（1, 51）=11.03, p<.01). Sub-effect test showed significant changes in theintervention group after intervention (F=（1, 103）=23.13, p<.001). However, in the control
group, no significant changes were observed. For the SDS score, a statistically significant time×group interaction effect was observed (F=（1, 52）=3.48, p<.10). Sub-effect test showedsignificant changes in the intervention group (F= after intervention（1, 104）=9.69, p<.05).
However, in the control group, no significant changes were observed. (Figure 1- Figure 4)

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score10

Mean self-esteem score

8

6

4
Intervention
Group

2

Control Group0
BeforeAfter

Figure 1 Mean self-esteem score for each group at pre-post assessment
score

Mean self-repression behavioral trait
score

20
18
16
14
12
10
8
6
Intervention
Group
Control Group4
2
0
BeforeAfter

Figure 2 Mean self-repression behavioral trait score for each group at pre-post assessment

score

Mean problem soving behavioral trait
score

20
18
16
14
12
10
8
6

Intervention
Group

4

Control Group20
BeforeAfter

Figure 3 Mean problem solving behavioral trait score for each group at pre-post assessment

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score60
55

Mean SDS score

50
45
40
35
30

Interventio
n Group

25

ControlGroup

20
BeforeAfter

Figure 4 Mean SDS score for each group at pre-post assessment
4. Discussion
In the intervention group, the scores on the self-esteem and problem solving behavioral trait
scales increased, and the score on the self-repression behavioral trait and SDS decreased after
intervention. In the control group, none of these scores significantly changed. The contents thatthe control group received were about mental health. This dissemination of knowledge isimportant for students to prevent the symptoms. However, the current findings indicated that it
is not reliable as prevention method for depression. The expectant results of the intervention
group might be because the self-image of the participants was improved by imagery work,
resulting in the changes of the ways of feeling and thinking. For example, some participants
answered “always” toward the question “I feel depression” before intervention. When theirself-image script was changed to a positive one after intervention, they answered“No/occasionally”. We considered that the positive self-image script enabled the participants toInternational Journal of Structured Association Technique No.6

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think positively, which resulted in the changes in score of depression. Why did the self-image
script change to positive? The imagery work assumes the existence of SKP to improve therepresentation of parent’s facial expressions. If participants imagine smiling and calm
expression of the SKP and think that the SKP always guards them, their demand level toward toparents will be decreased and their parental image changed automatically as well. As a result, they
have a positive self-image and improve the score of self-esteem and depression.

Munakata explained this as that the level of expectation for parents decreased in the presence of
SKP as providers [27]. By perceived more emotional support, the participants became confident
and the scores on the self-esteem and problem solving behavioral trait scales increased.
Moreover, the imagery work was carried out as peer training among the participants. It has beenreported that peer support helps reduce symptoms of depression [31] [32]. It seems that thescores were enhanced by support from classmates through the practice.
Moksnes et al. pointed out that it is important to increase self-esteem for preventing

depression [33]. The reports also show that positive self-image emphasizes the resilience todepression [34]. Therefore, the increased score on the self-esteem scale is considered to bemeaningful. As mentioned above, the self-repression behavioral trait scale measures thetendency to suppress one’s feeling to avoid being disliked by others. Munakata et al. pointed thatsince people with high scores on the interpersonal dependency and self-repression are likely toInternational Journal of Structured Association Technique No.6

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feel self-hatred, they lower their self-esteem and have the tendency to become anxious anddepressed [35]. It has also been reported that people who tend to obey others have fear ofabandonment and excessively repress their feeling as well [36]. Therefore, the change from aself-repression -type person to a self-assertion-type person becomes necessary. In this study, theparticipants obtained new emotional support from SKP and improved representation of theirparent’s facial expression thought SAT imagery work. Therefore, they felt a sense of security
and did not overly repress to their feelings. As a result, the score on the self-repression
behavioral trait scale decreased after the intervention.
Other approaches using imagery work include imagery rehearsal therapy [37] and imagery
rescripting and reprocessing therapy (IRRT) [38]. IRRT aims to change the abuse imagery to
produce a more favorable outcome and it has been applied to people with, for example, social
phobia [39] and bulimia nervosa [40]. However, the above methods target people with severe
symptoms and they are not suitable for general students. On the other hand, SAT imagery work
is a practical method that can be used for anyone who has undergone some training.

However,

because the subjects are not randomized in this research, this study has a limitation in theinterpretation of the results. In the future, we will examine the effect of intervention by arandomized controlled trial. We will also examine the effect for a wide range of university
students in addition to nursing students. Imagery work was carried out as peer. Peer support

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systems have been adopted in peer education to prevent sexually transmitted infection [41],school bullying [42] [43], and type 2 diabetes [44]. However, the application of peer support toprevent depression has not yet been reported. Imagery work is a practical method that can be
carried out by students alone. Moreover, it only requires selecting the positive parental facial
expression or SKP that will be a guardian from the drawing or a religious image and frequently
stimulate the brain by looking at it. In the future, we will train university instructors andconsider expanding practical use of this imagery work in other universities.

5. Conclusions
We examined the effectiveness of SAT imagery work to improve self-image to prevent
depression among Japanese female university students in Japan. The subjects were divided into
two group; an intervention group (N=42) and control group (N=12). The intervention group
participated in SAT imagery work to change the representation of parental facial expressions.
The intervention group showed significant improvements in self-image and the scores on the
behavioral trait and depression scales. In contrast, the control group did not show significant
improvements in these factors. These results indicate that the SAT imagery work is effective forpreventing depression among female university students. In the further, we will examine theeffect of intervention by a randomized controlled trial.

Acknowledgments

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We are grateful to the participants of the study. We would also like to thank the university
instructors and faculty members for their cooperation.

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