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

NUMBER

4 − DECEMBER 2010

CONTENTS

Original Article

1.

SAT-based Self-image Improvement Intervention to Ameliorate Anxiety in
Chinese College Students
Wen-Yan Hu, Tsunetsugu Munakata, Sayuri Hashimoto,

Wen-Jie Yang and Ying Feng ・・・・・・・・・・ 1

2.

AIDS and Human Security in Orphan Adolescents, Sub-Saharan Africa
F. N. Onuoha and T Munakata ・・・・・・・・・・ 18

3.

Examining the Effects of the group intervention using SAT to ameliorate mental
distress among Cancer Survivors
Tsunetsugu MUNAKATA, Noriko HIGUCHI, Kazue NAKASHIMA, Kiriko MURAKAMI,
Yoko WATANABE, Yutaka YAMAGUCHI, Hiroko IKENO, Yuka IWANAGA, Wen-yan HU,
Yoko ICHINOSE and Atsushi NOMOTO ・・・・・・・・・・ 43

International Journal of Structured Association Technique No.4

Original Article
SAT-based Self-image Improvement Intervention to Ameliorate Anxiety in ChineseCollege Students
Wen-Yan, Hu１）＊, Tsunetsugu, Munakata１）, Sayuri, Hashimoto１）, Wen-Jie, Yang２）, Ying, Feng3)*1） Department of Human Care Science, Graduate School of Comprehensive Human Science,

University of Tsukuba, Tennoudai, Tsukuba, Japan 305-8577
2） Mental Health Counseling Center, Yunnan University, Kunming 650091
3) School of Politics ＆Administration, Hainan University, Haikou 570228
E-mail addresses：hwy81＠hotmail.co.jp (W. H.); munakata21@yahoo.co.jp (T. M.)* Study on involvement in Enhancing College students Social ability by using SAT method—taking Hainan
University for example, Sponsored by 2009 Hainan education and science Eleventh Five-Year planning project■ Abstract
Objective: In this preliminary study, we examined the effectiveness of a 6 hours
self-image promotion intervention program on improving perceived emotional support
variables, self-image variables as well as on ameliorating anxiety. Participants andMethods: Participants were university students. We recruited 48 students andrandomly assigned them to one experimental group (n=24) and two control groups(n=24). Four participants of the control group 1 ceased participation prior tocompleting the post-intervention survey; thus, the final sample size of 44 (24experimental, 20 control) yielded a participation rate of 91%. Among them, 36% weremale, and 64% were female and ranging in age from 18 to 22 years (Mean=20±.98).
The self-image promotion intervention included 2 three-hour parts: Temperamentcoaching and SAT imagery therapy. Control groups were trained by communication
skill and stress management. Measures of perceived emotional support variables,
self-image variables and state anxiety were administered at pre-, post- and 5 monthfollow-up of the intervention to all these three groups. Trait anxiety was only
administered at pre- and 5 month follow-up of the intervention. Results: Analysis
indicated that relative to the control groups, experimental group had greater
improvement on the perceived emotional support and self-image (i.e., self-affirmationand problem solving) at post- and follow-up than per-intervention. In addition, theexperimental group had lower post- and follow-up scores on trait and state anxiety.
Discussion and Conclusions: The current study makes clear that the positive
self-image is very important for students to maintain low anxiety status. In order tocontrol anxiety disorder self-image change is needed firstly. Additionally, the indepthInternational Journal of Structured Association Technique No.4

1

understanding of self and self-care behaviors for stress temperament is necessary.
The findings indicate that the self-image promotion program might be useful for
enabling college students to manage anxiety successfully.
Keywords: anxiety, self-image, parental image, positive expectation, self-carebehavior
1. Introduction
Anxiety disorder is becoming one of the most common psychological disorders inschool aged children and adolescents with high prevalence rate and many of themremaining unidentified and untreated 1). A 17,415 college freshmen survey showed thatfrom 2005 to 2008, Chinese college freshmen s mental health problem such as
anxiety and depression symptoms significantly increased year by year 2). Furthermore,a study pointed that such psychological problems are becoming the main reasons forhigh rate of withdraw from school, suicide and murder cases for Chinese students 3). In
addition, studies have proved that anxious individuals tend to choose a negative
perception and interpretation on things over other possible ones, and anxiety trait
may enhance the interpretation and/or processing of the cues conveying negative
emotion 4-6). Given the high prevalence rate and associated adverse effects, the needto prevent the development of anxiety disorders is paramount 1).
Worldwide, there are an increasing number of school-based and classroom-based
intervention studies to treatment or prevention students mental health or physicalproblems 7). The school system has been identified as an ideal avenue for thepromotion of prevention and early intervention programs for anxiety 8). Schools are
viewed as having unparalleled contact with youth and provide an opportunity to reachchildren and adolescents who have previously been unidentified and untreated 9).
Alison L. N. et al. reviewed 20 individual school-based prevention and earlyintervention programs for anxiety and suggested that both indicated and universal
approaches produce positive results with small to moderate reductions in anxiety at
post-test and follow-up. However, most of those programs lost follow-up datacollected and almost of them take long intervention time range from 8 to 14 sections(one section is about 1.5h ) or even lasting for 1 year 1). Additionally, in another review
study, the authors pointed that none of the reviewed programs included among its
goals improving adolescents ability to enjoy life, to laugh at themselves and the world,
or to develop emotionally or spiritually, all of which are important components ofmental health and nor did they make much systematic use of young people s own
goals 7). Therefore a short anxiety treatment and prevention school based program

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that are easy to operate and designed based on focusing on supporting students makeself-growth should be considered.
People s anxiety level is related to how they expect things. Those people who tend
to feel anxiety is because of they have negative expectations to the future. In another
word, people would feel easy and relax if they could have a positive expectation tothings. So, what are the determining factors for expectation manner? Munakata
suggested that the way that people anticipate things is determined by self-image 10).
Negative self-image always cause people cognize and anticipate things from anegative perspective and people who have positive self-image tent to have good andpositive expectations about future.
Traditionally, the Cognitive Behavioral Therapy (CBT), stress management
intervention, communication, relaxation and problem solving skills training have beenused for treating and preventing anxiety symptom through improving participants
self-image such as self-esteem and self-efficacy 11-19). However, the effectiveness of
those methods was not consistent. This maybe because of the CBT relies heavily on
the compliance of the clients, and it focuses on client s problem directly but not
resolve the root causes 20, 21). In other words, CBT focus on solving problem
more than supporting self-growth and clients might have the risk of suffering
mental health troubles again when other problems happened. There is another problem
should be noticed. Emotions have more influence on determine human being s
behavior than thought. This is might be one of explanations that why people usuallyknow it is not good, want to make some changes but fail to change finally. Thus we
suppose that the characteristic of CBT which try to change people s behavior
through changing their thought and believe might be one of the reasons of theinconsistent effectiveness.
Social skills might easy to be carried out and show great effectiveness for managing
anxiety for people with positive and strong self-image. However, for those who havenegative self-image, the effectiveness might be limited since social skill training itself
could not make improvement of self-image. Thus, even people mastered the skills, but
it would be very difficult for some of them to put skills into action because of lacking
positive expectation, feel powerlessness and lack of confidence.
Ueda et al. s study pointed that the sense of self-denial, trait anxiety among
university students were related to their parents aversive expression 22). Young s
study also pointed that the negative parental images endorsed by individuals as adults,
are the origins of their maladaptive self-images or schemas and these images are inturn responsible for adult emotional distress and disturbances in interpersonalfunctioning 23). John et al. s study supported the predictive relationship between

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images of parents, self-image and emotional well-being 24). Munakata explained themechanism that how parental image determines self-image. He pointed that it s
because people who have negative parental image tend to give up being themselves(i.e., repress their true feelings; emotionally and interpersonal dependent on others)
and develop others-rewarded oriented lifestyle without realizing it 25). According to
Munakata (2010) 25), others-reward oriented behavior forms and related withaversive parental image. It means individual get dopamine secreted and obtainpleasure motivated by sufficing for human being s want to be loved desire ,pursuing social achievement, view social success as a primary goal and what s more,
the judgment and standard of the outcome is controlled and determined by others.
Such kind of behaviors will ceaselessly cause one feel anxiety, feel stress, cause
negative self-image forming and result in psycho-somatic symptoms. In conversely,
self-rewarded seeking behavior forms related with positive parental image. Itmeans individuals get dopamine secreted and obtain pleasure motivated by sufficing
for human being s want to love oneself desire
want to love others desire . For
example, only pursue living positively, getting hopes, self-satisfaction, enjoyable, andappreciate others can help people maintain real well-being in such a stressful society.
Because such kind of behavior is related to build positive self-image, the judgment
and standard of the outcome can be controlled and determined by oneself, thoserewards resource belongs to oneself.
Based on these previous research results, and with considering the problems of theexisting social skill training and CBT intervention programs, one technique we usedhere is SAT imagery therapy that developed by Munakata, aimed to improveparticipants self-image through the change of their parental image script firstly in animagery work.
In recent years, self-care has developed as an important health care concept 26).
Self-care behavior based on one s own gene temperaments is also related to build
positive self-image and maintain well-being 27). According to Munakata s temperament
theory, temperament is the genetic character about our desire and emotional reaction,
which in turn define our behaviors. It contains two parts, one is personality
temperament and another is stress temperament which defines the strength of oursensitiveness and reaction, and has been divided into persistence, neuroticism andnovelty-seeking temperament 27). Genetic temperament, nucleus of one s nature
consisting of hereditary factors and biological factors related to neurotransmitter,does not change throughout one s lifetime. Among them all, those who have either
persistence temperament
observed in perfectionists orneuroticism
temperament represented by pessimism and tendency to be opinionated incline toInternational Journal of Structured Association Technique No.4

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become powerless, hopeless, fearful, solitary and stressful. Therefore, the self-carebehavior becomes extremely essential for those people to manage stress andmaintain well-being. However, other researches pointed that the issue of personal
identity for the purpose of better understanding of the self, another main feature ofmanaging the self, has received little attention when consider how to improvestudent s competence 28).
Therefore, in the current intervention program, stress gene temperament coaching
was contained to improve participants self-image through deeply understanding
themselves, improvement their interpretation style toward to themselves andsignificant others and let participants know what kind of self-care behaviors should bedone to care their stress gene temperament weak points. In order to compare theeffectiveness of the current intervention program we set two control groups whichwere trained by communication skill and stress management coaching.
The aim of this study is to use a randomized controlled design and validated outcome
measures to examine the effectiveness of self-image promotion intervention programon enhancing college students positive self-image, and on improving participants
anxiety status. Our hypotheses are as the following: 1) social skill training couldn t
make self-image improvement; 2) by looking parental substitute representation,
self-image could be improved; 3) with the improvement of self-image, the anxiety level
would decrease.
2. Methods
2.1 Subjects
Participants were university students recruited to take part in a self-image
promotion program for improving anxiety status through improving self-image by doing
self-care behavior and changing behavior from others-reward oriented pattern toself-reward oriented pattern. We recruited 48 students and randomly assigned themto experimental (n=24) and two control groups (n=24). Before they completed a
pre-intervention survey, we informed all participants of the informed all participants of
the natural and purpose of the study, and they voluntarily provided informed consent.
Four participants (control group 1) ceased participation prior to completing thepost-intervention survey; thus, the final sample size of 44 (24 experimental, 20
control) yielded a participation rate of 91%. The majority of students were second year
(n=29, 66%), and then the first year (n=13, 29.5%)，only 2 come from the third year
(4.5%). Among them, 36% were male, and 64% were female and ranging in age from 18 to
22 years (Mean=20±.98). Persistence temperament score range from 1 to 5 points(Mean=3.91 ± 1.27), neuroticism temperament score range from 0 to 5 points

International Journal of Structured Association Technique No.4

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(Mean=3.36±1.36).
2.2 Procedure and Setting
Students volunteered by e-mail or telephone in response to flyers which wereposted around campus. We informed potential participants that they would be
randomly assigned to 1 of 2 groups: ① the experimental group (EG) involved
completing a pre-intervention survey, attending a one day intervention (2 parts, 3hours each) and completing a post-, one month and five month follow-up surveys; and② the control group involved completing pre-, post-, one month and five monthfollow-up surveys on the same days as the experimental group. In addition, the control
group was randomly divided into two groups: control group one (CG1) attending a one
day communication skill coaching course (2 parts, 3 hours each) and control group two(CG2) attending a one day university stress management coaching (4 parts, 1.5 hourseach). We give each one of the participants a ball pen and a notebook to encouragethem fulfill the checklist seriously.
Self-image promotion intervention
The self-image promotion intervention included 2 three-hour parts: ①Temperamentcoaching and ② SAT imagery work.
The first part is temperament coaching help participants change their interpretationstyle to themselves and others image by making them deep understanding thecharacteristics of self s and others genetic temperaments, and support them toknow what behaviors they should do to care of the weak point of their temperaments.
In this part participants were coached with genetic temperament knowledge andself-care behaviors about stress temperament, such as taking deep breath to calm
down, or letting inner voice say that s all right for several times to decrease theexpanded demand level. A human relationship improvement skill based on
temperament knowledge and self-care behavior also been trained.
Part 2 is SAT imagery work, with the aim of creating a positive self-image, andchanging students behaviors from others-reward oriented to self-reward oriented
pattern through changing their parental image to a positive one. SAT (structured
association technique) imagery work is a series of techniques that based on
structured questions, through makes use of intuition and association to support
people finding problem solution method or change behaviors 29). It is the Third
Generation Cognitive Behavioral Therapy which is characterized by focusing on
emotional change first. Munakata pointed that parental substitute representation is avery effective, simple and practicable method to help people control emotions25). SAT
imagery work is a development of traditional CBT and offsetting its weakness whichtries to change people s behavior begin with thought change. In the current study, weInternational Journal of Structured Association Technique No.4

6

support participants change and control their emotion by finding out and using parents
substitute representation. Through the imagery work, they would feel unconditional
love from parents, with the fulfillment of want to be loved desire their parental
image would change to a positive one naturally. After changing their parental image,
participants could change their behavior to self-rewarded oriented behavior which inturn both contribute to the fulfillment of want to love oneself desire and want tolove others desire , and contribute to self-image changing to a positive one.
Communication skill coaching
Communication skill coaching also included 2 three-hour parts: ① Communication
skill lecture and ② Practice in pairs.
At the part one, participants were taught with listening skill, assertion skill andnegotiation skill with the aim of support students well-being from building
empowerment interpersonal relationship. In order to strengthen the effect, at part two,
participants practice ask for helping game, refuse game, encourage game, and positive
feedback game by using these skills learned at part one.
Stress management coaching
It was with the aim of improving students well-being through learning how tomanage change and difficult situations more effectively. It also included 4 parts: ①
Stress management; ②Autonomy; ③ Emotional management; and ④ Case analysis
by watching DVD.
2.3 Measures
The questionnaire consisted three parts: ① attributes (age, gender, academic level,stress temperament types); ② anxiety status; and ③ self-image variables. In thepresent research, the Japanese version scales were first translated into Chinese andthen back-translated into Japanese by two bilingually fluent researchers. Highconvergence between the two versions was obtained.

Anxiety status
State-Trait Anxiety Inventory (STAI)
Spielberger et al. s (1983) 30) well-known STAI was designed to assess two types ofanxiety, one's mood in the moment (state anxiety), and in general (trait anxiety). It
contains two 20-item scales. For the state anxiety scale, response choices were from
(1) Strongly agree to (4) Strongly disagree . On the other hand, for trait anxiety
scale, response choices were from (1) not at all to (4) very often . Agreement topositive and disagreement to negative items scored 1 with a total score range from 20
to 80, respectively. We coded all items so that higher scores indicated higher levels ofanxiety. In the current study the internal consistency of the Chinese version was 0.91
and 0.89, respectively. In the current study, we estimated the state anxiety at each

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time, but for the trait anxiety, we only estimated it at pre- and 5 month follow-up.

Perceived emotional support
Two instruments―Perceived Emotional Support from Family (ESFFA) and Perceived
Emotional Support from Peers (ESFP) scales (Munakata, 1996)31) were used toestimate the subjective experience. Each scale had 10 items. Sample items in ESFP
scale were: Do you have any friend who supports your behavior . Any friend was
replaced with Family members in ESFFA scale. The Cronbach s alpha in thecurrent study was 0.70 for ESFFA and 0.66 for ESFP, respectively.

Self-image variables
Self-affirmation
The converse score of 10-item self-denial scale (Munakata2001)32) was used toestimate perceived positive feelings of self-affirmation. The scale has 1 positive item
( I do like myself ) and 9 negative items (e.g. I want to die ; I don t know why I
was born ; I am dirty ). In this study, the items were reverse scored: responses thatapproximated positive to self-denial were scored 0 ( I always think so ), 1
( sometimes I think so ), and 2 ( I don t think so ); responses that approximatedpositive to self-denial were scored 2 ( I always think so ), 2 ( sometimes I thinkso ), and 0 ( I don t think so ). The total scores range from 0 to 20. Higher scoresindicate a high level of positive feelings of self-affirmation. Cronbach s alpha for the
scale was 0.65 in this study.

Problem solving behavioral trait
10-item problem solving behavioral trait scale (Munakata, 2001)32) was used tomeasure individual s behavioral trait that try to deal with the tasks and problems
positively, effectively and realistically. The scale comprises of items such as I
always confirm the fact prior to make judgment and I always make plan and think
about steps to take about what to do . Response choices were scored 2 ( I
always do so ), 1 ( I do so ), or 0 ( I don t do so ), with total scores range
from 0 to 20 and higher scores indicate high realistic problem solving behavioral trait.
Lower score was suggested the tendency to repeat the same kind of failures orpostpone to solve problems rather than facing the reality of fact. Cronbach s alphafor the scale was 0.75 in this study.

Self-expression behavioral trait
In this study we used the converse score of 10-item self-repression scale(Munakata, 1996)31) to measure self-expression behavior trait. The original scalemeasures the expectations of being acceptable from others by repressing one s true
feelings to satisfy people around. An example of a typical item such as I tend to
suppress my feeling I usually can t express what I really think easily . Originally,

International Journal of Structured Association Technique No.48

responses that approximated to self-repression were scored 2 ( I always do so ),1 ( I do so ), or 0 ( I don t do so ). In the current study, responds werereverse scored 0 ( I always do so ), 1 ( I do so ), or 2 ( I don t do so )with total scores range from 0 to 20 and higher scores indicate a high level ofself-expression behavior trait. Cronbach s alpha for the scale was 0.62 in this study.

Emotional autonomy behavior trait
The converse score of Japanese version of Hirschfeld, Gough, and Barrett (1977) 33)
interpersonal dependency scale was used to estimate interpersonal independency
behavioral trait. The original scale was used for personality assessment (Franche &Dobson, 1992) 34) and validity and reliability was examined. It is an 18-item scalemeasures one s tendency to socially depend on others and has both dependence
and independence domains. Independence items include I always rely on my own
efforts and I don t care about what the other people say . Dependence domainquestions include I m worried when I lose others favor and I d rather likebecome a follower than a leader . In this study the items were reverse scored: thedependence items were scored as 0 ( That s very true ), 0 ( That s true ),1 ( That s generally true ), and 1 ( That s not so ); those independence items
were scored as 1 ( That s very true ), 1 ( That s true ), 1 ( That s
generally true ) and 0 ( That s not so ). The total scores range from 0 to 18 andhigher scores indicate high emotional autonomy behavioral trait. Cronbach s alpha forthe scale was 0.66 in this study.
2.4 Ethical Considerations
Before starting the study procedures, the ethical permission was first obtained fromthe Ethical Committee of Graduate School of Comprehensive Human Sciences,
University of Tsukuba. The permission number is No.21-175. Before the test wasadministered, each student signed an informed consent agreement. A brief descriptionof the study was given to the participants, along with assurance that all answers would
remain completely anonymous.
2.5 Data Analysis
SPSS Version 17.0 statistical software was utilized for the statistic analysis of thisstudy. Means, standard deviations and reliability coefficients were conducted forexperimental group, for all variables pre-, post- and 5month follow up of theintervention. We also conducted Mann-Whitney tests to determine whether there
were any systematic differences between the groups at the baseline prior to theintervention. For each group, we conducted the Friedman test to examine whether
there is significant change within group and if it was significant, we conducted
Wilcoxon signed-ranks test continually to compare the changes of the data collectedInternational Journal of Structured Association Technique No.4

9

at pre-, post- and 5month follow-up of the intervention. A p-value<0.05 wasconsidered significant (Post hoc test with Bon ferroni correction).
3. Results

3.1 Baseline
The median age of all participants was 20 with no difference between the groups.
63.6% was female and 36.4% was male. All the demographic variables of this study
population are depicted in Table 1. By using Mann-Whitney tests the demographics ofage, gender, stress temperament (persistence and neuroticism temperament) have nosignificant difference among study groups (p>0.05). However, for the outcome
variables, with regards to perceived emotional support from family there was asignificant difference between experimental group (EG) and control group two (CG2)(p=0.049), and between control group one (CG1) and control group two (CG2)(p=0.005). With regards to problem solving, there was a difference between control
group one (CG1) and control group two (CG2) (p=0.057), however it was notstatistically significant. With regards to self-expression, there was a significant
difference between between control group one (CG1) and control group two (CG2)(p=0.039). These differences would be considered which will validity affect the final
result.
Table 1. Demographic variables and outcome variables of the participants at pre-intervention
VariableEG

CG 1

p Value

CG 2

Demographics
Age (Median±SD)20.08±1.10

20.13±0.64

19.75±0.96

n.s.

10/14

2/6

4/8

n.s.

Persistence temperament

3.96±1.26

3.75±1.48

3.92±1.24

n.s.

Neuroticism temperament

3.54±1.17

3.00±1.51

3.25±1.65

n.s.

8.58±1.47

9.38±0.74

7.08±2.27

Gender (male/female)

Outcome variables
Perceived emotional support from family

EG vs CG2 p=.038*
CG1 vs CG2 p=.005**

Perceived emotional support from peers

8.54±1.91

9.50±0.53

9.00±1.20

n.s.

Self-affirmation

15.67±2.33

15.63±2.77

14.25±2.95

n.s.

Problem solving

8.79±3.85

9.00±1.60

7.50±1.73

CG1 vs CG2 p=.057†

Self-expression

9.87±3.23

8.25±1.83

10.42±2.53

CG1 vs CG2 p=.039*

Emotional autonomy

12.79±3.3412.50±2.26

12.83±2.75

n.s.

State anxiety

39.62±10.60

37.12±7.40

38.25±8.30

n.s.

Trait anxiety

41.67±11.00

46.25±8.4945.83±12.20

n.s.

Note. *** p<.001; ** p<.01; *p<.05; n.s. no significant

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3.2 Changes after intervention
Table 2 showed all of the outcome variables changes for three groups from pre- tofollow-up of the intervention. For experimental group, except the self expression scale(Friedman test, x2 =4.22, p=0.121) and emotional autonomy scale (Friedman test, x2=4.76, p=0.092), all the other scales showed significant changes after intervention(Table 2). Comparison with the baseline, Wilcoxon signed-ranks test showed that theperceived emotional support from family significantly increased at post-intervention(p=0.004) and 5 month follow-up (p=0.028), the perceived emotional support frompeers significantly increased at post-intervention (p=0.003) and 5 month follow-up(p=0.046), the self conceit significantly increased at post-intervention (p=0.000) and 5
month follow-up (p=0.006), the problem solving behavior significantly increased at
post-intervention (p=0.007) and 5 month follow-up (p=0.018). The trait anxiety
significantly decreased at 5 month follow-up (p=0.034), and the state anxiety
significantly decreased at post-intervention (p=0.000) and 5 month follow-up(p=0.044).
On the other hand, in control group 1 all of the scales did not show any statisticalsignificant changes between at baseline, post-intervention and 5 month later. All mostthe same, in control group 2, except the self-affirmation scale (Friedman test, x2=10.44, p=0.015), all the other scales did not showed significant changes after
intervention. The post hoc test of self-affirmation significantly increased at
post-intervention (p=0.022) and at 5 month follow up (p=0.045). Although theperceived emotional support from family showed statistical significant at Friedman
test (Friedman test, x2 =10.73, p=0.013), however, it lost significant at the post hoc
test post-intervention vs. pre-intervention (p=0.078) and at 5 month follow up(p=0.062).
Table 2. Outcome variables changes for three groups from pre- to follow-up of the intervention
Scale

Group

Pre-

Friedman

Post-

5 month-Wilcoxon signed-ranks test

test (P Value)

PESFFAPESFPP Value (vs. Pre-intervention)
25%

median75%

25%

median75%

25%

median75%

Post-

5 month-EG.001 **

8.00

9.00

10.00

10.00

10.00

10.00

9.00

10.00

10.00

.008 **

.032*

CG1

.077 †.

9.00

9.50

10.00

9.00

10.00

10.00

10.00

10.00

10.00

——

——

CG2

.013 *

4.50

8.00

8.75

8.00

8.00

9.00

7.25

9.00

10.00

.078 †.062 †

EG.008 **

8.00

9.00

10.00

10.00

10.00

10.00

9.00

10.00

10.00

.006 **.050 †

CG1.112n.s.

9.00

9.50

10.00

10.00

10.00

10.00

10.00

10.00

10.00

——

——

CG2

.706 n.s.

8.00

9.50

10.00

8.25

10.00

10.00

9.00

9.50

10.00

——

——

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11

EG

.000 ***

14.00

16.00

17.75

17.25

18.50

19.00

16.25

18.00

19.00

.000 ***.008 **

Self-

CG1

.172 n.s.

12.75

17.00

17.00

17.00

18.00

19.00

17.00

17.00

18.00

——

——

affirmation

CG2.015 *

13.25

15.50

16.00

13.25

16.00

17.75

12.50

17.00

18.75

.022*

.045*

EG

.033 *

5.25

9.00

12.00

7.50

10.00

15.00

8.00

9.00

13.75

.014*

.028 *

Problem

CG1.361 n.s.

8.00

9.50

12.75

9.25

12.00

13.75

11.00

11.00

12.75

——

——

solving

CG2.096 †

4.50

7.50

8.00

4.25

5.50

8.50

6.25

8.50

10.00

——

——

EG

.121 n.s.

8.25

10.00

12.00

9.00

11.00

12.75

10.00

11.00

13.00

——

——

Self-

CG1

.266 n.s.

7.00

7.50

10.00

7.25

10.00

12.00

7.75

10.00

10.00

——

——

expression

CG2.697 n.s.

8.00

11.00

12.00

9.25

10.00

12.75

8.50

11.50

12.75

——

——

EG

.092 †

10.00

13.00

16.00

13.00

14.00

16.00

14.00

14.50

16.00

——

——

Emotional

CG1.090 †

10.50

12.50

14.00

13.00

14.00

15.75

12.25

13.50

15.00

——

——

autonomy

CG2.110 n.s.

10.25

13.00

15.50

10.25

13.00

15.00

11.25

14.50

16.00

——

——

EG

.000 ***

31.50

36.50

48.00

23.25

26.00

34.75

25.00

31.50

43.25

.000 ***.050 †

State

CG1.090 †

29.75

35.00

40.50

22.25

25.00

28.50

22.25

29.50

41.75

——

——

anxiety

CG2.086 †

28.25

36.00

44.75

32.50

42.50

44.75

31.25

36.50

42.25

——

——

EG

.049 *

33.00

41.00

48.75

——

——

——

29.00

36.00

42.00

——

.034 *

Trait

CG1.157 n.s.

40.25

46.00

53.50

——

——

——

39.25

43.00

48.00

——

——

anxietyCG2

1.00 n.s.

34.50

51.00

55.75

——

——

——

39.25

48.00

53.50

——

——

Note. Perceived emotional support from family (PESFFA), Perceived emotional support from peers (PESFP).
*** p<.001; ** p<.01; *p<.05; n.s. no significant
Wilcoxon signed-ranks test was conducted continually only when Friedman test showed statistic significant.

4. Discussion
In this preliminary study, we examined the effectiveness of a 6 hours self-image
promotion intervention program on improving self-image and anxiety status. Findings
indicated that experimental group had greater improvement on the perceived
emotional support and self-image (i.e., self-affirmation and problem solving) at postand follow-up than per-intervention. In addition, the experimental group had lower
post- and follow-up scores on trait and state anxiety. Oppositely, the social skill
training seemed failed to change self-image and failed to make improvement ofanxiety status. The reasons that caused different results between the experimentalgroup and control groups might be determined by that whether the method focused on
supporting self-growth, and whether the method could make improving of self-image.
A strength of current intervention is that different with traditional CBT and social
skill training programs, it emphasized the importance role of parental substituterepresentation and self-care behavior about stress temperament in both improving

International Journal of Structured Association Technique No.4

12

self-image and managing anxiety. The effectiveness of current intervention supports
the previous research results 22, 25, 35, 36). People have negative parental image
perception when they have high standard of expectation to their parents. However,through the SAT imagery work, participants could awareness the existing of theirunborn siblings who might be their sisters or brothers. They can get energy andemotional support from the unborn siblings, and through this imagery work the
expectation standard to their parents would decrease at the same time. Then theirparental image script would improve naturally and leads fulfillment of three love
desires . When participants feel secure they can take self-reward oriented behavior
which could result in improving perceived emotional support ability, forming positive
self-image and positive expectation.
Students also improved their interpretation style of self and others image script bytemperament coaching, make them deep understanding self and others, and knowwhat they should do to care of their temperament. With improving of perceived
emotional support and self-image, students could recognize and interpret things in apositive manner (i.e., others emotion, support, and even see a stress thing as achallenge), have positive expectation, and establish secure attachments with others,
which in turn contribute to maintain low anxiety status.
Above all, the current study makes clear that the positive self-image is very
important for students to control anxiety symptoms. In order to development positive
self-image, deep understanding of self and self-care behaviors about stress
temperament is needed. Such as students who have anxious temperament shouldtake a deep breath let themselves cool down when they become emotional, and thosestudents who have persistence temperament should let inner voice say It s ok,that s all right when they demand a perfect thing. In order to development a positive
self-image, parental image must be considered to satisfy student s to be loved
desire . For example, to establish positive parental image by using a parental
substitute representation or unborn sibling s substitute representation (theymight be photographs with happy face, or Buddha picture or animated character) anddo some efforts such as make the substitute representation portable, or set it to adesktop picture, with such high frequency of stimulation, the positive parental image
would be fixed in the mind, replacing the negative one. Along with the parental imagechanging, students
love desire are satisfied, their perceived emotional support
ability improved and finally these efforts would contribute to self-reward oriented
behavior and individuals would develop positive self-image naturally while such
behaviors continued.
Only the stress management training group (CG2) showed effectiveness on

International Journal of Structured Association Technique No.4

13

improving the self-affirmation, however, neither the perceived emotional support
variables nor anxiety status showed any changes in both the two control groups.
Different with the previous researches results 1, 8, 9), in the current study, it seems thattraining by social skills alone seems impossible to help students who with negative
self-image to improve their anxiety status without self-image change. We suggest thatunless students develop a positive self-image first, they cannot perform those skills intheir daily life, because of the lack of positive expectation, lack of self-confidence andpowerlessness.
There are several limitations should be considered when interpret the current results.
One is come from the program itself. Among the outcome variables, however, nosignificant change was observed in the self-affirmation and self-expression. Additional
approaches seemed necessary. Second is the relatively small size of the sample,
especially the small size of the control groups, which may have been a contributing
factor in no significant results. Thirdly, we did not randomly select participants fromthe population which has implications for the generalizability of the results. The fourthis come from the questionnaires. Most of the scales were translated from Japanese to
Chinese, although a back-translated was performed, but we did not make muchmodification to make the items more suitable for Chinese expression style, moreeasier understanding for Chinese college students which may be the reason thatcaused the low Cronbanch s alpha coefficient and affect the current results. Fifth isthe ceiling effect which might affect the validity of the result, participants in control
groups had a high score on perceived emotional support from peers at the baseline.
■ Authors Contributions
Hu Wen-Yan suggested the idea of this study and facilitated the study procedures;she contributed to the conception, the design and the methodology; she conductedintervention training for the experimental group and the first control group, performed
the statistical, interpreted the results and the discussion, and drafted the manuscript.
Munakata and Hasimoto were involved in the study design and methodology revised
the result. Munakata has made substantial contribution to interpretation of data,revise and improvement the final manuscript. Yang Wen-Jie and Feng Ying have been
involved in the study design, getting permission for doing this study from Yunnan
University, provided the training for the second control group and collecting
references.
■ Acknowledgements
We grateful to the participants of the study, who showed great interesting in theInternational Journal of Structured Association Technique No.4

14

current program and cooperated to complete survey questionnaires for 4 times withserious attitude which in turn encourage we greatly. We also grateful thanks to all thestaff of Mental Health Counseling Center Yunnan University for their continuous
support of recruiting participant s, printing text, providing room and other materials
and questionnaires collection. Without their help the current intervention study
wouldn t be accomplished smoothly. At last, we d like to extend our grateful thanks
to our families for their unconditional emotional support.
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evidence-based medicine review, Journal of the American Academy of Child and Adolescent
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(24) John J. Cecero, Talia S. Marmon, Mark Beitel, Aida Hutz, Christine Jones: Images of mother, self
and god as Predictors of dysphoria in non-clinical samples, Personality and Individual Differences,Vol. 36:1669-1680 (2004)(25) Tunetsugu Munakata: SAT therapy reconstructing life & society: Foundations of the newgeneration CBT, Journal of Health Counseling, Vol. 16:1-9 (2010)(26) Ursula Naue: Self-care without a self': Alzheimer's disease and the concept of personal
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Original Article
AIDS and Human Security in Orphan Adolescents, Sub-Saharan Africa
F. N. Onuoha & T Munakata
Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
E-mail address: fnonuoha@yahoo.com■Abstract

Human security has been defined as the dignity, mental peace, and stability of theindividual (UN 2003). This study examines human security factors of adolescentsorphaned by AIDS in two sub-Sahara African countries – Uganda and South Africa. Six
hundred and eighty-eight adolescents aged 10-19 (M=14.1 years) in three groups:
AIDS-orphaned (n=178), other-causes orphaned (n=217), and non-orphaned (n=293) arerecruited from schools, and child support centres in Kampala (Uganda, n=371), andMafikeng/Klerksdorp (South Africa, n=317). Human security factors are food availability,
perceived good health, friendly environment, and education. Others are self-esteem,social support, and foster/parental care. Child abuse, social discrimination, anxiety anddepression are categorized as human security threat factors. The ANOVA showed thatwhile adolescents orphaned by other-causes scored lower human security than did
non-orphaned group, AIDS-orphaned adolescents scored lowest human security in the 3groups. We concluded that although orphans face great human security threat factors,
adolescents orphaned by AIDS face the greater threats.
International Journal of Structured Association Technique No.4

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Keywords: human security; orphan health; AIDS-orphaned adolescents

1.

Introduction

1.1

Human Security

The traditional concept of security, with roots in the cold-war era, is the territorial protection of thestate against external aggression; in most cases by military power. The result is theunprecedented arms race of the era (for defense and deterrence) that has failed to guarantee
world peace. In the post-cold war era has emerged the contemporary advocacy for paradigm shift
from “state” to “human” security.

Human security is less about armament or surveillance cameras to monitor crime, but more about
the dignity and well-being of the individuals of the nation. It is the totality of grass root foodsecurity, health security, environment/community security, and political security (UNDP, 1994) forthe mental peace and comfort of the individual. Human security not only protects the individualfrom the daily dangers of violence, hunger and poverty, but empowers him/her to overcome these
dangers (UN, 2003). Ultimately, the individual’s security translates to community, state/national,
regional, and international safety.

According to US President J.F. Kennedy, “Political sovereignty is but a mockery without meetingpoverty, illiteracy and disease. Self-determination is but a slogan if the future holds no hope” (UNInternational Journal of Structured Association Technique No.4

19

General Assembly, 1961). Human security guarantees 3 freedoms to the individual: freedom fromfear, freedom from want, and freedom to live in a dignified mental state (UN, 2003). These
freedoms are crafted in the UN Millennium Development Goals. Regrettably, one of the greatest
threats to meeting the millennium goals and human security are the challenges of global
infectious diseases, particularly HIV/AIDS.

1. 2

HIV/AIDSOver the centuries, science has resolved the global infectious disease challenges of the time –from the bubonic plague of the medieval era in Europe

to the cholera in Latin America,

pneumonic plague in India, ebola in Africa, dengue fever in Southeast Asia, mad cow in UK,
anthrax attack in USA, SARS (severe acute respiratory syndrome) in China, bird flu in Korea, andswine flu in Mexico, among others – but AIDS that has defied resolution/cure.

“HIV/AIDS is … the greatest weapon of mass destruction on the earth” (Collin Powell, US
Secretary of State, 2004). It is a threat to human peace and security (US National Intelligence
Council, 2000; G8 meetings in Okinawa 2000, in Genoa 2001; UN Security Council, 1999). “The
impact of AIDS is no less destructive than that of warfare itself …. Last year, AIDS killed about 10
times more people in Africa than did armed conflict.” (Koffi Annan, UN Secretary General, June,
2000). In July 2001, the UN Resolution 1308 officially recognized AIDS as the global “risk to[human] stability and security” of our time.
International Journal of Structured Association Technique No.4

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Since its emergence over a quarter of a century ago, AIDS has claimed more lives than the two
World Wars, the Vietnam War and the Korean War combined did (Washington Post Editorial,
2000). In 2007 alone, about 2 million adults and children died of AIDS, 33.2 million living with thevirus, and 1.7 million new infections reported, worldwide (UNAIDS, 2008). Of these, over 67%
occurred in sub-Saharan Africa (UNAIDS, 2008). Among children and adolescents below 18
years in sub-Saharan Africa, over 12% (or 42 million) of the children are orphans and 35% (or 15
million) of them orphaned by AIDS (UNAIDS, 2006).

1.3

Orphaning

Adolescents orphaned by AIDS may experience unique human security threat factors (Chitiyo,
Changara, and Chitiyo, 2007). In sub-Saharan Africa, they face dual sad experiences: first, they
are affected by AIDS when parent falls sick and they have to shoulder stressful responsibilities
such as nursing ailing parent and/or engage in income generating activities; next they areaffected by orphaning when parent dies (Gillespie, Norman, & Finley, 2005). These adolescentstend to grieve longer before parental death than other orphans, owing to the human wasting,
AIDS-defining illnesses that often precede death (WHO, 2005). Because of the moral shame andlife-terminality associated with AIDS, children left behind by AIDS-deceased parents may
encounter higher externalized (Cluver, Gardner, & Operario, 2008) and internalized (Nyblade etal., 2003) social stigma/discrimination than children orphaned by other reasons. It is oftenInternational Journal of Structured Association Technique No.4

21

believed that AIDS-orphaned children, like their departed parents, may be HIV-positives who may
die earlier than the “normal” children.

According to the UN, the distinctive social characteristic of AIDS is that it is more likely
than other causes of death to create double orphaning - the loss of both parents (UNAIDS,UNICEF, & USAID, 2004). In South Africa and Uganda, double orphaning is four times more likely
in AIDS-affected homes than in other homes (UNAIDS, UNICEF, & USAID, 2004). Studies ofadolescent parental loss report that orphans tend to encounter such human security threat factors
as social depression (Furukawa, Yokouchi, Hirai, Kitamura, & Takahashi, 1999), personality
disorders (Paris, Zweig-Frank, & Guzder, 1994), anxiety/insomnia (Tweed, Schoenbach, George,& Blazer, 1989), hopelessness, and frustration (Mbozi, Debit, & Munyati, 2006).

Abebe andAase (2007), however, disagree. They argue that the symptomatic construct of orphans are
media-induced stereotyping, orchestrated by academic scholars of traditionalist persuasions.
Most orphans have the resilience and agency to get on with the challenges of life following
parental death (Abebe & Aase, 2007).

The purpose of this study is to examine the human security of sub-Sahara Africanadolescents orphaned by AIDS. Human security is defined as mental peace and stability of theindividual (UN, 2003; UNDP, 1994). The design is people-focused rather thanhardware-concerned. Thus it captures the main thrust of human security – the individual. We
hypothesized that adolescents affected by AIDS may show lower human security factors thanInternational Journal of Structured Association Technique No.4

22

those orphaned by other reasons.

2.

Method2.1

Participants

The initial study participants are 957 sub-Sahara African adolescents in Uganda (n=474) andSouth Africa (n=483), recruited from 9 community schools, and 6 NGO child support centres in
two towns – Mafikeng/Klerksdorp (South Africa) and Kampala (Uganda). The World HealthOrganization definition of adolescence as persons aged 10-19 years (WHO, 2003), and the UN
classification of orphanhood as the loss of one or both parents (UNAIDS, UNICEF, & USAID,
2004) guided the study.

The study design has 3 groups: AIDS-orphaned, other-causes orphaned, andnon-orphaned. Participants who responded in the affirmative to the questions: “Is your father
living? (Yes/No); is your mother living? (Yes/No)” are categorized as non-orphans (n=293).
Those who responded “no” to either question are asked the cause of death: “1. HIV/AIDS,
Others,

3. Don’t know.”

2.

Responses 1=HIV/AIDS (n=178), and 2=Others (n=217) are so

categorized. Those who “don’t know” cause of parental death (n=269) are excluded from thestudy.

2.2

Ethical consideration

The Uganda National Council for Science and Technology (UNCST), the School ofInternational Journal of Structured Association Technique No.4

23

Economics & Decision Sciences, North-West University, South Africa, and the Department of
Human Care Science, University of Tsukuba, Japan, approved the study protocols, which
required confidentiality, anonymity, and voluntary participation of the study participants (Mann &Tolfree, 2003).

Interviewers were Luganda (Uganda) and Xhosa/Afrikaans (South Africa) speaking
research collaborators. When expedient the interviewer-administered questionnaire method was
adopted for the low educational level participants; otherwise the self-report method was
dominantly used. The first method required the interviewer to read out the question items in thelocal language to the respondent, and filled out the questionnaire on his/her behalf. In the second,
the respondent completed the questionnaires unassisted. The interview duration lasted
approximately 45 minutes per session at the end of which the respondent received a ball pen.

2.3

MeasuresFood availability, perceived good health, education, friendly environment, self-esteem, social
support, and foster/parental care as human dignity enhancing factors constituted the humansecurity measures. In contrast, factors such as child abuse, social discrimination, anxiety, anddepression are human security threats (UN, 2003).
We utilized Schwarzer and Schulz (2000) Received Support Scale, as adapted (alpha=.72),
to estimate perceived social support received by the adolescents. The measure positively
associated with self-esteem (r = .42, p < .01) and negatively with anxiety (r = -.37, p < .01). The
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24

measure requires the respondent to “think about person(s) that is closest to you - your friend(s),guardian(s), or parent(s)/foster parent(s) - how does this person treat you?”

Typical items are:S/he “is there when I need him/her; shows love to me; takes care of my financial needs; ingeneral, I am satisfied with the way s/he treats me.”Self-esteem is estimated with the Rosenberg (1965) Self-Esteem Scale, the most utilizedmeasure of the favorable/unfavorable perceptions of the self (Blascovich & Tomaka, 1991). The
Cronbach alpha for the Scale in the present study is .60, which compares favorably with the value
found by Lorenzo-Hernandez and Ouellette (1998). The measure shows negative associations
with anxiety (r = -.34, p < .01), and social discrimination (r = -.38, p < .01), suggestive of its
validity.
We assessed foster/parental care with the Parker, Tupling, and Brown (1979) Parental
Bonding Instrument (PBI). The PBI assesses both parental care and parental over-protection.
Support for the reliability and validity of the PBI has been reported (Neale et al., 1994).

Weutilized the “care” subscale (alpha = .82) which estimates empathy, affection, warmth, andindependence in the present study. Typical items include parents/foster parents: are affectionate
to me; understand my problems and worries; let me do things I enjoy doing; enjoy discussing
things with me; give me as much freedom as I want.

We utilized the anxiety subscale of the renowned General Health Questionnaire (GHQ-28,
Golderberg & Hillier, 1979) to estimate anxiety. The subscale (alpha = .82) negatively (r = -.34, p
International Journal of Structured Association Technique No.4

25

< .01) correlates with self-esteem, and positively (r = .40, p < .01) with the Weissman, Orvaschel,and Padian (1980) Center for Epidemiological Studies Depression Scale (CES-DC), as adapted.
The CES-DC, which test-retest reliability and concurrent validity are adequate (Faulstich,
Carey, Ruggiero, Enyart, & Gresham, 1986) measures depression. Sample items on the Scale(alpha=.77) include: “I was bothered by things that usually don’t bother me; I didn’t feel like eating,
I wasn’t very hungry; I wasn’t able to feel happy, even when friends tried to make me feel good; I
felt like I was too tired to do things.”
The 1995 Detroit Area Study Measure of Discrimination as modified (alpha = .77) measuressocial discrimination. In your daily life, compared to other people around you, do you: Feeldifferently treated?

Feel unfairly treated?

things others are allowed to do?
typical questions.

Made to feel inferior?

Prevented from doing

People behave as though they are afraid of you? – are the

The measure correlates positively with depression (r = .38, p < .01), but

negatively with social support (r = -.27, p < .01).
The Child abuse scale measures the physical, verbal, sexual, and labor dimensions ofchild abuse (Bagley & King, 1990). For example, are you - physically beaten in a manner you
consider unfair; verbally abused in a manner you consider unfair; forced to “sleep”/have sex withanyone; forced against your wish to work on the farm for someone? The alpha reliability of themeasure, which discriminates depression (r = .22, p < .01) and self-esteem (r = -.27, p < .01) is
0.76.
Food availability. On a scale of 0 to 3 times, respondents rated their daily meal intake.
International Journal of Structured Association Technique No.4

26

Perceived good health: On a score of 0=don’t know, 1=sick, 2=a little sick, 3=good health,
respondents rated their perceived health status. We scored If currently attending school as Yes=2,
No=0.

Friendly environment is estimated with the question: Is the person you are living withkind to you? Yes=2, No=0.

Human security factors (25 items, alpha = .86) are the summation of food availability,
friendly environment, good health, currently attending school, social support, parental/foster care,and self-esteem scores.

Human security threat factors (24 items, alpha = .87) summatedchild abuse, social discrimination, anxiety, and depression scores.

3. Analysis

We performed the alpha reliability of the human security factors to estimate the internalconsistency of the measures. Table 1 shows Pearson’s directional association of the factors withhuman security to establish the validity of the measures. We executed the ANOVA of humansecurity factors in the 3 groups to estimate the performance of the AIDS-orphaned adolescents(Table 2). We separated the orphan groups into single and double orphan-types, and examined
their human security scores (Table 3).

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27

International Journal of Structured Association Technique No.4

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4.

Results

Demographic characteristics: Six hundred and eighty-eight (688) sub-Saharan Africa adolescentsof Ugandan (n=371) and South African (n=317) origins validly participated in the study. There
were significantly more females (56%) than males (44%), p < .01. But between participants in thethree groups no significant sex difference was observed [F(1,686)= 0.78, p=.38]. Age wassignificantly different between the three groups – AIDS (M=13.8 years), other-causes (M=14.3
years), and non-orphaned (M=14.2 years), F(2,685)=2.94, p < .05; grand age mean = 14.1 years.
Expectedly, educational levels also varied between the groups, with the non-orphaned showing
the highest education (M=1.64, SD=.73), and AIDS-orphaned showing the lowest (M=1.42,
SD=.69), p < .01.
Other outcomes. Alpha reliability for each of the study measures was admissible (alpha M= .75). The measures also showed admissible discriminant validity (Table 1). Human security
threat factors were significantly higher in adolescents orphaned by AIDS, than in the other twogroups, p < .01. AIDS-orphaned adolescents showed highest child abuse, social discrimination,
anxiety, depression, and lowest self-esteem, social support, and foster/parental care (Table 2).
There was no significant human security risk difference between adolescents whose one parent
died of AIDS, and those whose both parents died of the disease (Table 3). However, each of thetwo groups of AIDS-orphaned adolescents showed lower human security than their other-causes
orphaned counterparts.

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5.

Discussion

The dignity of the individual rests in the self-esteem (Trzesniewski, Donnella, & Robins, 2003).
Self-esteem defines everything about us. It is the foundation of personality (Spritize.blogspot,2006). Self-esteem is more than self-confidence, the knowledge that one can succeed. It is thesum of self-confidence, self-acceptance and self-identity, each of which is desirable for humansecurity. If one is not happy or satisfied with one’s life for reasons one cannot pinpoint, it isprobably because of one’s self-esteem, which might be at a low ebb (Spritize.blogspot, 2006).

In the present study, adolescents orphaned by AIDS showed significantly lowest self-esteem.
They scored significantly highest on the items “felt useless at times, felt unhappy with myself,
people don’t respect me, and overall I’m a failure.” Reasons for their low self-esteem were notobvious. But the Pearson’s association of variables suggests that social discrimination whichshowed the weightiest negative association with self-esteem in the group - followed by anxiety
and child abuse, in that order – might account for their low self-esteem. It seemed likely thathighest social discrimination against the AIDS-affected adolescents, could trigger their highest
anxiety that precipitated lowest self-esteem and human dignity in the group.

The strongest associate of self-esteem was social support. The preponderance of
psychosocial health literature agrees that social support is a rich factor for human dignity, mental
peace and stability (Uchino, Cacioppo, & Kiecolt-Glaser, 1996). Social support whether tangible(monetary, social participation, material care) or intangible (emotional care, cognitive guidance) isInternational Journal of Structured Association Technique No.430

essential for the affective enrichment of the mind and body. But the AIDS-orphaned participants,in the study, scored least on all domains of this important factor, and in the foster/parental carevariable. Friends and family members showed them least love, least comforted them when theyfelt bad, least took care of their financial needs or helped them do things they could not do. In
general, compared with participants in the control groups, AIDS-orphaned adolescents weresignificantly most marginalized from the available social support in their environment. Perhaps theoutcome to the question “are persons you are living with kind to you” further illustrates theunfriendly immediate social milieu of the AIDS-orphaned participants. Half (50%) of them reported“no”, compared with few (34%) other-causes orphaned, and less (17%) non-orphaned groups thatso reported.
Food insecurity and malnutrition are critical in sub-Saharan Africa, where thevagaries of desertification and famine are not uncommon. But the depletion of the available
productive human labor by AIDS may exacerbate the food situation. AIDS-affectedhouseholds, typically characterized by double-parental loss, are most likely to confront foodand nutritional inadequacy. In this study, over half (53%) of the AIDS-orphaned adolescents
retired to bed daily on one or less meal intake, against 34% and 23%, respectively, in theother-causes and the non-orphaned groups. Any wonder that perceived good health wassignificantly lowest in the AIDS-orphaned group?

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There was no measure of the daily meal intake of parents/guardians to permit aninformed judgement whether the highest hunger prevalence among the AIDS-orphanedadolescents may be attributed to child abuse, social discrimination or their unfriendly
immediate social environment. However, if as many as 23% of the non-orphanedadolescents had zero to one meal daily, then it may be a pointer to the permeating presenceof material poverty in the study population.
Poverty has a symbiotic relationship with human insecurity; each strives on the other.
Thus, locally and internationally, whereas poverty may be the underpin for most economic,
food, health, environmental, community, political and personal insecurity crises, thesecrises themselves produce and deepen poverty. Most intra-community or state

armedconflicts, private/organized crimes, “failed” state syndromes, terrorist actions, drug andhuman trafficking, environmental degradation, infectious disease spread, voluntary andinvoluntary human movements, and many other antisocial human activities that threaten
local, national, regional and global peace are the direct or indirect products of poverty. In
sub-Saharan Africa, poverty is both a cause, and a consequence of AIDS. The sexuallyactive male poor, unable to afford condoms may engage in unprotected sex probably withmultiple partners. The female poor, unable to provide for herself, may indulge in
unprotected transactional sex with multiple partners that may lead to infection.

Infected,

the poor may be unable to afford ARV treatment, may borrow money to meet risingInternational Journal of Structured Association Technique No.4

32

hospital bills, may be unable to work on his/farm to guarantee food supply, and may be
fired from work, among other adverse consequences that deepens poverty and humaninsecurity.
According to a model developed in Zambia (Kelly, 2000), AIDS is threatening
education at three fronts: the demand for education (parents); the availability of resources
for education (teachers); and the potential clientele for education (children). With fewer
parents demanding to send their wards to school, fewer teachers as facilitators, and fewer
children/adolescents as clients, the education demand-supply chain is at the risk of acollapse from AIDS. Yet education and human development are central to human security(UN, 2003; UNDP 1994). In the present study, we estimated education by whether or not
one was “currently attending school.” This measure seemed more resourceful than themeasure of “educational level attainment,” which varied significantly in the groups due toage variances. Adolescents orphaned by AIDS were significantly 1.64 times more likely todrop out of school than those orphaned by other causes. Against non-orphaned adolescents,
they (AIDS-orphaned) were 3.48 times significantly more likely, suggesting higher
diminishing prevalence of valuable human capital development in AIDS-affectedhouseholds.
Good health, defined by WHO as not only the absence of disease but a positive stateof physical, mental, and social well-being, is synonymous with human security. Good healthInternational Journal of Structured Association Technique No.4

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is both essential and instrumental to achieving human security. But AIDS-orphanedadolescents in the study scored the least perceived good health condition.
The human security circumstance of single and double AIDS-orphaned adolescentsin the study seemed the same; no significant difference observed. So was the case between
the two orphan types in the other-causes orphaned group (Table 3).

The outcome wasagainst popular view that children with no parent may show greater human security threat
factors than those with at least one parent (Onuoha, et al. 2009; UNAIDS, 2004). However,irrespective of whether single or double orphaned, adolescents orphaned by AIDS scoredhighest human security threat factors than did adolescents in the control groups, supporting
the study hypothesis.
The discussion of human security may not be complete without reference to wars as
threats to global security. Wars and arms procurement for state security may continue to remainpart of our human experience. But armed conflicts aid and abet the spread of AIDS. They
generate displaced populations (refugees), many of whom may be single women andunaccompanied children. These women and children are vulnerable to being pressured into
exchanging sex for food or being raped. Also there is a correlation between military presence andcommercial sex boom in most localities. UNAIDS estimates that the military is 2 to 5 times more
likely than their civilian counterparts to contract STD, including HIV, in times of peace; in times ofInternational Journal of Structured Association Technique No.4

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war, they are 50 times more likely (UNAIDS, 1998). A depleted, dilapidated, demoralized armed
force from AIDS inevitably compromises state and global security.

6.

Conclusions

Orphaning is a significant threat to human security. But AIDS-orphaning presents higher humansecurity threats. In sub-Saharan Africa, prior to the advent of AIDS, deaths among persons aged
20-49 accounted for only 20% of overall deaths in the region, against prevailing 60% owing to
AIDS (UNAIDS, 2006). Many of these adults bequeath children and adolescents as
AIDS-orphans, whose human dignity seemed more debased than that of other orphans.
Human security epitomizes “faith in tomorrow” (UN, 2003), but adolescents orphaned by
AIDS face higher uncertainty about the future owing to lower school attendance prevalence rates.
If human security represents “a child who did not die, a disease that did not spread” (UN, 2003),
then adolescents orphaned by AIDS are direst in need of human security owing to their lowest
perceived good health conditions. We did not directly measure poverty in the study. But theinvisible hands of poverty, judged by hunger prevalence was apparent in the population,
especially among the AIDS-orphaned group.
In sub-Saharan Africa, AIDS may negatively impact on good governance required forhuman security. It creates high worker absenteeism, high worker mortality, high demand of
medical goods and services, but lower productivity, and revenue/income tax generation. These
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factors may undermine government financial resources to effectively control the disease, leading
to its further aggravation.

■ Recommendations
AIDS prevention and control for enhanced human security is critical for community, national,
regional, and global peace. Without intensified prevention efforts directed at the ABC (abstinence,
being partner-faithful, and condom use) therapy, 62 million people are projected to be newly
infected by 2015 (Global Health Council, 2009).
Expanded and free access to ARV (antiretroviral) drugs particularly in sub-Saharan Africa,
where need is greatest, is advocated. The US President’s Emergency Plan for AIDS Relief(PEPFAR) fund in which more than 100 countries have received support (Global Health Council,2009) is commendable. Other major international donors for AIDS programs are the World Bank,UNAIDS, and the Global Fund. Unfortunately, as global funding increases arithmetically, global
fund need seems to increase geometrically due to old and emerging new infections.
Recognizing poverty alleviation as a global responsibility is crucial for human security. The
UN Millennium Summit (September, 2000) declaration to reduce global poverty at least by half by2015 is praise-worthy. However, current global economic recession, continued intra-state armed
conflicts and weak governance in Africa and elsewhere may conspire to render the millennium
goals unachievable.
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AIDS-orphaned adolescents are special vulnerable children, requiring distinctive humansecurity protection policy programs■Acknowledgement

We are thankful to the Japanese Society for the Promotion of Science (JSPS) for its
financial grant for this study. We thank Prof P A E Serumaga-Zake, School of Economics &Decision Sciences, North-West University, Mafikeng, South Africa; Dr. R M Nyonyintono, Schoolof Postgraduate Studies, Ndejje University, Uganda and Mr S M Bogere, Department of
Sociology, Makerere University, Kampala, Uganda, for their collaboration in the study. We also
acknowledge the support of members and staff of the South African and Ugandan community
schools/child support centers from where the study sample was drawn. We thank them all.

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

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

43

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

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

1. Introduction

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

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

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

Other characteristics of the type C personality include

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

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

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

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

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

The behavior is motivated in early childhood

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

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

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

46

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

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

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

47

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

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

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

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

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

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

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

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

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

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

2. Study method
2.1

Subjects

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

49

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

The study period was from October 2009 to April 2010.

2.2

Intervention group(1) 1st intervention: October 2009

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

50

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

(2) 2nd intervention: November 2009

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

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

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

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

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2.3

Non-intervention group

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

2.4

Ethical considerations

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

2.5Structure of questionnaire

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

52

stress syndrome (Munakata, 2007).

2.6

Biochemical index

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

2.7

Analytical method

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

3.

Results

3.1

Intervention group

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

3.2

Non-intervention group

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

3.3

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

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

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

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

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

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

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

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

Cortisol

3-generation image script

3-generation image script

BeforeAfter

BeforeAfter

BeforeAfterMedian325.95385.55148.85317.60.26.16Interquartile

203.58307.80117.75264.45

.29

.07

range
International Journal of Structured Association Technique No.4

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

Self-repression

2-3months

3-4

after

monthsBaseline

2-3months after

3-4 months after

3-generation

Ancestral-generation

after
3-generation

Ancestralgeneration

Median

7.00

10.00

9.00

11.00

6.00

4.00

Interquartil

5.00

2.00

1.00

7.00

6.00

6.00

e range

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

people other than family members)

Baseline

2-3 months

3-4 months

after

after

3-generation

Ancestral-Baseline

2-3 months

3-4 months after

after
3-generation Ancestral-generation

generation
Median

10.00

10.00

10.00

6.00

8.00

8.00

Interquartile

5.00

1.00

2.00

4.00

4.00

4.00

range
Problem-solving
Baseline

Interpersonal dependency

2-3 months

3-4 months

after

after

Baseline

3-generation Ancestral-generation

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

Median

11.00

10.00

17.00

9.00

4.00

4.00

Interquartile

5.00

13.00

6.00

7.00

3.00

2.00

range

International Journal of Structured Association Technique No.4

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Trait anxiety
Baseline

Depression

2-3 months

3-4 months

after

after

3-generation

Ancestral-Baseline

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

generation
Median

55.00

28.00

27.00

47.00

25.00

26.00

Interquartile

18.00

16.00

15.00

16.00

11.00

14.00

range
Required level of health counseling
Baseline

2-3 months

3-4 months

after

after

Difficulty in emotion recognition
Baseline

3-generation Ancestral-generation

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

Median

8.00

1.00

2.00

11.00

4.00

5.00

Interquartile

9.00

4.00

3.00

7.00

6.00

6.00

range
Self-pity
Baseline

Dissociative identity

2-3 months

3-4 months

after

after

Baseline

3-generation Ancestral-generation

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

Median

6.00

3.00

1.00

3.00

1.00

1.00

Interquartile

8.00

6.00

3.00

5.00

3.00

2.00

range
Self-denial
Baseline

PTSS

2-3 months

3-4 months

after

after

Baseline

3-generation Ancestral-generation

2-3 months

3-4 months

after

after

3-generation Ancestral-generation

Median

2.00

.00

.00

4.00

.00

.00

Interquartile

2.00

1.00

.00

3.00

2.00

3.00

range

International Journal of Structured Association Technique No.4

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< Non-intervention group >Self-repression
Baseline

1 month

Problem-solving

4 months later

Baseline

1 month later

4 months later

laterMedian

5.00

5.00

7.00

11.00

10.00

11.00

Interquartile

11.00

4.00

4.00

4.00

6.00

2.00

range
Interpersonal dependency inventory
Baseline

1 month

4 months

later

later

Trait anxiety
Baseline

1 month later

4 months laterMedian

4.00

4.00

3.00

39.00

38.00

41.00

Interquartile

2.00

1.00

1.00

8.00

12.00

21.00

range
Depression
Baseline

Difficulty in emotion recognition

1 month

4 months

later

later

Baseline

1 month

4 months later

laterMedian

32.00

32.00

33.00

5.00

5.00

4.00

Interquartile

5.00

5.00

14.00

2.00

4.00

7.00

range

Self-pity
Baseline

Dissociative identity

1 month

4 months

later

later

Baseline

1 month later

4 months laterMedian

7.00

7.00

6.00

2.00

3.00

3.00

Interquartile

5.00

3.00

4.00

3.00

4.00

2.00

range
PTSS
Baseline

1 month

4 months

later

later

Median

1.00

2.00

2.00

Interquartile

1.00

2.00

5.00

range

International Journal of Structured Association Technique No.4

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4.

Discussion

4.1

Facilitatory effect of immune defenses

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

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

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

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

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4.2

Facilitatory effect of stress resilience

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

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

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

.

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

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prolongation of the survival period of cancer survivors.

4.3

Mental health improvement

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

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

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

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

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

4.4

Limitations and future tasks

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

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