Author: Editor | Date: August 24, 2013 | No Comments »

21 Spiritual Lessons for Surrendering Your Weight Forever

A Course in Weight Loss: by Marianne Williamson / Published by Hay House, Inc.

This article was published in Annals of Psychotherapy & Integrative Health in the spring, 2011 issue, Robert O’Block publisher.

Marianne Williamson

A journey and movement from the false to the true self, New York Times best-selling author Marianne Williamson’s 13th book is about surrendering.

In the final, 21st lesson on surrendering to weight, Williamson warns: “This is the path you will walk for the rest of your life—not just to manage your food issues, but in order to find and live the truest version of yourself.”

Her litany of lessons include, among others: Starting a love affair with food, tearing down the wall, invoking the real you, feeling your feelings, forgiving yourself and others, birthing who you really are, soul surgery, and the body brilliant.

With a foreword by medical doctor Dean Ornish and empty journal pages at the conclusion of the final lesson, in brief chapters, the author reminds the reader that this problem with weight started where one’s divine perfection was forgotten.

The course takes the participant through lessons involving self examination, getting honest, facing fears, and writing letters to and from different aspects of one’s self, such as “Thin-You” and “Not-So-Thin-You.”

Williamson prods: “You can play this shallow or you can play it deep.” Quickly, she warns that this is a long process and not one for the faint of heart.

What this weight book is not about is discipline or willpower or counting calories. The book takes a holistic approach to weight control and eating.

“The problem is not that diets or exercise programs don’t work, because they do,” she notes. “The problem is that when someone is deep into a compulsive or addictive pattern, no matter how much they keep with the diet or the exercise, time and time again, oceanic subconscious forces lead them to put the weight back on. In order to heal, we must address not only the issues of the body, but the issues of the mind and the issues of the Spirit.”

 So, how does one surrender when one is used to getting through life on one’s own? By learning to surrender to the divine design, to the love that is in all things. After all, we are already programmed to become the people God designed us to be.

Remember the Baltimore Catechism question, where is God? “God is everywhere” is the response. Therefore, God is in all things. Williamson takes the positive approach of learning to love food, be its friend and come to the awakening that brings to light the subconscious and sabotaging tapes in one’s head.

Chocolate cake, for example, is not a comfort food to one’s body, Williamson says. The aim is not swearing off prohibited foods nor attaining an iron will, but like Trappist monk Thomas Keating reminded, the solution is in a transformation of the self.

People don’t want to overeat. It’s not an exertion of conscious will. It’s that they ideally do not want to overeat.

Retraining one’s mind seems to be the answer here—correcting widely held beliefs like the notion of “comfort food” and eating too much because one loves it. Unwise eating is not an act of self-love; unwise eating is an act of self-sabotage on every level.

One chapter prescribes starting a love affair with food. Initially, that may sound confusing, since readers would think they are to do the opposite: end the love affair with food.

“An unwise or compulsive eater does not have a love affair with food,” Williamson says. They have an obsession with food. And obsession and love are not the same thing.

“Many people who eat most unwisely are actually lacking a relationship with the sort of culinary delights that we all are afforded on this planet. They are also denying themselves the joy of living with themselves in harmony with their own body and their own needs.”

Hard work is required in this effort at harmony. “But is it not hard to damn yourself to a life that’s an endless cycle of self-hate and self-abuse? A compulsive, addictive life is not an easy life. The disease gives you this illusion of comfort and this illusion of freedom. But it’s a life full of self-loathing at its core,” she notes.

The journey is worth the price, Williamson reminds. Short-term pain for long-term results is the road less traveled.

“With any kind of transformation, it’s like taking out a splinter. You can either deal with the sharp pain of self-discovery that lasts for a second, or the dull pain of denial and illusion that, if left uninterrupted, will last your entire life and severely limit your possibilities for joy and creativity. Sometimes, it’s in the difficulty of the quest that we find the richness of it.”

A good read. Williamson wants people to have a lifelong love affair with food beyond a fight. The book is worth the price. It could save your life, and your heart, for sure.

Reviewed by the Rev. Lawrence M. Ventline, DMin, DAPA, BCPC, a pastor and psychotherapist who is a Diplomate with the American Psychotherapy Association, a board-certified professional counselor, and nationally certified spiritual director, personal trainer, and nutrition consultant. A longtime religion writer for The Detroit News and The Michigan Catholic, he currently writes and blogs for The Oakland Press. Reach him

Author: Editor | Date: | No Comments »

The following was published in Annals of Psychotherapy & Integrative Health in the spring, 2011 issue, published by Robert O’Block.


[Piper methysticum G. Forst]

Natural Standard Professional Monograph, Copyright © 2011 (

Clinical Bottom Line/Effectiveness

Brief Background

Kava beverages, made from dried roots of the shrub Piper methysticum, have been used ceremonially and socially in the South Pacific for hundreds of years and in Europe since the 1700s. The drink is reported to have pleasant mild psychoactive effects1, similar to alcoholic beverages. Recreational use of kava has spread over the last 20 years to Aboriginal communities in Australia2, where it is often consumed in combination with alcohol3. In Fiji, kava is still used today during welcome ceremonies for local and international political and religious dignitaries.

Several well-conducted human trials and meta-analysis4,5,6,7 have shown that kava can effectively treat anxiety, with effects observed after as few as 1-2 doses, and progressive improvements over 1-4 weeks. Preliminary evidence suggests that kava’s effectiveness may be equivalent to benzodiazepines. The pharmaceutical preparations of kava were widely used in Europe and the United States as anxiolytics, but they have since been withdrawn in several European markets and Canada due to safety concerns8,9,10,11,12,13.

Although kava has been studied as a possible treatment for insomnia, many experts believe that kava is neither sedating nor tolerance-forming in recommended doses. Some trials report occasional mild sedation, although preliminary data from small studies suggest a lack of neurological-psychological impairment. Chronic or heavy use of kava has been associated with cases of neurotoxicity, pulmonary hypertension, and dermatologic changes. However, most human trials have been shorter than two months, with the longest study being six months in duration14.

In addition, there is widespread concern regarding the potential hepatotoxicity of kava15,16,17,18,19,20,21,22,23,24,25,26. More than 30 cases of liver damage have been reported in Europe, including hepatitis27,28,29, cirrhosis, fulminant liver failure30,31, and reports of death32,33, although some authors have challenged these reports and maintained that kava is safe in most individuals at recommended doses34,35. It is not clear what dose or duration of use may be correlated with the risk of liver damage. This remains an area of controversy, and it is unclear if the safety profile of kava is comparable to other agents used in the management of anxiety.

Scientific Evidence for Common/Studied Use(s)

IndicationEvidence Grade

Anxiety: A

Insomnia: C

Parkinson’s disease: C

Stress: C

Historical or Theoretical Indications which Lack Sufficient Evidence

Addiction, analgesia, anesthesia2, anorexia, anticonvulsant36,37, antifungal, anti-inflammatory38, antipsychotic2,39, antispasmodic, aphrodisiac, arthritis, asthma38, brain damage, bust enhancement, cancer40, cerebral ischemia41, contraception, colds, cystitis, depression, diuretic, dizziness, dyspepsia, filariasis, gonorrhea, hemorrhoids, infections, jet lag, joint pain, kidney disorders, leprosy, menopausal symptoms (hot flashes, sleep disturbances), menstrual disorders, migraine, muscle relaxant42, neuroprotective41, otitis, pain, parasitic infection, premenstrual dysphoric disorder (PMDD), premenstrual syndrome (PMS)43, renal colic, respiratory tract infections, rheumatism, seizures, stomach upset, stroke, syphilis, toothache, tuberculosis, urinary incontinence, urinary tract disorders, urinary tract infections38, uterine inflammation, vaginal prolapse, vaginitis, weight reduction, wound healing.

Expert Opinion and Folkloric Precedent

An aqueous decoction of Piper methysticum has been used for centuries by Pacific Islanders at social religious-ceremonial and social events without hepatotoxic side effects44,45. Some South Pacific Island countries use fresh kava root or rhizome to prepare the traditional drink, while others use dried and ground roots or rhizomes. For fresh preparations, the root is chewed by young females who spit the juice into the kava bowl without swallowing it themselves. The juice is then mixed with water or coconut milk and further processed46. Another water extract of kava has been made by adding water to kava roots, which are finely ground and then filtered using cheesecloth47. These water extracts have been shown to contain only water-soluble carbohydrates, proteins, and about 6-8% organic compounds.

Kava has been approved in several European countries as a prescription or over-the-counter agent for the treatment of anxiety. Oral preparations are widely recommended by European physicians and natural medicine practitioners.

In the United States, kava has gained popularity, although U.S. physicians and pharmacists are more apt to recommend benzodiazepines to patients with anxiety due to lack of government enforced safety or manufacturing standards for kava. Kava is not on the U.S. Food and Drug Administration’s (FDA) Generally Recognized as Safe (GRAS) list.

Brief Safety Summary

Possibly safe: When used in recommended doses over short periods of time (<1-2 months), kava has historically been regarded as safe and well tolerated.

Possibly unsafe: There is widespread concern regarding the potential hepatotoxicity of kava15,16,17,18,19,20,21,22,23,24,25,26. More than 30 cases of liver damage have been reported, including hepatitis27,28,29, cirrhosis, fulminant liver failure30,31, and reports of death32,33. The U.S. Food & Drug Administration (FDA) has issued warnings to consumers and physicians19,20,48. Long-term use (>1-2 months) or doses greater than recommended (>300mg per day) should be avoided based on reports of significant hepatotoxicity, skin changes, neurotoxicity, and possible pulmonary hypertension15,30. Due to MAOI-like activity, kava may theoretically prolong the effects of anesthesia, and discontinuation should be considered prior to some surgery. Sedation has been reported anecdotally and in some trial subjects, although preliminary studies have found that kava does not impair neurological-psychological functioning at recommended doses. Kava may be unsafe during pregnancy or breastfeeding.

Likely unsafe: When used in patients with liver disease49,50, including hepatitis27,28,29.


Avoid long-term use (>1-2 months) or doses greater than recommended (>300mg per day), based on reports of significant hepatotoxicity, skin changes, neurotoxicity, and possible pulmonary hypertension.

Avoid in patients with known liver disease or in those taking hepatotoxic agents (e.g., acetaminophen, HMG CoA reductase inhibitors, isoniazid, methotraxate, etc.), based on more than 30 reports of hepatotoxicity15. Avoid driving or using heavy machinery while taking kava. Drowsiness has been reported in clinical trials, although no effect on driving motor vehicles has been found in two double-blind, placebo controlled trials.

Avoid concomitant use with other CNS depressants, such as alcohol or benzodiazepines, based on theoretical additive sedative effects, although it remains unclear if kava is sedating.

Avoid in patients with Parkinson’s disease or in patients with a history of medication-induced extrapyramidal effects, based on reports of extrapyramidal effects in people taking kava39,53,54,58.

Avoid in patients with chronic lung disease, based on reports of dyspnea and pulmonary hypertension after chronic heavy use.

Stop taking kava 2-3 weeks before some surgeries, as kava may lengthen the effects of anesthesia.

Use cautiously if pregnant or breastfeeding1.

Use cautiously in patients with endogenous depression or in those taking antidepressants, due to purported sedative activity of kava resin and the pyrones dihydrokawain and dihydromethysticin1,59.


Kava (Piper methysticum) is a shrub indigenous to South Sea Pacific islands. A beverage made from the roots of Piper methysticum has been used as a social, medicinal, and ceremonial drink since the beginning of recorded history in that region. The drink is reported to have pleasant mild psychoactive effects1, similar to alcoholic beverages in Western societies. The first descriptions of its usage were brought to Europe by Captain Cook’s expeditions in the late 1700s62. Welcome ceremonies using kava (for local and international political and religious dignitaries) continue in Fiji to the present day.

Recreational use of kava has spread over the last 20 years to Aboriginal communities in Australia2, where it is often heavily used in combination with alcohol3. Wives of kava users have felt deprived of basic family needs due to the amount of money spent on kava66. Local annual sales in Fiji have been reported in the range of $30 million, with exports amounting to $17 million. Reportedly, 350,000 prescriptions for kava are written in Germany every year. Kava has become a popular herbal supplement in the United States, with multimillion-dollar sales and several books supporting its use. Pharmacological and chemical properties of the plant have been studied since the 1960s61. A report in 2006 indicated that kava use among 11-17 year olds at a potentially harmful level (i.e. daily) was low in all Pacific countries tested67.

The U.S. Food and Drug Administration (FDA) issued a letter on December 18, 2001, stating that it was investigating whether kava-containing products were a health concern. The FDA noted 26 cases of liver toxicity in Germany and Switzerland, including one fatality and one liver transplant that were reportedly associated with kava products. In 2002, the U.S. Centers for Disease Control and Prevention (CDC) issued a report on hepatotoxicity associated with kava-containing products. On March 25, 2002, the FDA warned that kava may be linked to serious liver damage, including hepatitis, cirrhosis, and at least four urgent liver transplants68. A letter was also issued urging healthcare professionals to review cases of liver toxicity to determine if they were associated with kava. The quality of these case reports has been variable; several were vague, described use of products that did not actually list kava as an ingredient, or included patients who also drank large amounts of alcohol. Despite these health concerns, kava has not been taken off the U.S. market19,20,48.

In 2002, sales of products and preparations containing kava were suspended or withdrawn in several countries, including Canada, Germany, Switzerland, Australia, France, and Spain. In Japan, no new drug products containing kava were approved. In New Zealand, authorities recommended that labels contain warnings about the possible risk of liver damage. All of these countries released advisories cautioning about the use of kava-containing products.

In 2005, Germany considered making kava available by prescription only. In the same year, the Medicine’s and HealthCare Products Regulatory Agency (MHRA) launched a 12-week public consultation process for interested parties to submit evidence and representations as to whether the prohibition of kava should continue. Based on the evidence provided from the MHRA, Germany was one of the first countries to lift its ban on kava. The repeal does not mean that kava can be sold freely in Germany. Instead, it only removes the licensing ban on kava product registrations.

Evidence Discussion


The majority of relevant clinical trials identified by a systematic literature review report at least moderate efficacy of kava in the treatment of anxiety. A meta-analysis of randomized controlled trials found a statistically significant overall improvement of anxiety symptoms due to kava (standardized extract WS 1490, 300mg orally daily in three equal doses). Preliminary evidence suggests that kava may be equivalent to benzodiazepines in the treatment of non-psychotic anxiety. Kava’s effects were reported to be similar to the prescription drug buspirone (Buspar®) used for Generalized Anxiety Disorder (GAD) in one study51. In the past, the German expert panel, the Commission E, has approved kava for nervous anxiety, stress, and restlessness.


Kava has been reported occasionally to cause sedation or lethargy6,52. Sedation has been occasionally reported anecdotally, in case reports, and in trials, although preliminary evidence from three small human studies suggests lack of neurological-psychological impairment55,56,57. For this reason, researchers have studied kava as a possible treatment for insomnia. However, additional studies are needed to determine if kava is an effective treatment for this condition.


Summary: Early study results suggest that kava and valerian may improve health by reducing the body’s reactions during stressful situations and stress-induced insomnia. Further research is needed to confirm these results.

Parkinson’s disease

Summary: It is unclear whether kava is safe or effective for use in Parkinson’s patients. Kava has been reported to antagonize the effect of dopamine and elicit extrapyramidal effects in animal data and case reports39,53,54. Therefore, it may interfere with the effects of dopamine or dopamine agonists and exacerbate the extrapyramidal effects of dopaminergic antagonists such as droperidol, haloperidol, risperidol, and metoclopramide. Kava (Piper methysticum) increases ‘off’ periods in Parkinson patients taking levodopa and can cause a semicomatose state when given concomitantly with alprazolam58. Of note, neither high single doses nor chronic administration of kavain, from the lipophilic fraction of kava, altered dopaminergic or serotonergic tissue levels in rats63. Therefore, dopaminergic or serotonergic effects may reside in the water-soluble fraction of kava64,65. An observational study, however, noted that the extrapyramidal side effects caused by neuroleptic agents may be reduced by kava special extract WS 149060. Additional study is needed in this area to make a firm recommendation.


Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to Selected references are listed below.

1.     Singh, Y. N. Kava: an overview. J Ethnopharmacol. 1992;37(1):13-45.

2.     Cawte, J. Parameters of kava used as a challenge to alcohol. Aust.N.Z.J Psychiatry 1986;20(1):70-76.

3.     Douglas W. The effects of heavy usage of kava on physical health. Med J Australia 1988;149:341-342.

4.     Pittler, M. H. and Ernst, E. Kava extract for treating anxiety. Cochrane Database.Syst Rev 2003;(1):CD003383.

5.     Pittler, M. H. and Ernst, E. Kava extract for treating anxiety. Cochrane Database.Syst Rev 2002;(2):CD003383.

6.     Pittler, M. H. and Ernst, E. Efficacy of kava extract for treating anxiety: systematic review and meta-analysis. J Clin Psychopharmacol. 2000;20(1):84-89.

7.     Basch E, Ulbricht C, Hammerness P, and et al. Kava monograph. J Herbal Pharmacother 2002;2(4):65-91.

8.     Stafford N. Germany may ban kava kava herbal supplement, Reuter’s News Service Germany (November 19, 2001).

9.     Mills, E., Singh, R., Ross, C., Ernst, E., and Ray, J. G. Sale of kava extract in some health food stores. CMAJ. 11-25-2003;169(11):1158-1159.

10. Schulze, J., Raasch, W., and Siegers, C. P. Toxicity of kava pyrones, drug safety and precautions–a case study. Phytomedicine. 2003;10 Suppl 4:68-73.

11. Kava: first suspended, now prohibited. Prescrire.Int 2003;12(66):142.

12. Ernst, E. [Recall of the herbal anxiolytic kava. Underestimation of its value or overestimation of its risks?]. MMW.Fortschr.Med 10-10-2002;144(41):40.

13. Boon, H. S. and Wong, A. H. Kava: a test case for Canada’s new approach to natural health products. CMAJ. 11-25-2003;169(11):1163-1164.

14. De Leo, V, La Marca, A., Lanzetta, D., Palazzi, S., Torricelli, M., Facchini, C., and Morgante, G. [Assessment of the association of Kava-Kava extract and hormone replacement therapy in the treatment of postmenopause anxiety]. Minerva Ginecol. 2000;52(6):263-267.

15. Russmann, S., Lauterburg, B. H., and Helbling, A. Kava hepatotoxicity. Ann.Intern.Med 7-3-2001;135(1):68-69.

16. Kava kava may cause irreversible liver damage. S.Afr.Med J 2002;92(12):961.

17. Concerns over kava have the FDA’s attention. Mayo Clin Health Lett 2002;20(7):4.

18. Kava concerns. FDA, Botanical Council raises safety concerns. AWHONN.Lifelines. 2002;6(1):13-15.

19. Parkman, C. A. Another FDA warning: Kava supplements. Case.Manager. 2002;13(4):26-28.

20. Center for Food Safety and Applied Nutrition (US Food and Drug Administration). Letter to health care professionals: FDA issues consumer advisory that kava products may be associated with severe liver injury (document issued March 25, 2002), contact information for FDA Medwatch program: 1-800-332-1088.

21.De Smet, P. A. Safety concerns about kava not unique. Lancet 10-26-2002;360(9342):1336.

22. From the Centers for Disease Control and Prevention. Hepatic toxicity possibly associated with kava-containing products–United States, Germany, and Switzerland, 1999-2002. JAMA 1-1-2003;289(1):36-37.

23. Clough, A. R., Bailie, R. S., and Currie, B. Liver function test abnormalities in users of aqueous kava extracts. J Toxicol.Clin Toxicol. 2003;41(6):821-829.

24. Russmann, S., Barguil, Y., Cabalion, P., Kritsanida, M., Duhet, D., and Lauterburg, B. H. Hepatic injury due to traditional aqueous extracts of kava root in New Caledonia. Eur.J Gastroenterol.Hepatol. 2003;15(9):1033-1036.

25. Anonymous. Hepatic toxicity possibly associated with kava-containing products– United States, Germany, and Switzerland, 1999-2002. MMWR Morb.Mortal.Wkly.Rep 11-29-2002;51(47):1065-1067.

26. Ernst, E. Safety concerns about kava. Lancet 5-25-2002;359(9320):1865.

27. Bujanda, L., Palacios, A., Silvarino, R., Sanchez, A., and Munoz, C. [Kava-induced acute icteric hepatitis]. Gastroenterol.Hepatol. 2002;25(6):434-435.

28. Humberston, C. L., Akhtar, J., and Krenzelok, E. P. Acute hepatitis induced by kava kava. J Toxicol.Clin Toxicol. 2003;41(2):109-113.

29. Stickel, F., Baumuller, H. M., Seitz, K., Vasilakis, D., Seitz, G., Seitz, H. K., and Schuppan, D. Hepatitis induced by Kava (Piper methysticum rhizoma). J Hepatol. 2003;39(1):62-67.

30. Escher, M., Desmeules, J., Giostra, E., and Mentha, G. Hepatitis associated with Kava, a herbal remedy for anxiety. BMJ 1-20-2001;322(7279):139.

31. Kraft, M., Spahn, T. W., Menzel, J., Senninger, N., Dietl, K. H., Herbst, H., Domschke, W., and Lerch, M. M. [Fulminant liver failure after administration of the herbal antidepressant Kava-Kava]. Dtsch Med Wochenschr 9-7-2001;126(36):970-972.

32. Thomsen, M., Vitetta, L., Schmidt, M., and Sali, A. Fatal fulminant hepatic failure induced by a natural therapy containing kava. Med J Aust. 2-16-2004;180(4):198-199.

33. Gow, P. J., Connelly, N. J., Hill, R. L., Crowley, P., and Angus, P. W. Fatal fulminant hepatic failure induced by a natural therapy containing kava. Med J Aust. 5-5-2003;178(9):442-443.

34. Relevant hepatotoxic effects of kava still need to be proven. A statement of the Society for Medicinal Plant Research. Planta Med 2003;69(11):971-972.

35. Denham, A., McIntyre, M., and Whitehouse, J. Kava–the unfolding story: report on a work-in-progress. J Altern Complement Med 2002;8(3):237-263.

36. Gleitz, J., Friese, J., Beile, A., Ameri, A., and Peters, T. Anticonvulsive action of (+/-)-kavain estimated from its properties on stimulated synaptosomes and Na+ channel receptor sites. Eur.J Pharmacol 11-7-1996;315(1):89-97.

37. Schmitz, D., Zhang, C. L., Chatterjee, S. S., and Heinemann, U. Effects of methysticin on three different models of seizure like events studied in rat hippocampal and entorhinal cortex slices. Naunyn Schmiedebergs Arch Pharmacol. 1995;351(4):348-355.

38. Folmer, F., Blasius, R., Morceau, F., Tabudravu, J., Dicato, M., Jaspars, M., and Diederich, M. Inhibition of TNFalpha-induced activation of nuclear factor kappaB by kava (Piper methysticum) derivatives. Biochem Pharmacol 4-14-2006;71(8):1206-1218.

39. Baum, S. S., Hill, R., and Rommelspacher, H. Effect of kava extract and individual kavapyrones on neurotransmitter levels in the nucleus accumbens of rats. Prog.Neuropsychopharmacol.Biol Psychiatry 1998;22(7):1105-1120.

40. Steiner, G. G. The correlation between cancer incidence and kava consumption. Hawaii Med J 2000;59(11):420-422.

41. Backhauss, C. and Krieglstein, J. Extract of kava (Piper methysticum) and its methysticin constituents protect brain tissue against ischemic damage in rodents. European Journal of Pharmacology 5-14-1992;215(2-3):265-269.

42. Singh, Y. N. Effects of kava on neuromuscular transmission and muscle contractility. J Ethnopharmacol. 1983;7(3):267-276.

43. Girman, A., Lee, R., and Kligler, B. An integrative medicine approach to premenstrual syndrome. Am J Obstet.Gynecol. 2003;188(5 Suppl):S56-S65.

44. Lemert, E. M. Koni, kona, kava. Orange-beer culture of the Cook islands. J Stud Alcohol 1976;37(5):565-585.

45. Loew, D. and Franz, G. Quality aspects of traditional and industrial Kava-extracts. Phytomedicine. 2003;10(6-7):610-612.

46. Lebot, V., Merlin, M., and Lindstrom L. Kava the Pacific Drug. London: Yale University;1992.

47. Naiker, M., Devi, R., Ali, S., Sotheeswaran, S., and Winterhalter, P. Major chemical differences between the water extracts of kava and kava pills. Proceedings of the Pacific Kava Research Symposium, Suva, Figi 11-6-2002;9.

48. Center for Food Safety and Applied Nutrition (US Food and Drug Administration). Kava-containing dietary supplements may be associated with severe liver injury (document issued March 25, 2002).

49. Teschke, R., Gaus, W., and Loew, D. Kava extracts: safety and risks including rare hepatotoxicity. Phytomedicine. 2003;10(5):440-446.

50. Stoller, R. Reports of hepatotoxicity with kava. Proceedings of the 24th Annual Meeting of Representatives of National Centres Participating in the WHO Drug Monitoring Programme, Dunedin, New Zealand 2008;

51. Boerner, R. J., Sommer, H., Berger, W., Kuhn, U., Schmidt, U., and Mannel, M. Kava-Kava extract LI 150 is as effective as Opipramol and Buspirone in Generalised Anxiety Disorder–an 8-week randomized, double-blind multi-centre clinical trial in 129 out-patients. Phytomedicine. 2003;10 Suppl 4:38-49.

52. Mathews, J. D., Riley, M. D., Fejo, L., Munoz, E., Milns, N. R., Gardner, I. D., Powers, J. R., Ganygulpa, E., and Gununuwawuy, B. J. Effects of the heavy usage of kava on physical health: summary of a pilot survey in an aboriginal community. Med J Aust. 6-6-1988;148(11):548-555.

53. Spillane, P. K., Fisher, D. A., and Currie, B. J. Neurological manifestations of kava intoxication. Med J Aust. 8-4-1997;167(3):172-173.

54. Schelosky, L., Raffauf, C., Jendroska, K., and Poewe, W. Kava and dopamine antagonism. J Neurol.Neurosurg.Psychiatry 1995;58(5):639-640.

55. Gessner B and Cnota P. Extract of the kava-kava rhizome in comparison with diazepam and placebo. Z Phytother 1994;15(1):30-37.

56. Johnson D, Frauendorf A, Stecker K, and et al. Neurophysiological active profile and tolerance of kava extract WS 1490, A pilot study with randomized evaluation. TW Neurolgie Psychiatrie 1991;5(6):349-354.

57. Herberg KW. Driving ability after intake of kava special extract WS 1490, a double-blind, placebo-controlled study with volunteers. Zeitschrift für Allgemeinmedizin 1991;13:842-846.

58. Izzo AA and Ernst E. Interactions between herbal medicines and prescribed drugs: a systematic review. Drugs 2001;61(15):2163-2175.

59. Jamieson, D. D., Duffield, P. H., Cheng, D., and Duffield, A. M. Comparison of the central nervous system activity of the aqueous and lipid extract of kava (Piper methysticum). Arch Int Pharmacodyn Ther. 1989;301:66-80.

60. Boerner, R. J. and Klement, S. Attenuation of neuroleptic-induced extrapyramidal side effects by Kava special extract WS 1490. Wien.Med Wochenschr. 2004;154(21-22):508-510.

61. Hänsel R. Characterization and physiological activity of some Kawa constituents. Pacific Science 1968;22:293-313.

62. Singh Y and Blumenthal M. Kava: an overview. Distribution, mythology, botany, culture, chemistry and pharmacology of the South Pacific’s most revered herb. HerbalGram 1997;39(Suppl 1):34-56.

63. Boonen, G., Ferger, B., Kuschinsky, K., and Haberlein, H. In vivo effects of the kavapyrones (+)-dihydromethysticin and (+/-)- kavain on dopamine, 3,4-dihydroxyphenylacetic acid, serotonin and 5- hydroxyindoleacetic acid levels in striatal and cortical brain regions. Planta Med 1998;64(6):507-510.

64. Buckley, J. P., Furgiuele, A. R., and O’Hara, M. J. Pharmacology of kava. Ethnopharm Search Psych Drugs 1967;1:141-151.

65. Furgiuele AR, Kinnard WJ, Aceto MD, and et al. Central activity of aqueous extracts of Piper methysticum (kava). J Pharm Sci 1965;54:247-252.

66. Kava, R. The adverse effects of kava. Pac.Health Dialog. 2001;8(1):115-118.

67. Smith, B. J., Phongsavan, P., Bauman, A. E., Havea, D., and Chey, T. Comparison of tobacco, alcohol and illegal drug usage among school students in three Pacific Island societies. Drug Alcohol Depend. 4-17-2007;88(1):9-18.

68. Assessment of the Risk of Hepatotoxicity with Kava Products. 2000.

Natural Standard Monograph (

Copyright © 2011 Natural Standard Inc. Commercial distribution or reproduction prohibited.

The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

Author: Editor | Date: August 23, 2013 | No Comments »

The following article was first published in

Annals of Psychotherapy & Integrative Health,

Spring 2011,published by Robert O’Block

Mind-Body Medicine by Zhaoming Chen, MD, PhD, CFP, FAAIM

Zhaoming Chen, MD, PhD, CFP, FAAIM

Mind-body health is the discipline that studies the relationship between the brain, mind, and body, specifically involving changes in behavior.

It is generally believed that the brain is the organ responsible for judgment, insight, emotion, thought, body movement, and perception. The brain receives its nutrition, glucose, and oxygen supply through the blood circulation and feedback from the internal and external environment via the peripheral and central nervous systems. Normal brain function depends upon harmony between the multitude of body organs and the brain itself. Brain tumors or seizure disorders can result in individuals having irregular or bizarre behavior. Alcohol intoxication may result in delirium or confusion. End-stage kidney and liver disease also result in impaired mental states that lead to disorientation and confusion. Someone who suffers from a thalamic stroke may have refractory limb pain, even if the physical exam and laboratory, nerve, and muscle tests on the affected limbs are unremarkable1.

There are two autonomic nervous systems in the human body: sympathetic and parasympathetic. Through the release of catecholamines such as epinephrine and norepinephrine, the human body will increase cardiac output via a faster heart rate and a higher ejection volume. The blood glucose level will increase, and there will be elevations in the blood pressure through peripheral vasoconstriction and the cardiac changes mentioned previously. The final outcome will be a redistribution of blood to the brain, heart, and muscles, which is the natural physiological reaction to stress challenges. Its purpose is to protect humans from experiencing any life-threatening insults or allow them to escape from dangerous environments. This so-called “fight or flight” reaction, if overwhelming for extended periods of time, will result in significant negative impacts on the human body. Blood pressure and sugar will be kept at elevated levels constantly, leading to hypertension and diabetes. Patients will suffer chronic pain and disturbances of memory and sleep as well as other discomforts, leading to significant social, economic, and professional dysfunctions. More than 80 percent of medical visits are found to be associated with stress-related anxiety2. 

Mind-body health is the discipline that studies the relationship between the brain, mind, and body, specifically involving changes in behavior. It aims to reduce physical disease and ailments through techniques of mind regulation. Through the release of acetylcholine, cardiac output is reduced as a consequence of a slower heart rate and reduced cardiac stroke volume, and blood pressure is within a normal range due to the balance of vasoconstriction and vasodilation; blood sugar concentration is also normalized. The improved circulation of blood to the skin results in improved complexion and fewer wrinkles. Mind-body medicine is most commonly used for anxiety/depression and for musculoskeletal and myofascial pain syndromes. People have used these techniques either in conjunction with conventional medicine or independently. Most who practice mind-body techniques have felt positive changes3,4.

There are a number of modalities under the umbrella of mind/body medicine5, including relaxation techniques, guided imagery, tai chi, qigong, yoga, and meditation, such as transcendental meditation. Some other remedies such as group therapy or cognitive behavioral therapy are already integrated into modern Western medicine. The popularity of mind-body health is growing extensively due to its convenience, low cost, and minimal side effects.

Relaxation techniques are used to elicit a relaxation response that reduces physiological symptoms and enhances a sense of well-being. It has two key components: focused attention via repetition of phrases, words, or a simple physical activity such as breathing and attempts to ignore meaningless or frustrating thoughts. The breathing techniques can promote activity of the parasympathetic nervous system6.

Meditation is a process in which practitioners focus their concentration on an object or simple physical activity such as breathing or repeating a word or phrase. In transcendental meditation, the phrase is known as a “mantra.” The attention is turned inward. As the sympathetic nervous system calms down and the parasympathetic system kicks in, a peaceful state of mind is reached. During the meditation, the brain is probably in the state of active sleep with characteristics of enhanced cerebral blood flow supply accompanied by an overall slowing of electrical activity7.

Guided imagery is used to create a picture or movie based on a past enjoyable experience or an imagination involving a memory, dream, or vision. At the same time, the practitioner converts these images to a positive experience. Through repetition, the practitioner can achieve a state of relaxation. Sometimes, sounds, smells, touch, or taste can also be employed. The practitioners report significant reduction of anxiety, with improved mood and an overall healthier status compared with nonpractitioners8,9.

Yoga, originating from India, is a mind-body exercise involving body posture and physical stretching, or breathing and meditation, or both. Different styles of yoga are seen in the U.S. This exercise is very gentle and slow. Yoga is considered to reduce stress and stabilize the mood. After six weeks of training, participants have significant improvement in terms of clarity of mind, energy, and self-confidence, manifesting as life satisfaction10. 

Originating in China, qigong is an art of self-training in mind and body to reach homeostasis and decreased energy consumption. It also sends forth external energy. Practicing qigong has the benefit of preventing and curing some diseases, maintaining health, and prolonging one’s lifespan. Practitioners blend attention or mind, posture, and breathing together during exercise. The principles of practicing are relaxation and tranquilization—a combination of activity and tranquility, a concurrence of training and nourishing, and movements that proceed slowly and solidly. 

Tai chi is very useful for preserving health, preventing disease, and rehabilitating from chronic diseases. Learning to stay centered and calm in stressful environments is a fundamental element for health. In contrast to yoga, it is the movements of tai chi that have crucial significance. If practiced faster, tai chi can be used as self-defense. The difference between tai chi and qigong is that the former is more externally focused, while the latter is more internally focused. Thus qigong is the supreme level of all martial arts. Tai chi is effective for controlling pain, reducing cardiovascular-associated mortality, regulating autonomic dysfunction, improving sleep quality, and decreasing gait disturbance11.

Mind-body medicine has been proven to be very effective in treating neurological diseases such as headaches, migraines, back pain with sciatica, strokes, dementia, seizures, and memory loss. Based upon the 2007 National Health Interview Survey of more than 23,000 Americans, people with these common neurological conditions are inclined to seek help from mind-body therapists more often due to either failure or the high expense of conventional remedies12. The use of mind/body medicine can significantly reduce physician clinic visits with satisfactory outcomes and is certainly cost-effective13,14,15. It is consistent with the goal of health care reform: to provide an affordable high-quality health care service to American people.

Zhaoming Chen, MD, PhD, CFP, FAAIM, is chairman of the American Association of Integrative Medicine.  He obtained his medical degree from Shanghai Jiao Tong University College of Medicine, with hematology and medicine residency at Rui-Jin Hospital, and neurology residency at Georgetown University. He earned his neuroscience PhD from Drexel University and completed a research fellowship at the University of Pennsylvania and a clinical neurophysiology fellowship at Georgetown University. He was trained in acupuncture at Shanghai University of Traditional Chinese Medicine and Harvard Medical School.  He has decades of experience in tai chi and holds a certificate from Shanghai Institute of Qigong. He is now a board-certified neurologist and clinical neurophysiologist. He was selected for America’s Top Physicians 2009.


1. Bradley WG et al. Neurology in Clinical Practice, 4th edition. Boston: Butterworth-Heinemann; 2004

2. Kroenke K, Mangelsdorff, AD. Common symptoms in ambulatory care, incidence, evaluation, therapy, and outcome. Am J Med. 1989;86:262-267.

3. Bertisch SM et al. Alternative mind-body therapies used by adults with medical conditions. J Psychosom Res. 2009;66(6):511-9.

4. Mclndoe R. A behavioral approach to the management of chronic pain. A self management perspective. Austr Fam Phys. 1995;May;24(5):931

5. <>

6. Pramanik T et al. Immediate effect of slow pace bhastrika pranayama on blood pressure and heart rate. J Altern Complem Med. 2009;Mar;15(3):293-5.

7. Cahn BR, Polich J. Meditation states and traits: EEG, ERP, and neuroimaging studies. Psychol Bull. 2006;Mar:132(2):180-211

8. Schwab D et al. A study of efficacy and cost-effectiveness of guided imagery as a portable, self-administered, presurgical intervention delivered by a health plan. Adv Mind Body Med. 2007;22(1):8-14.

9. Watanabe E et al. Effects among healthy subjects of the duration of regularly practicing a guided imagery program. BMC Complement Altern Med. 2005;Dec 20;5:21

10. Hartfiel N et al. The effectiveness of yoga for the improvement of well-being and resilience to stress in the workplace. Scand J Work Environ Health. 2011;Jan;37(1):70-6

11. Irwin MR, Olmstead R, Motivala SJ. Improving sleep quality in older adults with moderate sleep complaints: a randomized controlled trial of Taichi. Sleep. 2008;31(7):1001-1008

12. Wells RE et al. Patterns of mind-body therapies in adults with common neurological conditions. Neuroepidemiology. 2011;36:46-51.

13. Peters L et al. The COPE program: treatment efficacy and medical utilization outcome of a chronic pain management program at a major military hospital. Mil Med. 2000;Dec;165(12):954-60

14. Smeeding SJ et al. Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic pain and stress-related depression, anxiety, and post-traumatic stress disorder. J Altern Complem Med. 2010;Aug;16(8):823-35.

15. Smeeding SJ. et al. Outcome evaluation of the veterans affairs salt lake city integrative health clinic for chronic nonmalignant pain. Clin J Pain. 2011;Feb;27(2):146-55.

Annals Spring 2011

Author: Editor | Date: | No Comments »

The following article was first published in Annals of Psychotherapy & Integrative HealthRobert O’Block publisher. 

Some Lessons To Be Learned From The Debacle At Penn State

About the Author

Irene Rosenberg Javors, LMHC, DAPA is a psychotherapist in NYC. She is on the faculty of the Mental Health Counseling Program of the Ferkauf Graduate School of Psychology, Yeshiva University. She is the author of Culture Notes: Essays on Sane Living.


Penn State University

In November a client of mine came to a session terribly upset about the Penn State sexual abuse scandals. His concern revolved around sports in schools, specifically, the participation of his son on the high school wrestling team. My client expressed anxiety about the coaches and their ‘rah, rah’ attitudes about loyalty to the team.

After this session I started thinking about American sports cultures, in particular, sports in schools and in colleges. The terrible events at Penn State have given us a window into the worst-case scenario of what might happen within any institution if certain conditions prevailed.

Let us look at collegiate sports programs today. They bring in billions of dollars in endowments. They bring in students who want to be part of a ‘winning’ culture. These ‘sports dollars’ provide the needed funds to hire faculty and create jobs. They provide future professional football stars. In short, many colleges need these teams to survive, if not thrive.

The emphasis on athletic programs bringing in needed revenue inevitably results in a de-emphasis on everything else, including ethics and stringent oversight. In the case of Penn State, the football team had its own separate building as well as its own training facility. The football team had achieved a level of unparalleled insularity. Up to this point the coaches had been answerable to no one.

On top of all this, the football players were indoctrinated in what I term ‘team think.’ As a member of a team, you are taught that the team is all important and comes first regardless of what you might need, think, or feel. To think differently is to betray the team. To report inappropriate behavior may betray the team if the information puts the team in a compromising position. Add to this the billions of dollars at stake if the team is implicated in a scandal, and you have the perfect recipe for a cover-up.

When I watch football on television, whether collegiate or professional, these days it is very hard to tell the difference. I do not see athletes; rather, I see gladiators who enter the arena to sacrifice their all, regardless of the risks. Such a militaristic sports culture is far removed from the notion of, “it’s not whether you win or lose, it’s how you play the game.” Today it’s only about winning because it’s all about money, and collegiate players are no longer amateurs but professionals who bring in the money.  Collegiate sports are big businesses.

Penn State is learning that to be a real winner they must play the game ethically and with concern for the individual over the team. Hopefully these scandalous events will lead to greater attention by the National College Athletic Association (NCAA), as well as to encourage college officials to contact the police immediately if there are any allegations of criminal activity. In addition, colleges need to review how athletic departments supervise staff members who are in contact with children, as well as to establish some sort of policy or guidelines for protecting children who are involved with sports activities within educational settings.

As an undergraduate in the late 1960’s, I was a member of the women’s fencing team. I loved the sport and competed in tournaments. I learned self-discipline and valued all the members of my team. No big money fueled our endeavors. We fenced out of a love for the game. Unfortunately this is a concept that has all but disappeared today. The extreme commercialization of collegiate sports has offered dollar success while at the same time fueled criminal cover-ups, non-compliance of NCAA rules, federal laws that give women gender parity in sports, and outright cheating.

As therapists, school counselors, college advisors, mentors, and coaches, we need to be at the forefront in calling for these reforms. The disheartening events at Penn State should serve as a wake-up call for long overdue changes in collegiate sports.


Author: Editor | Date: August 21, 2013 | No Comments »

Communication  by Ronald Hixson, MBA, BCPC, MT, DAPA.  The following article was first published in Annals of Psychotherapy & Integrative Health, fall 2012, Robert O’Block publisher.

Ronald Hixson, MBA, PhD

Since birth we have been sharing our wants, our feelings, and our displeasure with those in our families, peers at school or work, and in our social cycles. We have used guttural sounds, words, non-verbal gestures or expressions, and sometimes we write memos or letters, articles, or books. Voting is an expression, as is not voting. Public speaking is taught to increase our individual abilities; to fight through stage fear in order to share ideas. Debate classes teach individuals in high school and college how to formulate ideas quickly in response to a challenge from an adversary who disagrees with your position. Businesses of all sizes use marketing strategies to send messages to their communities about their products or services, hoping that enough people will purchase from them rather than from a competitor. Managers use communication strategies to build teams, church organizations, politics, and businesses.

A coach uses communication to encourage team bonding. One person may win or lose a game, but it takes the team to win a championship. In health care organizations, communication can save lives while the lack of communication may be a contributing factor in a death. In one situation, an individual waited for over 24 hours in an ER to be seen by a doctor. It took other patients to identify this urgent situation to ER staff, at which time they discovered that the person had died while waiting for emergency services. In crisis centers vital information may be lost if the crisis team does not communicate in a timely fashion. For example, when a caller gives an address to the 911 operator, but due to a late arrival, the person is deceased when the Emergency Medical Technicians (EMTs) arrive. With the health care reform have come demands for collaboration in order to decrease duplication; however, this can also help provide information to be shared with members of the health care team, such as sharing their views of the symptoms, medication side effects, or significant factors that can cause harm. Sharing information about new laws, regulations, and administrative changes among a professional group or among community health care providers can save some from being audited.

Team building in an organization, profit or non-profit, is extremely important for the survival of the organization due to the fact that grant funds have dried up or have been shifted to other organizations. A psychologist shared an example of withholding information for some but not for others. She had joined a non-profit to work as a clinician and to help the administration create a team of behavioral health staff, with procedures and policies that might be different from the other professions (medical and substance abuse) providers in the organization. After she was hired, her supervisor, who had the title of Clinical Coordinator, stayed away from her and did not offer any advice or guidance about where to start, what was available in the budget, or what contracts she was allowed to pursue, and which ones the supervisor and CEO did not want to be associated with. The main focus of her new position was to see 8 patients a day. She was told that the clerks would help her with appointment scheduling and obtaining office supplies. They did encourage her to visit physicians and other agencies to market the business.

The problem between the psychologist and her supervisor began when she had questions and needed clarification and guidance. She was given a cell phone number and an email address, as well as an office fax number, and was encouraged to call; however, her supervisor did not answer any of her emails, calls, or faxes. She stopped by her supervisor’s office and was told that she was busy. The secretary took a note for the supervisor to call the psychologist when she was available.

Weeks went by with no communication between the two. Frustrated the psychologist asked her clerk for ideas about communicating with the supervisor. She then talked to another therapist, but nothing was offered that was successful in obtaining a call back or a meeting time. Then one day she got a call from the CEO assistant informing her that the CEO was sending her an email. Several hours later the email arrived. When opened it said in part:

·   The business cards you requested have been ordered.

·   It has come to our attention that you have shared a number of messages with fellow employees that were negative regarding your supervisors. This will not be tolerated. We expect a professional attitude.

·   We also expect that you will make your quota for each week as discussed at the time of your employment. If you need any clarification or have other questions, please feel free to discuss them with your immediate supervisor.

What she learned was that the supervisor had two assistants and these secretaries gather information about the behavior and attitude of other employees including licensed providers. Neither assistant had a college degree and had very little professional training in management and leadership. Their knowledge of addressing problems was more on the line of snooping and bullying people to get information. They would have the department clerks write down when anyone left the office including the time they arrived for work. Then they had the clerks ask the employees and providers where they were going and when they would be back. This did not seem particularly exasperating, but it did put the clerks in the position of spying and treating professional providers like technicians rather than professionals. The organization had a problem with turnover rates, and appeared to hire relatives and friends rather than outsiders with talent the organization needed. This small town mentality eroded the quality of service and discouraged educated and skilled providers from staying. A healthy communication climate discourages nourishing pettiness and encourages quality interpersonal communication. This starts with the CEO who sets the agenda and appoints those in leadership positions to execute a program of training in the value of quality relationships at work.

H.S. Mackenzie Burns, former president of Shell Oil, once said: “Take care of those who work for you and you will float to greatness on their achievements” (Cunningham, 2012).

Building a healthy communication climate takes more than developing relationships through improved communication skills. It also requires a return to the basic concept for the organization, starting with the mission and vision and then using small groups to begin working on developing ways to improve the quality of services, as well as replacing outdated programs. Putting small teams together provides the opportunity for each member to have an important role in making changes that could improve their work station as well as encouraging each member to see the value they have within the group, and in a larger framework, the organization. An example may be a group practice or a non-profit organization which has the following groups:

·   Administration

·   Medical

·   Behavioral health

·   Dental

·   Substance abuse providers

·   Prevention specialists

·   Maintenance

A group composition might have a mixture of people from each department. That could total 7 people per group working on a project such as “improving our messages to the community about the value of our services.” At the end of the day, or at a predetermined time, the groups would adjourn and then re-assemble into one group where each group would offer their issues and recommendations to the larger group. The leader of the group project would then be responsible for having the material assimilated into a report, then published for internal use by each department manager.

Factors that interfere with success in communications include bi-passing; when you say something that the listener does not understand. Asking the listener for feedback can help change this problem. The use of allness phrases should alert the listener of a potential problem. For example, allness phrases such as, “all Americans are not alike,” “all Ford trucks are not exactly alike,” and “all secondary education programs are duplicates of every other secondary education program.” Failure to differentiate can distort messages. Failure to provide adequate, accurate, and timely messages leads to miscommunications and misunderstandings.

There are six questions to ask before communicating:

1.     What is the challenge or opportunity we are hoping to address?

2.     What do we want? What is our goal?

3.     Who matters? What do we know about them? What are the barriers to their receptivity, and how do we overcome those barriers?

4.     What do we need to think, feel, and know to accomplish our goal?

5.     What do they need to see us do, hear us say, or hear others say about us?

6.     How do we make that happen? (Garcia, 2012).

The burden on leadership at any level of an organization is to communicate effectively (Ambler, 2009). It is too easy for us to get lazy or sloppy in our appearance and presentations, and to neglect critical elements that can increase adequate information and more accurate information provided in a timely fashion. Harnessing the skills of communication is a life-long discipline that can bring power to the word and to the presenter. Every day things are changing within our personal lives that affect our attitude at work where even more changes are developing each week, month, and quarter. Change needs to be taken seriously, as does the way we address those changes, because we are important to the organization, to our patients, and to our families.


Ambler, George (2009). No communication = No leadership.

Cunningham, John O. (2012). Leadership and communications – What is required.

Garcia, Helio Fred (2012). Leadership communication isn’t about saying things; it’s about taking change seriously.


About the Author

Ronald Hixson, MBA, BCPC, MT, DAPA, is a licensed psychotherapist in private practice on the Texas-Mexico border. His background includes 10 years in the military mental health field (substance abuse, crisis center, community mental health, and teaching), and for the past 23 years, he has worked in an inpatient psychiatric hospital, a biofeedback outpatient clinic, an outpatient group practice, and then in private practice. His graduate degrees are in communication studies, psychology, business management, and health care administration. He has been a regular columnist for Annals, the quarterly journal for the American Psychotherapy Association, for the past seven years, and is the author of In the Practice of Healthcare, which is available for purchase on He has served as chairman, Board of Professional Counselors, the Executive Advisory Board for the American Psychotherapy Association and is a board member of the American Mental Health Alliance. He is a trained hypnotherapist and a licensed sex offender treatment provider in Texas.

Author: Editor | Date: | No Comments »

From Disparities to Shortages By Ronald Hixson, PhD, LPC, LMFT, BCPC.

The following article was first published in Annals of Psychotherapy & Integrative Health, spring 2011, Robert O’Block publisher.

Ronald M Hixson, MBA, PhD

The concept of the business of therapy can be foreign to new therapists. For some, the concept may trigger images from a corner convenience store to a medical clinic. Such a wide range may explain, in part, why some therapists prefer to work in government, schools, or hospitals. Being sensitive to one’s limitations or preferences can be an asset. While others jump into the pool of private practitioners because of an early life dream, they do so ignoring the signs of danger. For the balance of the time in private practice, they will play catch-up, feeling dragged along by demands of licensing boards, health maintenance organizations (HMOs), and managed care organizations (MCOs).

Every day, we pass 18-wheelers speeding products and supplies to the next town or the next state. The transportation industry is colossal in its reach and in the number of tons transported each day. While this industry has restrictions and guidelines attached to its operating policies, as any American corporation does, transportation companies are not told what they can charge or how they can charge, as health care providers are. However, health care providers are primarily reimbursed by organizations that represent the individual patient when it comes to paying for health care benefits. In the transportation comparison, providers receive payment for invoices from those sending the package or cargo.

The basic concept of letting the market determine the price is what motivates investors, small or large. Supply and demand has been a key philosophy of the marketplace since Adam Smith wrote his often quoted book An Inquiry into the Nature and Causes of the Wealth of Nations in 1776. America was formed by immigrants searching for freedom of religion, freedom from tyrants, free speech, and the pursuit of happiness. Smith argued that individuals can attain wealth for themselves and their country when they are free to use their skills and capital in their own self-interest, which translates into when individuals feel free to make the choices that benefit their family. Smith was a firm believer in education because knowledge tends to increase the value of an individual, both in the marketplace and in their community. Today America is a proud leader in global commerce, which explains why there are more employees in small businesses than in giant corporations.

Physicians once practiced without all the outside interference of today and enjoyed a sense of autonomy, which has been lost in all the process of change. HMOs and MCOs were created, in large part, at the urging of congressional leaders, including some presidents, who saw how hospitals were growing rapidly and wanted a way to control their expansion. Many of these hospitals were built by physicians who controlled access and delivery. Criticisms of this practice led to federal regulations that determined when and where a new hospital could be built and who could or could not own shares in the hospital. As Medicare and Medicaid grew, the national budget also became a concern. Since the development of HMOs and MCOs, there has been an rapid growth of organizations bidding for the right to represent patients who need medical services.

Over the past 35 years, these organizations have learned to redefine the power structure that places bean counters in the driver’s seat for health care access and delivery, rather than medical/clinician trained professionals. This has occurred on a fast track because of the rising expenditures for health care services; in other words, more people want some form of health care services. In economic terminology, the demand for quality health care has steadily risen above the capacity to meet the need. Then graduate schools quickly saw a way to increase their profits, so they developed more degree programs in physical and mental health. However, graduate schools have been very slow in adding business courses to their curriculum, which has led to a shortage of therapists with business degrees.

Shortages are part of the business cycle of change, including supply and demand. Just as fads change, there are times of the year when people shop more than at other times. In health care, providers will talk about “the flu season” or the time just prior to the start of school when mothers bring their children to the doctor for school required physicals. Psychotherapists who specialize in working with children and adolescents will have their schedules slowed by more no-shows at spring break, in the summer months, and during weeks of testing at the schools. Many have closed their offices or are only working part time.

A larger contributor to the growing shortages in health care, but more prominent in mental health, has been the declining rates of reimbursement. Last summer, licensed professional counselors (LPCs) in Texas, and perhaps in most states, lost almost 30% overnight on reimbursement, beginning with Medicaid but spreading to other MCOs. The vast majority of those who provide mental health services in rural communities are LPCs. Over the past seven years, the number of rural communities experiencing shortages has grown. Today, many rural residents can access mental health care services only by driving two or more hours one way. While Medicaid patients do receive some cash reimbursements for their travel, few are driving new cars, thus they are vulnerable to breakdowns and flat tires that will take more than their cash reimbursement to fix. They have an alternative; Medicaid-sponsored vans drive to metropolitan communities, but they normally pick patients up at their home around 4:30 a.m. and often return them around 8 p.m.

Health care providers have seldom been comfortable with asking for money. Perhaps they grew up thinking that they were “called” to service and may have seen the discussion of money as an invasion of their clinical space. Others have commented that when they are successful financially, they feel embarrassed. Still others hire staff to deal with billing and collection tasks. Over time, the costs of a practice drain the payroll funds.

With each passing election, we witness more physicians running for office. They have learned something that other health providers have not yet acknowledged. If you let others go to Congress, they will make the decisions affecting health care. Lawyers, businesspeople, and teachers do not understand the dynamics and obstacles facing health care providers as well as the providers do. However, few providers even write or demonstrate in favor of, or against, any health care reform bill. Health care providers are normally more willing to complain than to act. That is why there has been no concerted effort to form a national health care association that could provide a more united stance on issues of concern. Another reason is the issue of turf and fears that other specialists will take tasks or jobs away.

After the Mental Health Parity and Addiction Equity Act of 2008, HMOs and MCOs had to rewrite their benefits packages because they could no longer charge a co-payment of $100 for a mental health provider vs. $25 for an office visit to a primary care physician. Disparity still exists, normally in reimbursement rates. First, companies allow corporations to select what benefits they offer their employees. Some of these cafeteria programs exclude mental health services. Second, MCOs tend to reimburse hospitals at a rate of 130% of costs, but for mental health hospitals, they fail to pay even the hospital costs. “The result of the inpatient reimbursement disparity is the closure of psychiatric hospital units. With the units closed, patients who do not have an inpatient option may be boarded in emergency rooms, or jails, or are discharged prematurely” (Miller, 2009). Miller compared the reimbursement rates for a physical therapist (physical medicine) with a master’s degree to those for a clinical psychologist with a doctorate: Blue Cross pays $72 for a 25-minute session with the physical therapist and pays the psychologist $72 for a 50-minute session. Compare the cost of a doctorate education to a master’s degree. Is it just that one is an apple and the other an orange?

According to Miller, MCOs are paid by the states or the federal government at a flat rate of service for a predetermined number or population in a state. In his research, Miller found that MCOs are keeping 25% to 30% for administrative costs and profit, with the rest going to providers. For mental health, he discovered that MCOs use creative accounting methodology when considering the formula to reimburse behavioral health care services. He found that using a formula is similar to physical medicine, they take their 25% to 30% fee for administrative costs and profit but then give mental health providers a smaller piece of the remaining funds, which leaves another large amount of money for the MCO, increasing their profits from 25% to 50%! What may be needed in the reform discussion is a high-level audit that is made public and with testimony to Congress. But in the meantime, what the field of mental health needs more activists such as Miller.

Note: Ivan Miller’s Open Letter About Financial Discrimination Against Mental Health Services is available online at Miller can be reached at 350 Broadway, Suite 210, Boulder, CO, 80305; (303)499-3888.


Miller, I. J. (2009). An open letter about financial discrimination against mental health services. The Independent Practitioner, (29)3, 151-157.

Ronald Hixson, PhD, LPC, LMFT, BCPC, has been a therapist for more than 25 years. He has a Texas corporation private practice and has founded a nonprofit group mental health organization where he serves as president and executive director. He has a PhD in Health Administration from Kennedy-Western University, an MBA from Webster University, and graduate degrees from the University of Northern Colorado and the University of California (Sacramento).

Author: Editor | Date: | No Comments »

Medicating Children and Adolescents by Irene Rosenberg Javors.  The following article was first published in Annals of Psychotherapy & Integrative Health, fall/winter 2011, Robert O’Block publisher.

Culture Notes was written by Irene Rosenberg Javors

In the article “So Young and So Many Pills (Wall Street Journal, December 28, 2010, sec.D, p.1), Anna Wilde Mathews reports that “more than 25% of kids and teens in the U.S. take prescriptions on a regular basis.” She goes on to inform us that “children and teens (are taking a wide variety of) medications once considered only to be for adults, from statins to diabetes pills and sleep drugs.” She also states that “prescriptions for antihypertensives in people aged 19 and younger could hit 5.5 million this year.”

Mathews further informs us that anti-psychotic medications have been prescribed to 6,546,000 young people, with the following breakdown: 1,396,000 to children 0–9 years and 5,150,000 to those 10–19 years; antidepressants to 9,614,000: 1,026,000 to children 0-9 years and 8,588,000, 10–19 years; and medications for ADHD (attention deficit hyperactivity disorder) to 24,357,00: 7,018,000 to ages 0–9 years and 17,339,000 to ages 10–19 years.

My first response to reading these statistics: “Wow!” My next: What is going on here? And why are so many of our children and teens suffering from such chronic conditions? Mathews suggests that early detection may account for some of these numbers. She also points out that researchers attribute some of what’s going on to “unhealthy diets and lack of exercise among children, which lead to too much weight gain and obesity,” and that this “also fuels the use of some treatments, such as those for hypertension.”

For the most part, children are given medications that have been tested in adults and not young people. We have no idea what these drugs are doing to children. Mathews quotes Dr. Danny Benjamin, who is “leading a new National Institutes of Health initiative to study drugs in children,” as saying, “we know we’re making errors in dosing and safety.” He suggests that “parents do as much research as they can to understand the evidence for the medicine.”

As mental health professionals working with children, teens, parents, and other health care providers, we need to become very well-informed about all the medications that are prescribed for our clients. We need to be cautious in making a diagnosis as well as making sure to watch out for and identify side effects from the prescribed medication(s). We need to support parents’ efforts to find out as much as possible about the medications that are given to their children.

Mathews reports that “parents and doctors also say nondrug alternatives should be explored where possible.” She quotes Tom Wells, professor of pediatrics at the University of Arkansas for Medical Sciences, as saying, “obesity is really the biggest cause I see for high blood pressure in adolescents…but only 10% of families adhere to (his) diet and exercise recommendations.”

As counselors, we need to re-evaluate our relationship to medication. Do we suggest medication too quickly? Are there other ways of dealing with the problem? Are we still searching for the “magic bullet,” the quick fix to cure what ails us? How do we find a balance between over-reliance on drugs for symptom relief and finding a drug-free path to cope with and/or overcome pain and ill health? Are these chronically sick children who are suffering from asthma, high blood pressure and cholesterol, depression, bipolar disorder, ADHD, insomnia, and diabetes the proverbial “canaries in the mine,” sending us a loud message that the way we live, now, is making us very sick, if not killing us?

I hope that we are listening!

About the author

Irene Rosenberg Javors is a Diplomate of the American PsychotherapyAssociation, a licensed mental health counselor, and a psychotherapist in New York City. She is also an adjunct associate professor of mental health counseling in the Mental Health Counseling Program of the Ferkauf Graduate School of Psychology at Yeshiva University. She is the author of Culture Notes: Essays on Sane Living (ACFEI Media, 2010).

Author: Admin | Date: August 20, 2013 | No Comments »

Just a Little Elbow Grease By Daniel J. Reidenberg, PsyD, FAPA, BCPC, MTAPA.  The following article was first published in Annals of Psychotherapy & Integrative Health, spring 2011, published by Robert O’Block.

Painting by Albin Egger-leinz

Most of us know this profile well: a dual-income family with parents working opposite shifts; two or three kids who were raised in a day care or by a combination of relatives, schools, and TV or video games; and maybe one family vacation a year (before the 2008 recession), now a “staycation.” A middle-class family with a home that is probably a little too big, and a pet or two, lots of toys and sports. Sports, sports, and more sports. They are constantly running kids to dance and hockey, baseball, practice, games, or just to watch another game. In our typical client family, life generally goes along pretty well. There are no major catastrophes outside of some expected sibling rivalry or fears of not passing the next test at school.

Then something changes, and our typical family becomes our client. Maybe it is one of the children; maybe it is one of the parents. It could be that there is a parenting issue that brings in Mom, Dad, and daughter or son. As we dig into why they are in our office, we ask the routine questions: Any history of mental illness in the family? Any concerns about drug or alcohol use? Any history of head trauma or significant event that was traumatic? No, no, no are often the answers, and we continue looking.

We often say, “Let me meet with the parents alone and each of the kids alone,” in hopes of finding out what is going on that isn’t being spoken. Maybe we talk to the school and see whether there have been any changes there. As we continue working to understand the family and what is really behind why they have come to our office, we don’t find the golden nugget, the smoking gun that they expected or hoped we’d find. And of course, they want a “quick fix”; doesn’t everyone these days? “Doctor, what is the problem? Why don’t they listen to me? Why do I feel like the kids are running the house?”

Maybe they are. Maybe they are not. And maybe there is merely a generation gap that is being overlooked.

Recently I was on a flight from Minneapolis to San Francisco. It is a long, 4½-hour flight, regardless of what you bring on the plane to pass the time. I brought my computer to work and listen to iTunes, the newspaper to keep up with what is happening in the world, and had hopes of sleeping for a little while to try and catch up on very little sleep for some time. On my right for this cross-country flight is Michael. Not tall, blonde, with a full head of hair and six-pack abs, Michael is in his mid-50s, a well-built, strong, solid guy. He still has some precious hair left and a thick beard, both turning from dark to not dark anymore. Michael is wearing jeans and tennis shoes with a blue and white checkered, long-sleeved, collared polo shirt, telling me that he is a man who can be down to earth but also has good taste. At first, I’m not sure what he does professionally, but I assume since we were both upgraded to first class that he travels frequently and likely has a good job. Michael does not at all look like he is rolling in money (no fancy watch or jewelry, no expensive, modern glasses, and a fairly standard black carry-on, although it is a Tumi).

As we begin the flight and a conversation which we both probably think will just help pass the time, I learn a lot about Michael and his family, his job, and his views on life. It is probably not uncommon for most of us that once you mention what you do, it becomes a free therapy session for the duration of the flight, but that wasn’t the case with Michael. Sure, he had many questions about psychology and diagnoses, medications, and treatments. But this wasn’t about therapy or problems for him. As a matter of fact, Michael turned out to be this normal, real person who is going about living his life the way I guess many would say it is supposed to be. He is living and not letting his life be run by something else, like texting or tweets, posts, or even video games. Michael is married for some 30 years, defying most statistics. He and his wife have two children in their 20s, both seemingly doing well. He works in finance, an understandably difficult place to be in this economy, but he is very levelheaded about his business and other people’s money. During part of our conversation about parenting—in which he says he is a strong supporter of parents needing to get licensed before they can have children—Michael tells me a great story.

Not long after Michael’s son Will got his driver’s license, there was a small accident. Michael was inside one day, and Will came in the house very anxious and upset. Clearly worried about his dad’s reaction and what the consequence(s) might be, he got the words out to tell his dad that when backing out of the garage, he ever-so-slightly hit the other car in the driveway. Michael asked how bad it was, and Will said that it wasn’t too bad, but never having been in this situation before, he wasn’t sure exactly what to say. So Michael and Will headed out to take a look at the damage. Calmly, Michael looked at the cars and said, “Well, there are a few small scratches here, and some black from the bumper hitting the side of the car, but it’s not too bad.” With Will relieved at both how his dad handled the news and that it wasn’t going to cost a small fortune to get fixed (fearing, of course, that he’d be washing dishes and mowing the lawn until the day he died), Michael said, “why don’t we go up to the store and get some things to buff it out and you can work on it?,” and that they did. Upon returning home, Will was really intent on doing the job and doing it right. He rubbed and buffed, he shined and worked away at the car for a good couple of hours. Michael knew he was outside and was proud of his son for taking responsibility, and so seriously. When Will had finished what he thought was a masterpiece of work getting out all of the scratches, he called for his dad to come look at the car and deliver the “Good job, son” speech he was so hoping for, and he almost did. But what his dad got was ultimately so much more.

Michael looked at the work his son had done, and it was, in all reality, very good. He was impressed at how good the side of the car looked. But—and there’s always the proverbial “but” in every parent’s handbook of responses: “It all looks really good, son. But, there are a couple of marks left right here. They’re pretty small, and I’ll bet if you just put a little elbow grease into it, they’ll all be gone.” Excited about the possibility that he was almost done, almost saved from whatever he originally feared might be the worst outcome possible, and as sincere as the day is long, Will looked at his dad and said: “Great! Where can we buy that?”

It was at that moment that Michael realized he was learning a lesson, even one greater than the one he was trying to teach his son. At that moment, Michael had a choice to make. He could get angry at Will for being so naïve as to say such a thing. He could look at his son with great disappointment, not say anything more, and walk away. He could think his son isn’t nearly as smart as he once believed he was. He could also, as he did, burst out laughing and like any good and reasonable parent would do, he thought to himself, “Where did I go wrong in my parenting for him to think you can go buy elbow grease?!”

After laughing for a few minutes and realizing that he was in a generational gap between his youth and his son’s youth, Michael finally said to Will, “It’s not something you buy. It’s something you have to apply.” A little disappointed that there was no way to buy something that would give him a quick and easy fix, Will put some more time and effort—and just a little elbow grease—into his task and fixed up the car like it was new.

The reason this story struck me was that I think too often, parents or families come to us a) looking for a quick fix, b) not really sure where the problem is, c) having spent little time thinking or talking about where things have been missed in common communication, and/or d) without having considered how different the world is today from when they were their children’s age. All of that is only to say that there really might not be the “problem” that they thought there is/was. There may not be a diagnosable disorder or characterological problem at all. Ironically, the quick fix that most parents want is the same quick fix that Will wanted! And ultimately, as Michael pointed out to his son, sometimes it is just that you have to put in a little more time and effort, and things will work out.

So what eventually happened to my cross-country flight partner, Michael, and his son Will? They lived happily ever after, and both were better off for the chance to experience a unique moment in time that ended up teaching them both a lifetime lesson.

Take-away lessons:

Whether you are counseling the parents, the children, or anyone else, make sure they understand the message to be the best that you can be. Help them define realistic expectations based on their skills, aptitude, and intelligence. Work with clients to understand that comparing themselves to others helps about as much as setting too-high expectations for themselves. Clients need to strive to be the best that they can be in everything that they do. Having goals to help them achieve that will help even more.

A little more elbow grease goes a long way. As you work with someone, keep at it. Don’t get distracted by other clients’ problems, your personal problems outside of the office, or other things. Make sure that you work just as hard as your client does, and harder at other times, to keep them engaged in the therapeutic and healing process. However, when you feel like it is only you who is working (i.e., you are the only one putting in the elbow grease), it is time to stop, step back, and reassess yourself and with your client on where things are and where you are headed.

Realize that there is always, always, always another possibility. If we learn anything from Michael and Will, we learn that what we thought and intended might not be the same as what is real for someone else. There are always multiple possibilities to human dilemmas and opportunities.

A message I always try and share with parents is what I call the 3 C’s: Always try to be clear, consistent, and concrete. The more clear you can be in what you say, want, need, don’t want, etc., the easier it will be for the child(ren) to understand you. The better you are at being consistent about your needs, expectations, plans, etc., the more likely children are to get the same message and learn how to respond appropriately to it. Finally, if you can be concrete about whatever you are talking to children about, you are much more likely to connect with them in a way that they can understand.

Daniel J. Reidenberg, PsyD, FAPA, DAPA, MTAPA, is the chair of the American Psychotherapy Association’s Executive Advisory Board and has been a member since 1997. He is a Fellow and Master Therapist of the American Psychotherapy Association and executive director of Suicide Awareness Voices of Education (SAVE) in Minneapolis, Minnesota. Contact him with your thoughts at

Author: Contributing Editor | Date: August 18, 2013 | No Comments »

The Experiential Therapy of Shoma Morita A Comparison to Contemporary Cognitive Behavior Therapies By C. Richard Spates, PhD, Ayumu Tateno, MD, Kei Nakamura, MD, Richard W. Seim, MA, and Christina M. Sheerin, MA. This article was first published in the Annals of Psychotherapy & Integrative Health, spring 2011, Robert O’Block publisher.

C. Richard Spates, PhD


A recent trend in psychotherapies has been to utilize techniques that have an unmistakable Eastern signature, such as mindfulness and acceptance-based strategies. Although these approaches have been met with widespread clinical and empirical support, an analysis of the origins of these approaches has so far been limited. This paper will redress this tendency by highlighting a Japanese form of treatment known as Morita Therapy, note the development of this approach, and outline how it is currently practiced. A further objective is to delineate how this approach aligns with contemporary cognitive behavior therapies (sometimes known as “third wave” therapies) such as Acceptance and Commitment Therapy, Dialectical Behavior Therapy, and Mindfulness-Based Cognitive Therapy in regards to case conceptualization, diagnosis, and intervention. It is hoped that this effort will open a stronger narrative regarding the core processes of these approaches and foster a greater integration and synthesis of contemporary Eastern and Western therapies.


Science is a constantly evolving enterprise. While well-known ideas are outright challenged and ultimately either embraced or cast away, more obscure or culturally isolated ideas often fade into history, only to be resurfaced, reinvigorated, or completely rediscovered years later. Like all sciences, this occurs with psychotherapeutic modalities and techniques. For example, many have applauded the increased use of mindfulness and acceptance-based strategies in behavioral and cognitive-behavioral therapies, and various approaches, such as Acceptance and Commitment Therapy, Dialectical Behavior Therapy, Mindfulness-Based Cognitive Therapy, Mindfulness-Based Stress Reduction, and Buddhist-inspired substance abuse treatments have arisen from both basic and applied research validating the efficacy of these techniques.

Though it is a controversial distinction, some have seen these collective approaches as a “new wave,” a “third wave,” or a paradigm shift in empirically based treatments (Hayes, 2004). However, while this may be a new movement within the cognitive-behavioral tradition, these techniques have been an integral part of Eastern therapies for years. This paper will elucidate a Japanese form of treatment know as Morita Therapy. Since its inception, Morita Therapy has developed into an established brand of psychotherapy in Asia, and some have commented on the similarities between third-wave cognitive behavior therapies and Morita’s approach (e.g., Hofmann, 2008).

The point of this paper is not to highlight the proprietary nature of Morita’s work but to shed scholarly light first on the core features and processes of Morita Therapy to a degree that has been absent from the ongoing discussion. Also, by identifying original or early sources for what might have proved to be difficult-to-access works on Morita Therapy, we intend to examine how these processes align with Western therapies at a level of depth heretofore unaddressed. In a similar vein, we hope Easterners will be able to appreciate the relevance of concepts heretofore thought uniquely Eastern and how they interlace or hold a central conceptual position in contemporary cognitive behavior therapies. It is also hoped that by doing this, we will foster a greater degree of communication, integration, and synthesis of Eastern and Western approaches and spur more informed clinical research.

The Development of Morita Therapy

Morita Therapy was developed by Shoma Morita, a Japanese psychiatrist who lived during the Meiji Period in Japan, a period roughly beginning in 1864 and ending around 1925. During this period, Japan   had adopted an “empirical science” approach to education that emphasized the importance of direct observation in analyzing events (Frühstück, 2005; Kitanishi & Mori, 1995). This approach was adopted in part from China and was further expanded  through contact with the West, notably Germany and Great Britain (Low, 2005).

After graduation from medical school, Morita began working with a series of patients presenting with a problem then known as neurasthenia (Beard, 1880; Charcot, 1877; Dubois, 1908; Freud, 1896/1962; Mitchell, 1900), a constellation of symptoms including fatigue, anxiety, and somatic issues. While neurasthenia had been documented in German, British, French, and American medical literatures, it was not well understood and was considered especially difficult to treat. Given the difficulty in treating such problems, Morita initiated a telegram correspondence with Sigmund Freud seeking advice. Although much of the Western world had adopted Freud’s approach, Morita reported that his patients did not seem to respond well to psychoanalysis, and he later took serious issue with a number of Freud’s concepts (Morita, 1928/1998). Instead, Morita began borrowing ideas from the works of Mitchell (1900), Dubois (1908), and Binswanger (1911), which emphasized the importance of direct experiences and the paradoxical nature of emotional control. He assimilated these ideas into his own approach, which he continued to develop and revise over time (Kitanishi, 1991; Kitanishi & Mori, 1995).

Case Conceptualization in Morita Therapy

After conducting his initial studies on psychotherapies, Morita believed that the definition of neurasthenia was too broad and impractical to be of any diagnostic or clinical utility. Instead, he used the term shinkeishitsu to describe mood, anxiety, and psychosomatic concerns that arise due to a “hypochondriacal temperament” or a tendency to overly focus on the state or functioning of one’s body and to exhibit hyperreactivity to both mental and physical symptoms. Morita argued that shinkeishitsu was not a biological disorder but a mental attitude or a mode of living (Fujita, 1986; Ohara, 1975).

Morita believed that physical and psychological pain are normal reactions to one’s circumstances and should not be seen as problematic. However, when an individual perseverates on these reactions, views them as intolerable, and attempts to control them, problems occur. As one contemporary Morita therapist stated, “The patient’s attempt to cure the disorder … has the opposite effect, similar to one’s awareness of becoming more mentally tenacious in remembering something the harder one tries to forget it” (Fujita, 1986). Thus, instead of allowing his or her discomfort to wane naturally, the patient inadvertently exacerbates his or her symptoms, leading to a vicious circle of anxiety, avoidance, and more anxiety (a term used most extensively by Hurry, 1915). Over time, this pattern may cause some to confuse their subjective experiences with reality (Morita, 1928/1998).

Therefore, for Morita, the goal of therapy was to provide patients with a set of direct experiences that would teach them to let go of the struggle to control their private experiences and to eventually reach an acceptance of one’s self, one’s symptoms, and one’s reality “as it is” (known as arugamama in Japanese). Morita argued that an abstract understanding of this goal was insufficient; arugamama could only be attained through situations where patients could not escape or avoid their emotions (Kitanishi, 1991). He believed that, through regular contact with these situations, patients eventually learn to accept their emotions, and the mind returns to a natural state of balance (Morita, 1928/1998).

Morita advised clinicians to focus on their patients’ ability to live a “constructive” or “purposeful” life, and he warned them to not become preoccupied with treating their patient’s symptoms. These preoccupations, he said, are like “killing the ox by attempting to reshape the horns” (Morita, 1928/1998). He also urged therapists against using the patient’s discomfort as an indication of the severity of his or her disorder.

The actual severity of a disorder does not always coincide with or run parallel to the sufferer’s awareness of the symptoms. Some fatal illnesses carry no subjective symptoms, while others are not a matter for alarm regardless of severe suffering. When the physicians and therapists regard only subjective symptoms as important in treating an illness, they may be concerning themselves with minor details and neglecting fundamental points (Morita, 1928/1998).

The Process of Morita Therapy

Although it is now delivered in both outpatient settings and residential clinics (e.g., the Jikei University Center for Morita Therapy in Tokyo and Sansei Hospital in Kyoto), in its classical form, Morita Therapy was delivered primarily as an inpatient treatment. Before beginning treatment, new patients would be introduced to the theory and practice of Morita Therapy through informal meetings known as keigaikai where they could interact with past and current patients and hear lectures from clinic directors. After this orientation, the four-stage process of treatment would begin.

Bed-Rest Period

During the first seven to 10 days of treatment, patients were required to remain in bed in a single room, with time permitted only to go to the toilet, maintain bodily cleanliness, and have meals. The purpose of this stage was to help patients learn to mindfully observe their anxiety without engaging in distracting activities. A variety of psychological and somatic reactions have been noted to occur in patients during this phase, and recent research has examined biological rhythm patterns along with autonomic and CNS reactivity during this period (Zhang, Nan, & Wang, 2007). Because the goal of this stage was to help patients fully encounter their anxiety and experience its natural rise and fall, the length of each patient’s bed rest was individually tailored (Fujita, 1986).

Light Work Period

During this stage, which lasted one or two weeks, the patient was required to go outside to experience fresh air and silently observe others working in the garden. Morita advised patients to write about their daily experiences at the clinic but not about their symptoms. In fact, he recommended that therapists be “strategically inattentive” (known as fumon or the non-inquiry technique) to patient reports of symptoms through all stages of treatment. Morita provided brief written feedback and advice to his patients during this stage, and he encouraged them to act only according to their “desire to live fully.” The goal of this period was to promote spontaneous activity following natural impulses and curiosity and to “break down the client’s self evaluating attitudes by de-emphasizing a focus on feelings or comfort and discomfort.” Fujita (1986) suggests:

Around the third and fourth day of this stage, interest in physical and mental work will accelerate gradually, much as when an infant begins to find pleasure in manifesting his or her vitality by taking some sort of action …. Around this time, a patient’s facial expression, attitude and manner of speech become charged with vitality, as if he or she were a new person compared to his or her condition before entering therapy (1986).

Heavy Work Period

During this stage, the patient was to engage in more significant tasks, such as cleaning, gardening, assisting with cooking, shopping, or participation in maintenance of the group milieu. Morita believed that this occupational therapy helped to promote awareness of oneself in relation to external reality, as opposed to a focus on the patient’s subjective experiences. Furthermore, it was thought to stimulate surrender to the present situation and promote an adaptation to nature with or without symptoms still present (Fujita, 1986). It was during this stage that the patient began to experience the joy and confidence of work achieved through his or her own efforts. For Morita:

Such experiences foster a subjective attitude in the client that invigorates her or his self to endure pain, overcome difficulty, and engage in lively and spontaneous mental and physical activities. The experiential understanding of confidence and courage, represented by the idea that much is possible in life, can be regarded as a kind of spiritual enlightenment (1928/1998).

The goals of this stage were usually achieved in one or two weeks in classical Morita Therapy, but the duration of this stage tends to be extended in recent practice. This stage is terminated when the patient notices that he or she is busy every day with the work that needs to be done, and this marks the point for proceeding to the next stage (Fujita, 1986).

Training Period for Practical Living

During this final stage, which lasted from a few weeks to one month, the patient prepared to return to his or her usual life in society. A primary goal of this stage was to help each patient to continue to focus on external reality as opposed to subjective experiences and to encourage engagement in valued actions, regardless of whether or not symptoms were still present. One way of practicing this was through reading exercises. Morita (1928/1998) instructed his patients to “open the book to any page at random and read silently without making any special effort to understand or remember the content.” This training was thought to decrease a patient’s anticipatory emotions that arise from perfectionistic values, such as focusing on symptoms of being unable to concentrate, unable to comprehend, complaints of being distracted by noises, etc. Morita reported that after a few days his patients began to read calmly despite any such distractions. Through this, “Clients are trained to adjust to changes in external circumstances,” (Morita, 1928/1998). In so doing, they are believed to be better prepared to return to a natural rhythm of life.

Modern Variations

This classical model of Morita Therapy has since been altered in recent years. It is now often used in conjunction with pharmacotherapies, and many therapists place less of an emphasis on the Zen Buddhist philosophy endemic to traditional Japanese culture. But, arguably, the most significant change has been the shift from Morita Therapy being used mainly in residential settings to it being predominantly used in outpatient centers. This shift largely occurred as a response to modern limitations on insurance reimbursement, changes in health care policy in Japan, and prohibitive expense (Fujita, 1986; Nakamura, 2000). Some have also called attention to contemporary changes in Morita Therapy being brought on by the changing cultural context of contemporary Japan in response to what is recognized as a change in shinkeishitsu and evolving characteristics of contemporary patients seen by Morita therapists (Kitanishi & Azuma, 2005; Nakamura, 2000). These patients are said to resist the authoritarian style of the doctor/patient relationship commonly seen in Morita’s day and prefer the egalitarian relationship fostered in many outpatient settings.

The therapeutic targets of this modern approach are very similar to those in classical or residential Morita Therapy, with the visible deletion of absolute bed rest. Goals such as clarifying the concept of vicious circle that maintains anxiety, increasing awareness and acceptance of one’s emotional and physiological states, and encouraging constructive actions are met during one or two sessions per week along with the continued use of diary feedback through verbal interviews with patients (Nakamura et al., 2009). In many ways, the outpatient implementation takes on a more didactic format than one based on direct experiences arranged by the therapeutic environment of the inpatient or residential setting.

While adhering to many of the traditions laid forth by its progenitor, contemporary Morita Therapy is adapting to face modern problems, such as dealing with patient drop-out, encouraging adherence to treatment, and recognizing the need for greater client-therapist rapport (Fujita, 1986; Fujita, 1992; Kitanishi & Mori, 1995). In addition, some scholars, such as Ishiyama (Ishiyama, 1991, 1994, 2000, 2007; Ishiyama & Azuma, 2004) have reported extensively on the use of outpatient Morita Therapy and adaptations found necessary within a cross-cultural, non-exclusively Japanese context. Moreover, efforts are being undertaken to standardize the practice of Morita Therapy. The Consensus Guideline for the Implementation of Outpatient Morita Therapy has been prepared by the Japanese Society for Morita Therapy (Nakamura et al., 2009), and the English version of this guideline was published early in 2010.

Contemporary Cognitive Behavior Therapies

Contemporary behavioral and cognitive-behavioral therapies are best understood as an applied progression of conventional behavior therapy toward the incorporation of techniques and approaches that bear an Eastern signature. Among these contemporary approaches are Acceptance and Commitment Therapy (ACT), Dialectal Behavior Therapy (DBT), Mindfulness-Based Cognitive Therapy (MBCT), Mindfulness-Based Stress Reduction (MBSR), and certain aspects of Behavioral Activation (BA). In this section, we first provide an overview of several representative contemporary behavioral/cognitive-behavioral approaches and then compare them to Morita Therapy with the goal of contributing to the continuing discussion surrounding their similarities and differences (see also Corrigan, 2001; Gibson, 1974; Hayes, 2008; Hofmann, 2008; Spates, 2004).

Acceptance & Commitment Therapy

One of the more public comparisons (cf. Hayes, 2008; Hofmann, 2008) has been made between Morita Therapy and Acceptance and Commitment Therapy, otherwise known as ACT. ACT was born out of problems regarding the persistence of maladaptive behaviors due to language-based rule governance (Hayes, Barnes-Holmes, & Roche, 2001; Hayes, Strosahl, Bunting, Twohig, & Wilson, 2004). The attempt to resolve these problems led to a new approach to the study of language, titled Relational Frame Theory (RFT), and a revived philosophy of science that married pragmatism and functionalism into a view referred to as functional contextualism. Putative principles derived from RFT were then assembled into an approach to treatment known as ACT. By incorporating the notions of cognitive fusion/defusion, advances in the understanding of the paradoxical nature of thought suppression (e.g., Wegner, Schneider, Carter, & White, 1987), and techniques borrowed from other therapies (e.g., Gestalt therapy), ACT became a systematized treatment package amenable to scientific inquiry.

ACT starts from the contention that psychological pain is not pathological and that all healthy individuals will regularly experience emotional pain and distressful thoughts (Hayes, Strosahl, & Wilson, 1999). However, ACT goes further to differentiate this pain from suffering (Eifert & Forsyth, 2005). While pain results from the mere existence of these thoughts and emotions, psychological suffering is due to an insidious four-step process: (1) The individual becomes excessively attached or “fused” to the literal content of thoughts, causing him to view these experiences as highly meaningful while turning attention away from the present moment. (2) He or she views these private events as pernicious and unacceptable and develops an unwillingness to experience them. (3) Out of this unwillingness, the individual begins the vain effort to control these private events, known as experiential avoidance (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). (4) The individual then mistakenly assumes his thoughts and emotions are the causes of distress, which allows him to justify these unworkable coping strategies and rendering the symptoms less responsive to real contingencies in the environment (Strosahl, Hayes, Wilson, & Gifford, 2004).

Based on this conceptualization, the goals of ACT are to help the individual accept these unwanted private experiences, identify a set of valued life directions, and commit to acting in accordance with these values in spite of negative thoughts and feelings (Hayes et al., 1999). To accomplish these goals, ACT utilizes metaphors, experiential exercises, and various other techniques culled from numerous psychotherapeutic disciplines. These are all designed to help individuals distance themselves from the literality of their thoughts, become more aware that their thoughts do not constitute their identity, to undermine reason-giving, live more in the present moment, and commit to patterns of valued action (Strosahl et al., 2004).

Dialectal Behavior Therapy

Dialectical behavior therapy (DBT) developed out of clinical work with patients with borderline personality disorder. Through this work, it was suggested that traditional cognitive-behavioral interventions, which focused exclusively on symptom change, tended to make clients feel invalidated, while humanistic treatments, which focused almost exclusively on validation, rarely addressed timely change (Sanderson, 2002). Rather than choosing one or the other perspective, Linehan (1993a) reported she eventually found that a balance between these two strategies led to the most favorable treatment outcomes. This dialectical stance was also found to be a way to understand the dichotomous patterns of thinking and behaving seen in individuals with Axis II behavior problems, and, coupled with principles from Zen philosophy and behavioral theory, eventually developed into a comprehensive and multimodal treatment package (Sanderson, 2002).

According to DBT, psychological suffering occurs when individuals over-regulate and avoid their private experiences in attempts to please others. This is believed to lead to an invalidation of those experiences and a tendency to oversimplify the ease with which one should be able to solve one’s problems (McMain, Korman, & Dimeff, 2001). The individual is said to use vain attempts to regulate emotions, resulting in feelings of desperation, impulsivity, and a low threshold for distress, which leads to further hypersensitivity and often harmful coping strategies (Linehan, 1993a).

To counteract this cycle, the primary goals of DBT are to teach more effective coping skills, help the client stop thinking in rigid, black-or-white terms, and foster emotional engagement as opposed to emotional avoidance. Numerous therapeutic techniques are utilized in the context of group and individual psychotherapy to meet this end, including teaching mindfulness skills, distress-tolerance skills, interpersonal effectiveness skills, etc. (Linehan, 1993b; Linehan, Cochran, & Kehrer, 2001).

Mindfulness-Based Cognitive Therapy

Work in Mindfulness-Based Cognitive Therapy (MBCT) began through the study of factors of why some people are more likely to relapse than others after a major depressive episode. It was ultimately found that those who are able to distance themselves or be mindful of their thoughts were less likely to relapse (Teasdale et al., 2002; Teasdale et al., 2000). Thus, through a union of Beck’s cognitive therapy (Beck, Rush, Shaw, & Emery, 1979) and components of the Mindfulness-Based Stress Reduction program of Kabat-Zinn (1990), this empirically supported relapse prevention program was developed (Teasdale et al., 2000).

The core of MBCT case conceptualization is the differential activation hypothesis—the notion that negative, self-devaluative, hopeless thinking patterns become associated with one’s depressed mood states. Once this relation is established, even minor feelings of low mood can elicit a downward spiral of maladaptive thinking patterns (Segal, Williams, & Teasdale, 2002).

The main goals, then, of MBCT are to cultivate “a detached, decentered relationship to depression-related thoughts and feelings” (Teasdale et al., 2000) and provide the patient with skills necessary to prevent the escalation of such thoughts in the future. To reach this end, the patient is taught to not alter the content of his thoughts but, rather, to examine the way these thoughts are experienced and to develop a meta-cognitive awareness of the thoughts through meditation and other mindfulness exercises (Fennell, 2004).

Analysis of Shared Core Features

It is acknowledged that each of the aforementioned treatments has unique characteristics both in conceptualization and approaches to intervention. Such differences include Morita Therapy’s classical use of absolute bed rest and work therapy as the principal vehicle for achieving therapeutic aims, DBT’s emphasis on teaching coping skills, ACT’s focus on undermining maladaptive language processes, and MBCT’s attention to the prevention of relapse. In addition, each treatment has made an identifiable empirical contribution to treatment process and outcome literature. However, it can be seen that the treatments are united by several core concepts, leading to striking commonalities in case conceptualization and treatment process. Further, a more complete understanding of these similarities may foster a greater appreciation and potential integration of these treatments toward the end of better patient care. But beyond this, such an exercise may lead to higher quality strategic research that evaluates pertinent core components shared across these interventions and eventually to “constructive research designs” that lead to the most powerful empirically supported therapies for patients (Borkovec & Castonguay, 1998). In this section, we provide a comparison of these shared core features.

Case Conceptualization

The Normality of Suffering. Morita Therapy and many of the contemporary behavior therapies are aligned in the notion that much psychological suffering is a consequence of our reactions to normal psychological processes that are common to us all. Morita discussed this in terms of sei no yokubo, or the self-actualizing tendency (Reynolds, 1976). Each of us has the desire to live life fully and actualize our unique potential. However, in striving to be the best we can be, we inevitably encounter pitfalls, setbacks, and pain. None of these, in this view, should be considered pathological or deviant. Contemporary cognitive behavior therapies largely concur with this notion. For example, the DBT standpoint is that pain and distress are normal, unavoidable facts of life (Linehan, 1993a). Likewise, ACT rejects the notions of happiness being a normal state of humans, and similarly rejects the idea that psychological pain is a “mental disease” to be isolated and extracted from the individual’s thinking. Instead, it offers the assumption of a destructive normality; the notion that otherwise adaptive psychological processes sometimes tend to inadvertently lead to suffering (Hayes, et al. 1999).

Maladaptive Focus of Attention on One’s Symptoms. Morita Therapy and contemporary therapies also agree that psychological problems are not due to symptoms per se but to hyper-attention on these symptoms and the confusion of thoughts with reality (known in Morita Therapy by the Zen term akuchi). Morita believed that neurotic symptoms (shinkeishitsu) begin through a process known as seishin kogo sayo, or “psychic interaction” (Morita, 1928/1998). This is the observation that psychological problems arise when one does not permit the mind to flow naturally from one idea to another but, instead, becomes fixed or obsessed on bothersome thoughts or sensations (Fujita, 1986; Reynolds, 1976). Central to MBCT is the idea that problems occur when the client adopts the notion that “my thoughts are who I am” (Fennell, 2004), thus identifying the self according to the content of the thoughts and not merely his or her relationship to those thoughts (Segal, Williams, & Teasdale, 2002). This tendency leads the individual to become overly attentive to even minor psychological symptoms, triggering a downward spiral towards symptom relapse. ACT presents a similar conceptualization that problems occur when individuals identify themselves as the content of their thoughts (self-as-content), rather than simply the context for them (self-as-context). The individual is said to then focus on, or become fused to, to the literal meaning of these thoughts (cognitive fusion), diverting attention away from the present moment. In discussing the development of emotional dysregulation, DBT presents a similar notion, in that after experiencing a stressful event, the individual has difficulty reorienting his attention and returning to an emotional baseline (Sanderson, 2002).

The Vain Attempt to Control Private Events. Focusing on these thoughts and sensations often leads to the erroneous conclusion that these events are negative and must be controlled. The attempt to manipulate one’s private events and bring them in line with one’s desires was called shiso no mujun by Morita (1928/1998). He suggested that disorders are based in the faulty belief that one ought not to have private sensations and cannot live life normally until they are eliminated. The “vicious circle” formed between these ideas on the one hand, and attempts to control symptoms (toraware) on the other, becomes an early focus of therapeutic intervention in Morita Therapy. Similar concepts can be found in contemporary behavior therapies. DBT argues that the inability to accept pain as a part of life leads to frustrating attempts to over-regulate and invalidate one’s experiences (McMain et al., 2001). ACT believes that an unwillingness to have private events and futile attempts to avoid them are at the heart of suffering. And MBCT argues that the tendency to see minor dysphoric moods and depressive thoughts as catastrophes is the catalyst of further distress (Segal et al., 2002).

The Perpetuation of Symptoms. Morita Therapy and most of the contemporary cognitive behavior therapies agree that a vicious circle leads to the escalation of psychological symptoms. After over-attending to his or her thoughts and sensations, viewing them as negative, and engaging in a fruitless attempt to control them, the individual is said to recoil from life and focus even more on such events, thus perpetuating suffering.

Downplaying Diagnosis

Another commonality between Morita Therapy and contemporary therapies is the downplaying of syndromal classifications and a greater emphasis on functional diagnoses (Hayes, et al. 1996; Reynolds, 1976; Morita, 1928/1998) and their indications for treatment. As a physician, Morita advocated the use of thorough assessment and accurate diagnoses, but he argued that these diagnoses should not be construed as a way of pathologizing the patient or his or her problems: “I think that assessment and diagnosis requires a scrutiny of the client’s environmental living conditions, characteristics and the origin of her or his symptoms. However, no policy for treatment or prognosis can be established on the basis of diagnoses from symptoms alone” (Morita, 1928/1998). Like many contemporary therapies, which argue that pathologizing problems is a hallmark of an invalidating environment (Linehan, 1993a) and all individuals’ problems differ only in degree, not in kind (Hayes et al., 1999; Sanderson, 2002), Morita believed that the diagnostic emphasis should convey how much the patient is like other humans (Reynolds, 1976), and the patient’s distress should not be seen as an intractable disease. Through his mentor, Shuzo Kure (a student of Emil Kraepelin), Morita was only a generation removed from Kraepelin’s teachings, yet he rejected many of the structural notions found in that diagnostic system.


The Goal is Valued Living, Not Symptom Amelioration. Due to the conceptualizations of problems, each above referenced approach focuses not on a specific set of techniques, but on the processes of therapeutic change. For example, underlying all of these treatments is the common overarching goal to help the client live a valued life. After receiving Morita Therapy, “the patient may still have fears, unhappiness, or other symptoms. If, however, his behavior has changed, if he is capable of carrying out his living regardless of his symptoms, he is qualified for discharge,” (Reynolds, 1976). Similarly, contemporary behavior therapies will seek not to “alter the content of (one’s) cognitions… (but) the nature of the patient’s relationship to them” (Segal, Williams, & Teasdale, 2000); not the pain they are experiencing, but the suffering that is compounded by their hyper reactions to symptoms (Hayes, Strosahl, & Wilson, 1999); and to resolve, not the patient’s view of the presenting problem, but the behavior that is interfering with the individual’s life (Linehan, 1993a).

Separating Thoughts from Reality. One’s thoughts, perceptions, and desires sometimes correspond with one’s reality, but often they do not. Becoming entangled in one’s thoughts—perhaps even fearing them—is a path to psychological suffering. Thus, Morita Therapy and the contemporary behavior therapies all advocate a distinction between private events and the context in which they occur. For example, in Morita Therapy, “clients are discouraged from becoming attached to and preoccupied with their thoughts, from depending on their subjective ideals, or from behaving to satisfy their emotions and infatuations” (Morita, 1928/1998). Likewise, through cognitive defusion/meta-cognitive awareness exercises, cognitive content versus context distinctions, and de-centering techniques, contemporary cognitive behavior therapies seek to help clients begin viewing their “thoughts as transient mental events, rather than aspects of the self or reflections of objective truth” (Segal, Williams, & Teasdale, 2002).

Contact with the Present Moment. Simple recognition of the distinction between one’s private events and one’s reality is not sufficient. In each of these therapies, individuals must learn to accept themselves, their symptoms, and their reality “as it is” (a concept Morita termed arugamama). This is achieved by becoming open and attentive to one’s surroundings (mushoju-shin), confronting one’s emotions, and directly experiencing the rise and fall of these emotions as natural (Morita, 1928/1998). A salient parallel can be seen in ACT, which emphasizes the importance of accepting one’s private events (undermining the dominance of emotional control and avoidance) and fostering willingness to make contact with the present moment (Strosahl, Hayes, Wilson, & Gifford, 2004). Such parallels are also prominent in both DBT and MBCT, which place great emphasis on the development of mindfulness and acceptance.

Valued Action. Many argue that true happiness comes not from psychological insight but from effective engagement in life. Morita realized this fact early in his career and made it one of the key principles of his therapy. By shifting his patients’ attention away from their “symptoms” and toward meaningful or constructive activities, Morita was able to help them experience greater self-worth and joy in the simple tasks of everyday life.

Therapy is not based on those principles that encourage momentary happiness or superficial pleasure; rather therapy is conducted on the basis of the principles that highlight practice. In this way, clients will experientially understand that to make an effort is to move towards true contentment; true happiness is achieved by making an effort. This presents a more accurate view of life (Morita, 1998).

Not only is this found in ACT (i.e., values clarification exercises and commitment to action strategies that are aligned with personal values), DBT (i.e., emphasis on opposite action, decreasing mood-dependent behaviors, and simultaneous reinforcement of socially effective behaviors), and MBCT (i.e., use of mastery activities), but this is also intrinsic to many other contemporary therapies, such as Functional Analytic Psychotherapy (Kohlenberg & Tsai, 1991), Behavioral Activation (Addis & Martell, 2004), Integrative Behavioral Couples Therapy (Jacobson, Christensen, Prince, Cordova, & Eldridge, 2000), and Buddhist-inspired CBTs (e.g., Darnall, 2007; Witkeiwitz & Marlatt, 2007).


In this paper, we have attempted to provide an overview of Morita Therapy and selected contemporary cognitive behavior therapies to supply a richer sense of the parallels between them. As Tanaka-Matsumi (2004) has indicated: Like contemporary therapies, Morita Therapy “attempted to free patients from preoccupying fears and anxieties by encouraging acceptance of them without avoidance.”

However, it was not the purpose of this paper to laud the works of Morita or argue for the novelty or originality of his work or the work of any contemporary therapy. In fact, Morita clearly acknowledged that many of his ideas were borrowed from his Western contemporaries, such as Mitchell (1900), Dubois (1908), Binswager (1911), Beard (1880), Freud (1896/1962), and Kraepelin. Rather, Morita’s real significance was that he was able to synthesize these pre-existing ideas and package them in a way that made them accessible to his culture while conducting a functional account of the effects. Perhaps, modern progenitors of new therapies should also be commended for attempting similar strategies. Therefore, it would prove impossible to argue persuasively that any therapy is wholly original, as all scientific thought is inspired and influenced by intellectual predecessors. More than this, the repackaging of existing therapies in new or creative ways did not begin in the late 20th century. Even Mitchell was accused of borrowing his technique of isolation and bed rest therapy from his predecessors (see Mitchell, 1900).

We hope that our portrayal accomplishes its mission of permitting a primarily Western audience of contemporary behavior therapists to peer into an Eastern counterpart that has much in common with its basic functional approach, therapeutic processes, goals, and selected techniques for accomplishing them. Although Morita Therapy is a well-respected therapy in the East, its attempts to empirically validate its techniques and export them to the West have so far been underwhelming. This paper is an attempt to redress these deficits and make the process of this therapy more explicit so it can come under better scientific investigation and scrutiny. In addition, we hope that this discussion permits Eastern therapists to peer into contemporary developments within the Western tradition and appreciate the distance this field has come from its original focus on animal learning and conditioning.

It is readily acknowledged that both Morita Therapy and contemporary cognitive behavior therapies have their own identifiable strengths, but we hope that we have made a point that these treatments, though developed separately, are united in many features, processes, conceptualizations, and techniques. Furthermore, we believe a better understanding of these core processes could encourage more constructive research and foster a greater appreciation and potential integration of these treatments rather than the promotion of mere therapy “branding” alone.

In our opening, we addressed the process of the scientific evolution of ideas. It is propitious, therefore, that we end on a similar theme concerning the pivotal therapy that has been the subject of this review. According to Morita, “My study is not complete, of course, and my interpretations may be mistaken. However, I hope that other investigators will understand my intentions, discuss them, and exchange opinions.” And “I hope that further research in this field will be developed more vigorously by those who are stimulated by this book” (Morita, 1928/1998). We could collectively hope for nothing better pertaining to these and other emerging evidence-based therapies.


Addis, M., & Martell, C. (2004). Overcoming depression one step at a time: The new behavioral activation approach to getting your life back. New York: New Harbinger Press.

Beard, G. M. (1880). A practical treatise on nervous exhaustion (neurasthenia). New York: William Wood.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

Binswanger, O. L. (1911). Grundzuege fuer die behandlung des geistes krankheiten. Bortrage fuer prakt. Therapie H. 3. Jena: Fisher.

Borkovec, T. D., & Castonguay, L. G. (1998). What is the scientific meaning of “empirically supported therapy”? Journal of Consulting and Clinical Psychology, 66, 136-142.

Charcot, J. (1877). Lectures on the diseases of the nervous system. London: The New Sydenham Society.

Corrigan, P. W. (2001). Getting ahead of the data: A threat to some behavior therapies. The Behavior Therapist, 24, 189–193.

Darnall, K. T. (2007). Contemplative psychotherapy: Integrating Western psychology and Eastern philosophy. The Behavior Therapist, 30, 156-160.

Dubois, P. C. (1908). The psychic treatment of nervous disorders: The psychoneuroses and their moral treatment (6th ed.) (S. E. Jelliffee & W. White, Eds. & Trans.). New York: Frank & Wagnalls.

Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders: A practitioner’s treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger.

Fennell, M. J. V. (2004). Depression, low self-esteem, and mindfulness. Behaviour Research and Therapy, 42, 1053-1067.

Franks, C. M. (1969). Behavior therapy: Appraisal and status. New York: McGraw-Hill.

Freud, S. (1962). The aetiology of hysteria. In J. Strachey (Ed. & Trans.) The standard edition of the complete psychological works of Sigmund Freud (Vol. 3, pp. 191-221). London: Hogarth Press. (Original work published 1896)

Frühstück, S. (2005). Male anxieties: Nerve force, nation, and the power of sexual knowledge. Journal of the Royal Asiatic Society, 3, 71-88.

Fujita, C. (1986). Morita Therapy: A psychotherapeutic system for neurosis. Tokyo: Igaku-Shoin.

Fujita, C. (1992). On the possibility of standardizing “ambulatory Morita therapy.” Journal of Morita Therapy, 3, 17-27.

Gibson, H. B. (1974). Morita therapy and behavior therapy. Behaviour Research and Therapy, 12, 347-353.

Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35, 639-665.

Hayes, S. C. (2008, June 29). Criticism: ACT is outright taken from Morita therapy. Message posted to Association for Contextual Behavioral Science, archived at

Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York: Kluwer Academic/Plenum.

Hayes, S. C., Strosahl, K. D., Bunting, K., Twohig, M., & Wilson, K. G. (2004). What is Acceptance and Commitment Therapy? In S.C. Hayes & K.D. Strosahl (Eds.), A practical guide to acceptance and commitment therapy (pp. 3-29). New York: Springer.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford.

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. D. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152-1168.

Hofmann, S. G. (2008). Acceptance and commitment therapy: New wave or Morita therapy? Clinical Psychology: Science and Practice, 15, 280-285.

Hurry, J. (1915). Vicious circles in neurasthenia and their treatment. London: Churchill.

Ishiyama, F. I. (1991). Limitations and problems of directive outpatient Morita therapy: Necessity for modifications and process-related sensitivities. International Bulletin of Morita Therapy, 4, 17-36.

Ishiyama, F. I. (1994). Cross-cultural issues in introducing Morita therapy to the West. Journal of Morita Therapy, 5, 57-60.

Ishiyama, F. I. (2000). Practicing Morita therapy in multicultural society: Challenges and innovations. Journal of Morita Therapy, 11, 54-61.

Ishiyama, F. I. (2007). Multidimensionality of Morita therapy and its counseling application. Keynote address presented at the 6th International Congress of Morita Therapy, Vancouver, British Columbia.

Ishiyama, F. I., & Azuma, N. (2004). Introduction of active counseling: New interview technique that Morita therapy was introduced into. Tokyo: Seishin Shobo.

Jacobson, N. S., Christensen, A., Prince, S. E., Cordova, J., & Eldridge, K. (2000). Integrative behavioral couple therapy: An acceptance-based, promising new treatment for couple discord. Journal of Consulting and Clinical Psychology, 68, 351-355.

Kabat-Zinn, J. (1990). Full catastrophe living: The program of the stress reduction clinic at the University of Massachusetts Medical Center. New York: Delta.

Kitanishi, I. (1991). [Letter to the editor]. Transcultural Psychiatric Research Review, 29, 182-189.

Kitanishi, K., & Azuma, N. (2005). Morita therapy in modern times: Review from 1995 to 2004. International Journal of Counseling and Psychotherapy, 3, 67-85.

Kitanishi, K., & Mori, A. (1995). Morita Therapy: 1919 to 1995. Psychiatry and Clinical Neurosciences, 49, 245-254.

Kohlenberg, R., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. New York: Springer.

Linehan, M. M. (1993a). Cognitive behavior therapy for borderline personality disorder. New York: Guilford.

Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford.

Linehan, M. M., Cochran, B. N., & Kehrer, C. A. (2001). Dialectical behavior therapy for borderline personality disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (3rd ed.) (pp. 470-522). New York: Guilford.

Low, M. (2005). Building a modern Japan. New York: Palgrave Macmillan.

Marlatt, G. A. (2002). Buddhist psychology and the treatment of addictive behavior. Cognitive and Behavioral Practice, 9, 44-49.

McMain, S., Korman, L. M., & Dimeff, L. (2001). Dialectical behavior therapy and the treatment of emotion dysregulation. Psychotherapy in Practice, 57, 183-196.

Mitchell, S. W. (1900). Fat and blood: An essay on the treatment of certain forms of neurasthenia and hysteria. Philadelphia: J.B. Lippincott.

Morita, S. (1974). Dai 35 kai Keigaikai: Morita Shoma Zenshu (Vol. 5)(K. Kora, Ed.). Tokyo: Hakuyosha. (Original work published 1933)

Morita, S. (1998). Morita therapy and the true nature of anxiety-based disorders (shinkeishitsu). (A. Kondo, Trans.; P. LeVine, Ed.). Albany, NY: State University of New York Press. (Original work published 1928)

Nakamura, K. (2000). Morita therapy in Japan: Today and the future. Journal of Morita Therapy, 11, 66-70.

Nakamura, K., Kitanishi, K., Maruyama, S., Ishiyama, I., Ito, K., Tatematsu, K., et al. (2009). Guideline of outpatient Morita therapy. Journal of Morita Therapy, 20, 91-103.

Ohara, K. (1975). Morita Therapy. In M. Kato (Ed.), Dictionary of Psychiatry. Tokyo: Kobundo Publishing.

Öst, L.-G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46, 296–321.

Reynolds, D. K. (1976). Morita psychotherapy. Berkeley, CA: University of California Press.

Sanderson, C. (2002). Dialectical behavior therapy: A synthesis of acceptance and change in the treatment of borderline personality disorder. In L. VandeCreek & T.L. Jackson (Eds.), Innovations in clinical practice: A source book (Vol. 20)(pp. 23-39). Sarasota, FL: Professional Resource.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford.

Spates, C. R. (2004, May). A comparison of contemporary behavior therapy and Morita therapy. Paper presented at the annual convention of the Association for Behavior Analysis, Boston, Massachusetts.

Strosahl, K. D., Hayes, S. C., Wilson, K. G., & Gifford, E. V. (2004). An ACT primer: Core therapy processes, intervention strategies, and therapist competencies. In S.C. Hayes & K.D. Strosahl (Eds.), A practical guide to acceptance and commitment therapy (pp. 31-58). New York: Springer.

Tanaka-Matsumi, J. (2004). Japanese forms of psychotherapy: Naikan Therapy and Morita Therapy. In U. P. Gielen, J. M. Fish, & J. G. Draguns (Eds.), Handbook of culture, therapy and healing (pp. 277-292). New Jersey: Lawrence Erlbaum.

Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70, 275-287.

Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V., Soulsby, J., & Lau, M. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615-623.

Usa, S. (2000). Succession and development of Morita Therapy. Journal of Morita Therapy, 11, 114-115.

Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53, 5-13.

Zhang, X., Nan, D., & Wang, Z. (2007). The changes of evoked potentials before and after the bed-rest phase of anxiety disorder treatment. Proceedings from the 6th International Congress of Morita Therapy. Vancouver, British Columbia.

About the Authors

This work is an outcome of a collaboration between psychotherapy researchers in the United States and Japan. C. Richard Spates, PhD, Richard W. Seim, MA, and Christina M. Sheerin, MA, are in the Department of Psychology at Western Michigan University in Kalamazoo, Michigan. Their work focuses on contemporary evidence-based treatments for anxiety and mood disorders. Ayumu Tateno, MD, and Kei Nakamura, MD, are at the Jikei University Center for Morita Therapy in Tokyo, Japan, where they utilize inpatient and outpatient Morita Therapy to help clients suffering from anxiety, mood, and psychosomatic concerns. Spates spent a sabbatical experience studying at the Morita Therapy Center. Tateno spent a sabbatical year at Western Michigan University studying contemporary behavior therapies.

Author: Contributing Editor | Date: | No Comments »

Help Is On The Way: Policies, Procedures, Protocols, and Traditions to Aid the Grieving By Chaplain David J. Fair, PhD, CHS-V, CMC was first published in Annals of Psychotherapy & Integrative Health, Spring 2011, published by Robert O’Block.

As a young hospital chaplain, I remember that it was sometimes a daunting task to deal with family members, especially of the critically ill.

There were times when conflict would arise concerning who could make decisions for patients who were unresponsive and unable to speak for themselves.

If not careful, chaplains can complicate or confuse such situations by not having an understanding of the order of next of kin. To be sure, chaplains do not give legal advice or get involved in family squabbles. But they must be able to understand the pecking order so they can help empower the family to make decisions. While there is some variance from state to state, as a general rule, the following hierarchy applies:

Health care power of attorney

Court-appointed guardian

Spouse (unless legally separated)

Adult children, majority


Domestic partner (if unmarried and another person has not assumed  financial responsibility of the patient)

Adult brother or sister

Close friend

By knowing this order, the chaplain can make an educated decision about where to direct certain overtures.

It is important to remember that while the legal order of next of kin stands, there may be a family member with a stronger personality than the actual next of kin. Or there could be a family member to whom others turn for advice rather than that person.

When dealing with the death of someone who has been in the military, it is helpful for chaplains to know and understand how to assist the family of a military veteran when the veteran has died. If the soldier is killed in action, there is no question that full military honors are afforded. However, especially with older veterans, family members may not be aware of what their family member is entitled to.

As of January 1, 2000, Section 578 of Public Law 106-65 of the National Defense Authorization Act mandates that the U.S. Armed Forces shall provide the rendering of honors in a military funeral for any eligible veteran, if so requested by the family.

Generally, the honor guard for a funeral of an eligible veteran will consist of no fewer than two members. The honor guard is tasked with performing a ceremony that includes the folding and presenting of the flag to the next of kin and the playing of taps by a lone bugler, if available, or by audio recording.

There is also a regulation little known to civilian chaplains and ministers who must provide military funerals. It concerns the disposition of the remains of a military service member killed in action.

Several years ago, a clergy friend was relating to me the story of the military honors funeral he had conducted for a soldier killed in action in Iraq. He remarked to me that sometime after the funeral and burial, the funeral home received a crate containing additional remains of the soldier.

He was saddened at the additional grief this caused by having the grave reopened and the additional remains buried.

While I don’t know the full story, I do want to point out something every chaplain and minister needs to know in dealing with the death and funeral of one of our nation’s heroes.

The matter is covered in Title 10 USC, Sections 1481 through 1482, and relates to form CJMAB Form 1 (January 11, 2005) titled “Disposition of Remains—Election Statement Initial Notification of Identified Partial Remains.”

In a nutshell, the form—which is to be filled out by the primary next of kin—allows the family several choices. One is to have the partial remains immediately escorted to the funeral home of their choice. Or the family may elect to have the partial remains temporarily held in Dover, Delaware (where all military remains are first received). Perhaps most importantly, the family may also indicate if additional remains are later found, to either have them sent to the funeral home or to have the military make the appropriate disposition.

If you are involved in working with family members, please make sure you see to it that they have had the opportunity to fill out the election form after having made their decision. This obviously is a very delicate matter, but better to deal with it upfront than to inadvertently cause additional grief later.

Remember, this will only be applicable if partial remains are recovered by the military. The family assistance officer assigned to work with the family will have the appropriate forms and will normally cover this task. However, you may be called upon to assist the family in making the final decision.

It is my hope that discussion of these matters will be helpful to you. Let it suffice to say that knowing the appropriate regulations, protocols, and traditions can go a long way in equipping you to help relieve the suffering of grieving people.

David J. Fair, PhD, CHS-V,  CMC, holds a doctorate in pastoral counseling and psychology from Bethel Bible College and Seminary. Chaplain Fair is the president of the Officer Down Foundation and the CEO of Homeland Crisis Institute. Chaplain Fair has served at dozens of disasters including Ground Zero following 9/11, Hurricane Katrina, the NASA space shuttle disaster, Sri Lanka tsunami, the Fort Hood shootings, and the Haitian earthquake.