Taijin Kyofusho What Clinicians Needto Know Final PDF

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Taijin Kyofusho: What Clinicians Need to Know Thesis · September 2012 DOI: 10.13140/2.1.4420.2249

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Taijin Kyofusho: What Clinicians Need to Know

by Stephanie Haibloom

A doctoral project submitted to the faculty of the California School of Professional Psychology in partial fulfillment of the requirements for the degree of Doctor of Psychology at Alliant International University, Los Angeles

August 2012

2

Copyright by Stephanie Haibloom 2012

3 ALLIANT INTERNATIONAL UNIVERSITY Los Angeles

The doctoral project of Stephanie Haibloom, directed and approved by the candidate’s Committee, has been accepted by the Faculty of the California School of Professional Psychology in partial fulfillment of the requirement for the Degree of DOCTOR OF PSYCHOLOGY

________________ DATE

Doctoral Project Committee:

____________________________________________________ Rumiko Okada, Ph.D., Project Supervisor

____________________________________________________ Rhonda Brinkley-Kennedy, Psy.D., M.F.T., Project Consultant

4 DEDICATION This doctoral project is dedicated to my husband, Cory, for without his love and support I would never have been able to realize my dream.

5 ACKNOWLEDGEMENTS I would like to acknowledge Rumiko Okada, PhD for all the time she has dedicated to helping me with this doctoral project. Her tireless encouragement, inspiration, feedback, and support of both this project and me were integral to my completing it. I would also like to acknowledge Rhonda Brinkley-Kennedy, PsyD, MFT for all her assistance and valuable feedback. It was a privilege and a pleasure to work with both of them. I would also like to thank Christina Mohajerani and Shannon Hartman for their help in editing this doctoral project. I would also like to extend my gratitude to all of my Field Consultants, Glenn Masuda, PhD, Takanori Kurokawa, PsyD, and Rita Sequeira, PhD for their expertise and invaluable contribution to this doctoral project. I would also like to extend a special thank you to Glenn Masuda, PhD for allowing me to present at the Asian Pacific Family Center and for all of his efforts setting up the time and date for my presentation. Lastly, thank you to my husband Cory for your unconditional love and support, and for always being there for me. This is as much yours as it is mine. I love you.

6 TABLE OF CONTENTS Title Page .............................................................................................................................1 Copyright .............................................................................................................................2 Signature Page .....................................................................................................................3 Dedication ............................................................................................................................4 Acknowledgements..............................................................................................................5 List of Appendices ...............................................................................................................8 Abstract of the Doctoral Project ..........................................................................................9 CHAPTER I Introduction............................................................................................................10 Justification and Purpose ...........................................................................12 Goals and Objectives .................................................................................13 CHAPTER II Selective Literature Review...................................................................................16 Overview of the Japanese Culture .............................................................16 Allocentrism versus Idiocentrism ..................................................20 Harmony(和)................................................................................24 Conceptual Understanding of the Japanese Culture ..................................26 Tatemae (建て前) and honne (本音) .............................................27 Knowing one’s place/role in a hierarchical society .......................29 Amae (甘え)...................................................................................31 Culture-Bound Syndromes.........................................................................35 Taijin-kyofusho..........................................................................................40 Neurotic vs. Offensive Types .......................................................42 Four additional subtypes of Taijin-kyofusho..................................43 Taijin-kyofusho Cases in Non-Japanese Clients........................................44 Social Anxiety Disorder (Social Phobia) ...................................................46 Social Anxiety Disorder and Taijin-kyofusho............................................49 Conceptual Understanding of Taijin-kyofusho ..........................................52 Clinical Implications/Interventions............................................................54 Summary....................................................................................................63 CHAPTER III Methodology..........................................................................................................65 Design Concepts and Objectives ...............................................................65 Procedures..................................................................................................65 Target Audience.........................................................................................67 Resources ...................................................................................................67 Evaluation ..................................................................................................68

7 CHAPTER IV Results....................................................................................................................69 Description of the Product .........................................................................69 Field Consultant Interviews .......................................................................70 Evaluation and Feedback ...........................................................................77 CHAPTER V Discussion ..............................................................................................................80 Implications of the Project .........................................................................80 Personal Account and Critique ..................................................................82 Limitations of the Project...........................................................................84 Suggestions for Future Research ...............................................................85 Conclusions................................................................................................86 REFERENCES ..................................................................................................................88 APPENDICES Appendix A: Interview Consent Form for Field Consultants................................95 Appendix B: Field Consultant Interview Questions ..............................................97 Appendix C: Presentation Evaluation and Feedback Forms..................................99 Appendix D: Presentation Lecture Notes ............................................................102 Appendix E: Presentation ....................................................................................113 Appendix F: Vita..................................................................................................133

8 LIST OF APPENDICES Appendix A: Interview Consent Form for Field Consultants............................................95 Appendix B: Field Consultant Interview Questions ..........................................................97 Appendix C: Presentation Evaluation and Feedback Forms..............................................99 Appendix D: Presentation Lecture Notes ........................................................................102 Appendix E: Presentation ................................................................................................113 Appendix F: Vita..............................................................................................................133

9 ABSTRACT OF THE DOCTORAL PROJECT The diagnosis of Taijin-kyofusho (TKS) is currently relegated to the back of the DSMIV-TR as a Culture-bound Syndrome, and is an indigenous form of social anxiety seen in Japan. However, more cases are being clinically observed outside of Japan and Asia and yet, there is paucity of knowledge regarding this disorder in the mental health community. Not much is known about the various sub-types of Taijin-kyofusho (i.e., the “offensive” or allocentric type versus the “neurotic” or idiocentric type) and how this disorder is intricately and conceptually connected with the societal expectations of the Japanese culture. This doctoral thesis also examines Taijin-kyofusho and its relationship to Social Anxiety Disorder (Social Phobia) as well as the discriminating symptoms of both disorders so that clinicians may better diagnose and serve their clients.

Keywords: Taijin-kyofusho, Social Anxiety Disorder, Social Phobia, Japan, Japanese, Culture, Culture-Bound Syndrome, Idiocentric, Allocentric, Individualistic, Collectivistic.

10 CHAPTER I Introduction Taijin-kyofusho (TKS) is listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [Text Revision] (DSM-IV-TR) as a Culture-bound Syndrome (American Psychiatric Association, 2000). It is described in the DSM-IV-TR as a “culturally distinctive phobia in Japan, in some ways resembling Social Anxiety Disorder. It refers to an individual’s intense fear that they may embarrass, displease, or offend others with their appearance, actions, or odor” (APA, 2000, p.903). While the DSM-IV-TR uses both Social Anxiety Disorder and Social Phobia interchangeably to describe the same disorder, for the purposes of this doctoral thesis, the term “Social Anxiety Disorder” will be employed. While this description of Taijin-kyofusho in the DSM-IV-TR mentions Social Anxiety Disorder, it is limiting in that it does not address the other idiocentric “neurotic” sub-type of Taijin-kyofusho and focuses only on the allocentric “offensive” sub-type of this disorder (Sasaki & Tanno, 2006). – (D'Angelo, Gualdron, La Roche, & Leavell, 2006, p. 555). Its counterpart, – thus, people who are idiocentric would generally come from a more individualistic culture and may fear embarrassing themselves over offending others (D'Angelo et al., 2006, p. 555). The allocentric depiction of Taijin-kyofusho also fails to mention that this disorder has been diagnosed outside of Japan in Korea, America, and Australia (Gaston, Kim, & Rapee, 2008). Because of this, Western clinicians who rely on the DSM-IV-TR for assistance in

11 making a proper diagnosis may be misinformed not only on how to recognize Taijinkyofusho but also on how to conceptualize the disorder and treat it. Taijin-kyofusho has been described as being somewhat similar to Social Anxiety Disorder in that both have in common a fear of social interaction as well as having a fear of being inadequate in a social situation (Sasaki & Tanno, 2006). Where they conceptually differ is that in Taijin-kyofusho, there are two distinct types of the disorder instead of just one overarching disorder as in Social Anxiety Disorder (Russell, 1989). As previously mentioned, there is the “neurotic type” which is closest to the Western/DSM-IV-TR defined Social Anxiety Disorder in that the person fears embarrassment of the “self” (Nakamura, Kitanishi, Hashimoto, Miyake, Hashimoto, & Kubota, 2002). Then there is also the “

” which is categorized in the DSM-

IV-TR as a Culture-bound Syndrome indigenous to Japan.

(Hashimoto et al., 2002). However, symptoms such as the fear of being assessed by others, the fear of being negatively evaluated by other, and avoiding social situations can be found in Social Anxiety Disorder (Sasaki & Tanno, 2006). If clinicians are not fully aware of Taijin-kyofusho as a unique disorder and its symptoms, they may misdiagnose it as Social Anxiety Disorder or Social Phobia, or possibly even as a psychotic disorder which will then have severe implications on the client’s well-being. If the client in fact suffers from Taijin-kyofusho but is misdiagnosed, the client could then be given improper medication and/or an ineffective intervention. Misdiagnosis and improper conceptualization of the client’s psychological problems will lead to severe consequences for the client – especially if they are given a more serious diagnosis such as a psychotic

12 disorder or a delusional disorder. The client may then come away feeling misunderstood and/or not heard by the clinician, then may also not feel trusting of the clinician or the treatment, and therefore could prematurely terminate therapy which would be a disservice to the client. Justification and Purpose Clinicians have a professional responsibility to their clients to properly diagnose, conceptualize their issues, and formulate an effective treatment for them. If a client is misdiagnosed and thus improper treatment is rendered, this would tragically do more harm than good to the client. It is also the ethical obligation of psychologists and mental health professionals to be multiculturally competent in their practice of psychology as outlined in the Multicultural Guidelines from the American Psychological Association (APA Council of Representatives, 2011). However, relegating a disorder to the back of the DSM-IV-TR manual when more current research has found it to not be as “culturebound” as it was once thought; does a severe disservice to both the clinician and the client. For example, Choy and her associates assessed United States and Korean patients with Social Anxiety Disorder and found reported symptoms of the offensive type of Taijin-kyofusho in both the U.S. and Korean patients (Choy, Schneier, Heimberg, Oh, & Leibowitz, 2008). In the interest of best serving the client and of being more multicultural and less Western (or Eurocentric) in their view, clinicians should be better informed about Taijin-kyofusho, its symptoms (both offensive and neurotic types), how they manifest, how the condition is conceptually different from other related DSM diagnoses, and how it should be treated from an evidence-based standpoint. By becoming better informed about the disorder and its conceptualization, professionals will

13 be better equipped to treat clients with Taijin-kyofusho as well as people diagnosed with Social Anxiety Disorder. As psychology becomes more multicultural and more globalized, Western mental health practitioners need to expand their view of disorders and how they are treated in other countries. The purpose of this doctoral thesis is to expand the knowledgebase of the psychological community about Taijin-kyofusho in the hopes that it will educate clinicians in not only recognizing it but in helping them acquire theoretical and conceptual sophistication and thus expand treatment modalities for both Taijin-kyofusho as well as for Social Anxiety Disorder. While the two disorders do have their similarities, they do have their distinct conceptual differences, and the psychological community needs to be aware of this in order for them to properly assess and treat clients. Goals and Objectives The overall objective of this project is to impart knowledge and increase awareness about Taijin-kyofusho along with Social Anxiety Disorder, their symptoms, theoretical conceptualizations, and treatments to the psychological community at large so that they may better diagnose and treat their clients. Clinicians would also benefit from learning about other possible ways to treat Social Anxiety Disorder using evidence-based treatments that are used for Taijin-kyofusho as well as learning about ways to treat Taijinkyofusho by employing methods used for treating Social Anxiety Disorder. Another objective would be to increase clinicians’ multicultural awareness and sensitivity related to “culture-bound syndromes” in that they would be informed on therapeutic methods that are used in Japan to treat Taijin-kyofusho and Social Anxiety Disorder.

14 The author’s personal objectives include learning more about Japanese culture and expanding her own knowledge about treating the Asian population in general. The author would also like to increase her knowledge about interventions used in treating both Taijin-kyofusho and Social Anxiety Disorder and how to use them for the client’s best outcome. The author’s other personal objectives are to improve on her public speaking skills and Power-Point proficiency as well as improving her networking skills by connecting with experts on this topic so as to gain professional guidance from clinicians both here and in Japan. By achieving these objectives, the author hopes for the ultimate goal of not only improving her knowledge and expertise on the subjects, but through these professionals she can assist in helping clients that suffer from these disorders live a more functional and fulfilled life by effecting a change in the way psychologists look at Taijin-kyofusho and Social Anxiety Disorder. With proper diagnostic and conceptualization skills, professionals can then increase their therapeutic skills, build better rapport with their clients, feel more empathy towards their clients, reduce their own biases and misconceptions (stemming from lack of knowledge or cultural competency), and be able to provide more culturally sensitive services. These two diagnoses are currently conceptualized as two separate and distinct disorders (i.e., one being primarily a Westernoriented diagnosis, and the other being a rare “culture-bound syndrome”). However, with the fact of Taijin-kyofusho being diagnosed and witnessed more and more in non-Asian countries, it is imperative for professionals to become proficient in recognizing the clinical similarities and the differences between these two disorders. They may be conceptualized as being somewhat similar to one another and perhaps on different ends

15 of a spectrum, but knowing the origins and mechanisms behind these clients’ concerns and fears that lead to their ineffective coping behaviors need to be differentiated for proper treatment to occur. Therefore, it is this author’s hope that this doctoral thesis will become a springboard to promote more cultural sensitivity and competency that the mental health community can benefit through gaining more knowledge about the diagnosis of Taijin-kyofusho.

16 CHAPTER II Selective Literature Review Overview of the Japanese Culture To better understand Japanese culture, one needs to understand the land itself. Japan as a country is a collection of four large and over 6,000 small islands off the east coast of Asia (Shelley, 1993/1998). The four main islands from North to South, i.e., Hokkaido, Honshu, Shikoku, and Kyushu, comprise the majority of livable land. Japan has a total land area of 140,728.445 sq mi (The World Factbook 2012), which is barely the size of California. However, according to the 2005 Japan Census, the population of Japan is over 127.77 million (Ministry of Internal, 2008). Together with the fact that out ...