Hospital-based Naikan therapy system:
Current approaches and a Case report of a young schizophrenics

Kouhei Ohta MD, Ph.D Sapporo Ohta Hospital (Japan)

T. Hospital-based Naikan therapy (HBNT) can elucidate the developmental processes of cognition

A medical book describing Naikan therapy was first published in 1973 (Naikan Therapy by Nikichi Okumura and colleagues: Igakusyoin). Since that publication, more than 30 years ago, Naikan therapy has been widely recognized in psychiatric therapy. It is gratifying to those who have been using this therapy for a long time that this recognition has progressively increased. However, it appears that many people, including medical staff, remain confused about the differences between 1) Naikan method, 2) Naikan therapy and 3) HBNT. This paper will focus on the development of HBNT from its origins in the Naikan method. I will also address the successful mechanisms of Naikan therapy and the advantages of its use. It appears that one perspective of human cognitive development can be achieved through HBNT.

II. To popularize Naikan therapy

Even though Naikan therapy is better known than in the past, many people in different fields, such as education and business, remain unaware of its potential. Medical institutions that use Naikan therapy have been increasing, but only a few are equipped to administer Naikan therapy to many patients at the same time. They have neither sufficient staff, including clinical psychologists, nurses and doctors, nor a system to administer Naikan therapy in the hospital environment. The reasons that Naikan therapy is seldom applied in hospital include 1) the original Naikan method by Shin Yoshimoto targeted people with a strong desire to undergo the Naikan method; 2) it was believed that successful outcomes for the Naikan method, such as attaining spiritual enlightenment, were best achieved in small institutions and 3) until recently there was no incentive to change Naikan administration methods for its popularization and enlightenment. The Naikan method can be useful for our lives as a personal experience and its popularity should continue to grow.

III. The characteristics of the original Naikan method and the problems involved in adapting it to the hospital situation.

    1). The creator of the Naikan method was non-medical and so it lacks the medical perspectives of cure, nursing and medical cooperation.

    2). The original purpose of Naikan was that of psychological training or discipline, so it was unsuitable for the hospital situation.

    3). The original Naikan institution where people could experience the Naikan method was usually managed by a married couple as their daily life, a much different environment than a hospital.

    4). The original Naikan institution targeted healthy people with a willingness to undergo the experience.

    5). The original Naikan method does not include a way to manage people lacking insight into their diseases or for those with psychological problems.

    6). The religious background of the creator was sometimes projected into the original Naikan method, consequently some medical staff and patients are uncomfortable with features such as the gesture of joining palms or "byoubu" which surrounds the individual undergoing the Naikan method. Some people dislike this aspect of the original Naikan method.

    7). The Naikan method is unfamiliar to many medical staff.

    8). To apply the Naikan method to cure patients in hospital, the medical staff who administer it, including doctors, clinical psychologists and nurses should themselves undergo the Naikan method.
If these problems were solved, the Naikan method could be used in the hospital as "Naikan therapy." With the merits of the original Naikan method and with a system of administering Naikan therapy to patients constantly and stably, Naikan therapy could be termed a "Hospital-based Naikan Therapy." Such a Hospital-based therapy could be administered to patients with psychiatric and psychosomatic symptoms because of the existence of a full range of trained support staff. Patients with less severe symptoms can undergo the Naikan method in smaller Naikan institutions as usual.

The original Naikan method - is a kind of psychological training or discipline, which anyone can choose to experience. It has been used in Naikan institutions and has preserved its method and spirit.

Behavioral Naikan method- created by Tadashi Takahashi includes five Naikan questions and encourages harmony of mind. I hope it will become more widely used.

Naikan therapy-developed from the Naikan method and is administered in cooperation with medical staff including doctors, nurses and clinical psychologists, who have themselves undergone Naikan method.

HBNT- an in hospital medical service that depends on a system in which medical staff can cooperate and adapt to changes in the patients condition making it suitable for patients with severe psychological symptoms.

IV. The Hospital-based Naikan therapy that evolved from the original Naikan principles.

1. The HBNT consists of fifteen hours per day over an eight days period with continuous reflection on their lives by the three Naikan questions
People undergoing Naikan therapy usually recollect easily from the third day after its beginning because of their efforts to remember. Consequently, they often express their emotions from the third day. Most people have complex relationships with family and others, so therapy requires eight days. At the Sapporo Ohta Hospital the five questions from behavioral Naikan have recently been used depending on the patient's condition and background.

2. The ordinary Naikan emphasizes recollections of relationships with family and significant others. Patients with grudges against their parents or significant others are first instructed to think about their bodies such as thoughts of what you can do with your hands or legs.
There are many cases for which traumatic experiences during childhood influence their whole lives. Their childhood cognitive and emotional development also influences their subsequent lives. It seems that understanding how their bad mental habits have developed, helps reach a better outcome for patients. In the Sapporo Ohta Hospital, a daily Naikan report, written to address the above issues, is prepared by the Naikan interviewers and is available to all medical staff at any time.

3. Naikan therapy is undergone in a small space surrounded by "Byoubu" which is a small easily portable screen. This situation helps people recollect and introspect more effectively because it limits external stimulation.

When Ishin Yosimoto, the creator of the original Naikan method, attained enlightenment, he was in a cave which let in very little external light, just enough to distinguish day from night, and thus prevented virtually all external stimuli. This situation is recreated by the byoubu and its use during Naikan therapy is recommended by the Sapporo Ohta Hospital. Naikan therapy was originally taken sitting on the floor causing some people to complain of back pain or other discomfort. At the Sapporo Ohta Hospital, we have introduced various devices to improve comfort and patients are welcome to use a chair if they wish. It is even possible to take Naikan therapy while lying in bed if required by the patient's condition.

4. Except for visiting the bathroom or taking a bath patients should not leave the byoubu.
In the Sapporo Ohta Hospital, Naikan interviewers also cooperate with meal services for patients undergoing Naikan therapy. We also have dedicated Naikan rooms complete with toilet facilities some of which are private.

5. Naikan therapists interview patients at sixty to ninety minute intervals. Patients undergoing Naikan therapy are permitted to make notes to help remember their recollections.
Staff, such as doctors, nurses, and clinical psychologists, interview the patients in rotation. Usually a single interviewer is involved, however, in some cases two or more staff may interview the patient together, in which case, one of the interviewers will record the patients responses. The choice of interviewers for a particular patient is determined by the patient's personal background including gender, age, physical and mental condition.

6. It is recommended to bow and join palms together while sitting on the heels before and at the end of the interview but this is not mandatory.

These recommended acts between interviewer and patient, such as bowing and joining palms together, creates sympathy and a feeling of co-existence.
A few people feel these acts have religious significance and they are recommended only to bow before and after an interview. It is not strongly recommended to sit on the heels during an interview but many patients adopt this position towards the end of their Naikan therapy. It seems that people are expressing their gratitude, which is a result of their Naikan therapy.

V. Naikan method = Naikan therapy as a medical service

The Naikan therapy system in the Sapporo Ohta Hospital has progressed through four or five developmental stages because staff have made huge efforts and provided ideas for improvement. Thus the indications for Naikan therapy have expanded from mild to severe cases. In addition we have developed an outpatient Naikan therapy system at the hospital. These steps are:
    1. Naikan therapy by post cards, notebook or diary- serves as a preparation for ordinary Naikan therapy or as just practice, and as a prevention of relapse.
    2. Naikan therapy with hospital attendance- patients take Naikan therapy for about one to six hours per day in a Naikan room.
    3. Naikan counseling - introspection and recollection of self, using Naikan's three questions.

VI. Naikan therapy for hospitalized patients and its devices.

Naikan therapy is administered in a Naikan room and medical ward licensed for such use by medical law. The ward has a Naikan therapist station and has been given a stable number of doctors, nurses and clinical psychologists. Most of the staff have experienced the Naikan method and can provide medical services for any emergencies in patients undertaking Naikan. This system in a hospital setting provides a stable environment for patients so they can concentrate on Naikan therapy. The types of Naikan therapy provided for hospitalized patients include:
    1. Mild Naikan therapy - is given to patients immediately after admission or after their symptoms improve. It is voluntary.
    2. Daily Naikan therapy - is the next stage after 1. Patients who have taken Naikan therapy would also take this
    3. Naikan therapy in their usual room - is given to patients requiring privacy or those with severe general anxieties.
    4. Naikan therapy in an isolation room - used for patients who require isolation because of self-injury behavior or psychotic symptoms. This style of administration is useful for severely psychotic patients.
    5. Naikan therapy under restraint - used for severely psychotic patients who pose a threat to themselves or to others.
    6. Familial Naikan therapy - mother and child are given Naikan therapy together and in the same byoubu, as an example, but it can be applied to any relationships such as father and child, both parents and children or among siblings.

VII. The differences between hospital-based Naikan therapy and conventional Naikan method used in Naikan institutions.

Hospital-based Naikan therapy is administered to patients unable to take Naikan method in usual Naikan institutions because of their severe symptoms. HBNT is a medical treatment system developed by medical staff who have experienced Naikan method and Naikan therapy.
    1. It is applied in a hospital environment as a medical act approved by Labor Standards and Medical law.
    2. It is administered to patients by medical staff who have experienced Naikan method or therapy.
    3. It is used under circumstances in which staff can cooperate and follow a defined clinical and Naikan therapy path. The path includes clear schedules and staff assignments.
    4. It is a definite medical treatment, administered in rooms designed for taking Naikan therapy, adequate for one to four people. There should be a room for Naikan therapists to deal with any physical or psychological change in the patient as quickly as possible
    5. Staff must have the capability to deal with any physical or psychological change in the patient.
    6. Full patient records must be kept, including dates, room number, the theme of Naikan, the patient's answers, patient's condition, emotional expressions by the patient. The Naikan therapist is mainly responsible for these records.
    7. The system should allow reduction of therapists stress through reporting to other staff respecting resistance to Naikan therapy and other emotional traumas. Staff conferences should review these events and plan further care.
    8. Hospital -based Naikan therapy recommends administering Naikan to the family of patients using other locations than the hospital.
    9. Naikan therapy can be used as recollection therapy and administered to schizophrenics, major depressives or even severely psychotic patients. This group achieves moderate outcomes.
    10. Medical staff must be flexible and able to cope with difficult situations such as resistance against Naikan therapy.
    11. Recently, good outcomes have been achieved by a combination of HBNT and behavioral Naikan therapy, created by Tadashi Takahashi.
    12. It should be sensitive but affirmative for patients who lack insight into their disease such as semi-compulsory and compulsory patients.

VIII. The developmental steps: Naikan method RNaikan therapy R Hospital-based Naikan as the history of the Sapporo Ohta Hospital.

The first phase
Around 1975-1980 the only target of Naikan therapy at the Ohta hospital was alcoholic patients. The author was the only physician to try the Naikan method as a medical treatment because other physicians were skeptical. The Naikan method was administered to patients who refused any medical treatment or who showed uncontrollable excitement and thus it was usually applied in an isolation room during this first phase. Some of the alcoholics have successfully remained abstinent by participating in alcohol self-help groups, others have relapsed. However, the Naikan method did produce some good outcomes and it was incorporated into the clinical path, "Ten Steps Psychotherapy" as the fourth step. In the first phase, 39% of all patients were schizophrenic and 30% alcohol dependent. Many self-help groups for alcohol dependents were started so that many patients who had experienced Naikan therapy were able to exchange their experiences with those who had not. To facilitate in-patient treatment for the increasing number of alcoholics, group homes were established to encourage the earlier discharge of schizophrenics from hospital. Consequently, support from social workers became more important.

The second phase
From 1981 to 1986, 40% of new admissions were for alcohol dependency. Adolescent problems such as non-school attendance, substance abuse, delinquency and bullying were tending to increase and accounted for 23% of new admissions. Effective psychotherapy to achieve good outcomes in a short period including improved parental and family relationships didn't exist. In this second phase a fourteen day clinical path was designed for adolescent patients with non-school attendance. A new specialized ward for alcohol dependents was built and specialized Naikan therapists were employed. The woman's self-help group for alcohol dependents was founded and three more group homes were added.

The third phase
Adolescent maladjustment cases like non-school attendance often evolve into psychosomatic diseases which are progressive and compounded by additional symptoms. Often life events initiate a deteriorating spiral and produce a more complex situation such as parental divorce → relocation → Bullying in the new school → non-school attendance → social withdrawal → anxiety or panic → psychosomatic symptoms such as eating disorders → violent acts → family disruption. HBNT not only prevents this bad cycle but also cures the symptoms. In 1988, day care was introduced and a chief nurse for Naikan therapy was appointed to the Sapporo Ohta Hospital. Complete records of Naikan therapy have been maintained from this phase.

The fourth phase
Around 1993-2000, HBNT was administered, for the first time, to a schizophrenic patient in an isolation room because of her water intoxication symptoms. She recalled that she was taught to play the piano by her mother even though she had a grudge against her mother. This was a turning point for her because she became more confident in herself and able to trust her mother enabling her to become a music therapy assistant. It appears that careful recollection therapy as part of Naikan combined with medication is effective for patients with psychotic symptoms. A Naikan therapist station was introduced and clear tight schedules for Naikan therapy developed so that many patients could take hospital-based Naikan in the Ohta hospital simultaneously. Currently, about 300 patients per year undergo Naikan therapy in the hospital. A second day care facility for alcoholics and drug abusers was built and 10 more group homes constructed.

The fifth phase
From 2000 to the present, non-school attendance, eating disorders, self-injury behavior like wrist cutting, and drug abuse have increased and now make up 17% of newly hospitalized patients. HBNT remains effective for those symptoms. Methods for objectifying and quantifying its outcomes were added. One measures the depth of introspection of the patient and the other is self-evaluation by the Naikan therapists. As case numbers increased we recognized that traumatic experiences in childhood influenced self-cognition during adulthood. Thus, fractal theory and Mandara may possibly apply to those situations. A third day care facility for adolescents was opened in 2001 In HBNT due consideration of the patient's symptoms, and severity, age, gender, and past traumatic experiences, is important. These considerations along with careful selection of room type, choice of starting therapy and therapist, and how therapy is introduced make HBNT effective for a wide-range of symptoms including psychotic ones. This is based on experience at the Sapporo Ohta Hospital.

IX. A case of adolescent school truancy with HBNT

1 The Patient

She was a middle school student who attended two psychiatric hospitals because of her non-school attendance. She failed to improve and was referred to the Sapporo Ohta Hospital where she was hospitalized and administered HBNT. Her complaints included non-school attendance, insomnia, wrist cutting and phobia against males. Her family included her parents and a younger sister. During elementary school she sometimes said she didn't want to go to school but was never a non-attendant. She was an ordinary student who had many friends and good grades. In eighth grade she was warned by her teacher for playing on the roof of a building. She was attending school two or three times a week. She became depressed and developed insomnia and attended the first psychiatric hospital and was diagnosed as having an anxiety disorder, but failed to respond to medications. She was discussing her problems with her friend and thought their conversation was secret. However it was not and most of her classmates knew about the discussions. Thereafter she became a complete non-attendant. She went to a second psychiatric hospital with no improvement. She developed self-injury behavior and some psychotic symptoms, including auditory hallucinations, probably due to distress about not being able to continue her education. She was then referred to the Sapporo Ohta Hospital.

2. Hospitalization.

She first attended with her parents. She related that her schoolteacher told her she did not need to come to school anymore and she believed the teacher also said she should die. She also told about her friend breaking her confidences. She said she did not like herself because she did not like her father. When she was a child, a stranger had tried to take her somewhere, now, when she recalls that event, she feels frightened of all men including her father. This is why she dislikes herself. She also complained that she was unable to use public transport because of her fear of men. A further complaint was that she sometimes cut her wrists unconsciously. During her first interview she was crying continuously. She required hospitalization because she had already attended two other hospitals with possibly psychotic symptoms tending to get worse. HBNT was recommended.


From the early evening of the first day of Naikan therapy, she showed obvious emotion through her tears as she recollected what she had received from her mother. She came to the Naikan therapist station to say that she could not cry in the Naikan room because she cared about disturbing other people in the room. After therapists had listened to her carefully and sympathetically for about ten minutes, she calmed down and returned to her Naikan room. On the second day she was emotional and worried that her weeping might bother other Naikan patients. Consequently, her Naikan interviews were held in another room even though she and the therapists had to move on each occasion. Naikan therapists listened to her talking while she was separated from her family for the first time in her life. Mostly female therapists interviewed her and encouraged her by praising her efforts in Naikan therapy
On the Naikan three questions about her mother, she realized that her mother had given her a lot but that she demanded more and more. She wanted to thank her mother and told the therapists that she would help her mother a lot once she was discharged from hospital. In regard to her father, she related that she felt as though she was stung by a bee, because she did not like her father, which made her feel self-disgust. Although it was difficult for her to think about her father she persisted successfully. She remembered that when she was in the fifth grade, she upset him because she didn't want to go to school even though there were no valid reasons not to go. She recognized that her non-school attendance was caused by her dependence on her parents. After finishing the themes about her parents, her face brightened. This was on the third day of Naikan therapy.
On the fourth day, she remembered how she made people around her bothered and upset. She recalled that she worried many people by her school truancy even though her reasons were often trivial. She stated, "the reason I was absent from school was just I didn't want to wake up or little things like that" She also said "I will have to go to school after I finish Naikan therapy. I was a fool to try suicide and I couldn't say thank you to anyone who helped me because I have felt that I was worthless to anybody. Now I can appreciate the people around me. I will do my best to be a dutiful daughter for my parents."
Five days after completing Naikan therapy, she underwent familial Naikan with her father and mother. Her parents were instructed to think of the Naikan theme of their daughter while she was taking Naikan therapy in hospital. As a result, her mother apologized to her because she had not praised her much. Her father reported that he had realized he was stubborn because of thinking about the theme of his daughter. He said, "I realize I was stubborn because of my daughter. I now appreciate that and apologize."
Subsequently, she and her parents went to the school to meet the school principle and to indicate she would return to school. After she had gone to school from the hospital for three days she was discharged after a total hospitalization of eighteen days. Her prognosis looked great, she was attending school every day with enjoyment and already planning to go to high school.

4. Discussion

She could not only go to school but also had a will to go because of her separation anxiety prior to hospitalization. It was a factor in her non-school attendance that she received a rebuke from her teacher. This might have triggered her delusions of persecution and depressive symptoms, which progressed and lead to social withdrawal and self-injury. HBNT with hospitalization separated her from her parents and produced a situation in which both patient and parents could think of themselves and each other. The patient saw herself objectively so her delusions of persecution disappeared. She also perceived her parents love for her through recognition during Naikan and family Naikan therapy. Receiving this parental love made her stable and able to accept her traumatic experience and develop insight. Familial Naikan therapy created the will of the entire family to change with the experience, the family became healthy and cooperative providing another reason for the patient's good prognosis.
HBNT can be given to patients with severe symptoms and improves their cognition through recollection of their past life. Patients usually develop insight into how their cognition was distorted. Naikan therapy is one form of cognitive behavior therapy, which can be administered for short periods, and is also useful for non-school attendance, which should be recognized and treated as soon as possible.

X. The system of hospital-based Naikan is autopoiesis

At the Sapporo Ohta Hospital, the HBNT system has been evolving in response to patient needs and innovative developments respecting time and place of administration, who administers it, and how it is given. Methods were diversified and subdivided to reach today's approach. However it continues to evolve and expand. For the author, the development of HBNT is not only a joy but also a wonder. It seems like one of the system of lives and should be autopoiesis. Autopoiesis, is a systematic principle that does not reduce life to super-nature like soul and vigor, nor does it aim to explain life physiologically, seeing it as physiological processes , reproductions and movements as physically grounded as is widely taken for granted by current sciences. Time is lacking for a full explanation so the interested reader is referred to the literature on the subject.

HBNT can explain cognitive or personality development individually and progressively. It can reveal traumatic experiences or unsolved familial relationships such as conflicts, abuse or neglect, as the background to the development of distorted cognition on the patient. Human cognition develops with growth and maturity so HBNT should parallel this development because it is not only a therapy but also an observational tool on human development. The development of HBNT should be further encouraged.

One might question why the three or five Naikan questions are sufficient to make people recollect their lives and trigger deep introspection. The answer is probably that these questions focus on the earliest stages of the development of human relationships and on concepts such as, right and wrong, like and dislike, which are connected with human survival. Most human emotions are based in human relationships. Therefore, Naikan questions are effective in making people think about what they are and what others are, because these questions address the universality of being human and the reality that human beings cannot live without others. It seems that human cognitive development can expand similar to a fractal or Mandelbrot, thus such Mandara can be produced unconsciously. C.G. Jung was famous for his interest in Mandara and drew his original mandara. One schizophrenic patient drew eighteen pieces of Mandara after finishing Naikan therapy. He had a good recovery from psychological symptoms. There is a fractal on the development of the human brain neurologically and histomorphologically. HBNT can teach us that human cognitive development is also a fractal.

XI. The characteristics of HBNT system and its clinical effects.

A. For patients
    1. It is highly adaptable for various symptoms.
    2. It can shorten the stay in hospital (107.2 days on average)
    3. It can be used in patients with psychosomatic and neurotic disorders without medication.
    4. It can reduce the quantity of psychotic drugs.
    5. It can reconstruct the patient's family structure through familial therapy.
    6. It can produce better adjustment to day care
    7. It is flexible and can be administered to patients who initially refuse it
B. For Medical Staff
    1. Most medical staff members have experienced Naikan method or therapy so they develop closer staff relationships
    2. Most medical staff can instruct the patient with greater understanding because of their own experience.
    3. It helps staff understand and accept patients because of the developmental perspectives on human beings intrinsic to Naikan therapy
    4. It can identify past life risk factors for developing symptoms, so patients can recognize the targets for treatment.
Cases in which counseling or drug therapy are ineffective have been increasing recently. Thus, HBNT should be more generally available and developed to its full potential and applied broadly.

We appreciate the English language consultation provided by professor Peter M Olley.