Past Issues

Psycho therapy is a psychology-based intervention to enhance clients’ sense of well-being and reducing their subjective discomfort. Modern psychotherapy began in the 19th century with psychoanalysis; other approaches have been developed and continue to be created. In Taiwan, Tsung-yi Lin was the fi rst to introduce dynamic psychiatry in 1951. Dynamic psychotherapy made its debut in 1953, followed by group psychotherapy (1957), behavior and play therapy for children (1960), and family therapy (1965) [1]. According to community surveys, there were needs for psychotherapy, but practice of psychotherapy was uncommon [2]. In the past two decades , Taiwanese psychiatrists witnessed rapid development of psycho therapy models and growth of professional societies. For example, Association of Group Psycho therapy was founded in 1994, Association of Psycho therapy in 2001, Sandplay Association in 2002, Dance Therapy Association in 2002, Art Therapy Association in 2004, Center for the Development of Psychoanalysis in 2004, Erickson Institute in 2005, Association for Couple and Family Therapy in 2006.

With so many professionals from different disciplines performing psychotherapy, it is important to have good training program and well-designed system of certifi cation and practice. Being a psychiatrist, I would like to focus my following discussion on culture and psycho therapy as well as training of psychiatrists doing psychotherapy.

Psycho therapy is based on psychological theories of health and illness. Its theories and techniques may vary with cultures. Since psychotherapy has its roots in Western society, its application in other societies may need modifi cation [3]. Japanese Morita Therapy and Naikan Therapy are two well-known examples. In addition to doing therapy in the Japanese milieu, Morita added work and Naikan used introspection in their treatment. Doi even modifi ed the personality theory of psychoanalysis. He used “Amae” to characterize Japanese personality and culture. He believes that Amae phenomenon is universal, can be integrated into psychoanalytic theory, and should be dealt with in psycho therapy [4].

Most Taiwanese people have ancestors from China who brought with them Chinese ways of living and life philosophy. Confucianism is infl uential in Taiwan. Maintaining harmonious relationship with family and relatives is most important to many people. This kinship-centered collectivistic value system is different from the individual autonomy and self-actualization in Western world. Practice of respecting privacy and keeping confi dentiality in psycho therapy [5], formulation of goals and techniques of managing psychopathology in individual and family therapy settings, strategy of setting behavior therapy programs in Taiwan are all affected.

Many scholars have addressed the differences between Westerners and Chinese in terms of social structure, family structure, family function, personality structure and value system. In relation to this discussion of culture and psycho therapy, the works of Francis Francis L.K. Hsu [6-8] are briefl y summarized.

Western psycho therapy, especially psychoanalysis, is focused on individual mechanisms, i. e., personality structure, function, development, pathology and treatment, to restore intrapsychic homeostasis. Hsu argued that man is a social being that cannot be isolated from culture and society. He used “psychosociogram of man” to replace the construct of personality rooted in individualism, and introduced the concept of psychosocial homeostasis to explain the mental health of human beings. Psychosociogram consists of 8 layers. From inside out, layers 7 and 6 consist of Freudian unconsciousnesses and preconsciousness. Layers 5 and 4, unexpressed and expressible conscious, are further division of Freud’s conscious state. Layer 3, intimate society and culture, contains relationship of intimacy that is characterized by a high degree of affect. Layer 2, operative society and culture, is characterized by role relationships. Layers 1 and 0 are wider society and culture as well as outer world. Hsu advanced his hypothesis on psychosocial homeostasis. The traditional personality dwells in layers 4 through 7. He hypothesized that layers 3 and 4 formulate the human constant, within which every human individual tends to maintain a satisfactory level of intrapsychic and interpersonal equilibrium. He called the process in the human constant psychosocial homeostasis. He stated that, especially in cultures emphasizing kinship relations. Layer 3 is the principal source of support and the major origin of distress [6, 7]. In another paper, Hsu compared relations-oriented psycho therapy with individual- oriented psycho therapy and their treatment strategies [8].

Hsu’s relation-oriented psychopathology and psycho therapy has been re-illustrated by Wen as Guanxi-oriented psycho therapy [9,10]. Wen’s empirical studies demonstrated that confl icts in parent-child and spouse relations were major risk factors of mental disorders, or suicide in contemporary Taiwan. Wen further high-lighted several important elements of guanxi-oriented psychotherapy. He suggested to aim to offer counseling about life, to achieve and maintain ying-yang balance, to deal with symbiotic antagonism, to value endurance-containment, to encourage self-sacrifi ce, and to attend to the state of “no-self, no-me”. However, more comprehensive techniques integrating these elements, evidence of treatment effect, and proof of healing mechanisms are to be developed or explored.

In addition to Confucianism, Buddhism, Taoism, Shamanism, and indigenous beliefs are all deeply rooted in the Taiwanese culture. Modernization and Westernization are extremely rapid. Is it necessary and possible to develop our own theories and techniques of psycho therapy? In a changing society with mixed old and modern features, Up to now there have been attempts to develop new approaches from different belief systems. I hope there will be some results in the near future.

For the time being, only the Center for the Development of Psychoanalysis has designed a system for membership and certifi cation in Taiwan. Other psycho therapy associations have no certifi cation system yet, but they do have certain requirements for membership. For instance, a full membership of Psycho therapy Association needs medical license, psychiatry board certifi cate and a two-year psychiatry practice after having obtained the status of specialist psychiatrist. Thameans any specialist psychiatrist who during residency had attended certain reading seminars, did a few short and one long-term individual psychotherapy under supervision, and conducted treatment, even without psycho therapy, for two years, will be qualifi ed to be full member of the Psychotherapy Association.

The psycho therapy fee schedule of the National Health Insurance (NHI) makes practicing psycho therapy even easier. Right now no matter what training one has had, as long as he becomes board-certifi ed specialist psychiatrist, he will be eligible to order, to do and to charge for intensive psycho therapy .

Since psychosocial assessment and treatment is an indispensable part of the contemporary psychiatric practice and will continue to be so in the near future. I recommend the training of and the certifi cation system for psycho therapy to be established in Taiwanese Society of Psychiatry in the near future. Currently we have only basic requirements for psycho therapy training in our Society. But there is no mechanism to enforce their implementation. I hope this mechanism will be developed and implemented as soon as possible. The certifi cation for psychotherapist is a more complicated issue, it will involve many disciplines and professional associations. As to psychiatrist specializing in psycho therapy, advance training with certain forms of psycho therapy, e.g., dynamic psycho therapy, cognitive behavior therapy, family therapy, group therapy, or child psycho therapy should be necessary for their certifi cation. I also suggest that only those psychiatrists specializing in psycho therapy will be granted to do and to charge intensive forms of psycho therapy to NHI. I look forward to further discussion on this issue.

Neuroscience has progressed rapidly and helped us better understand the mechanisms of mental disorders and their treatments. Our understanding about psycho therapy may change CNS is still very primitive. Knowledge of brain-mind-intervention interactions will continue to grow. New neuroscience evidence-based psycho therapy theories and techniques may develop. Psycho therapy will continue to be a special expertise of psychiatric practice. We psychiatrists in Taiwan should have better understanding of the interplay among brain, mind, culture and psycho therapy, develop or modify theories and techniques to suit our needs, review and develop appropriate psychotherapy training program in Taiwanese Society of Psychiatry, and, if possible, to develop a psychotherapy certifi cation system.