At Shibata hospital, a few miles from the Shinkansen (bullet train) station at Kurashiki, a revolution in the care of cancer patients is beginning in Japan. Along with the usual surgical, radiation, and chemotherapy treatments for cancer, a new kind of psychotherapeutic technique is being utilized. It is called Meaningful Life Therapy (MLT), or Ikigai Ryoho in Japanese. The information for this brief report was drawn from interviews with pioneers of MLT, a visit to Shibata Hospital, two videotapes, and various issues of the newsletter Ikigai Tsushin.

Jinro Itami, a physician at Shibata Hospital, is the originator of this new technique. He has skillfully pulled together psychological techniques from several cultures and molded them into an auxiliary method of cancer treatment, with profound effects on the lives of cancer patients. Let's consider the theory, the practice, the values underlying MLT and a brief history of the method.

Much of the psychological theory underlying this method is explicitly borrowed from Moritist thought. Dying patients, too, must consider what is best to do about feelings and what is best to do about behavior.

Feelings are seen as natural phenomena, welling up from character, personal history, and circumstances. Fear and anxiety about death are normal. Effort to eliminate fears associated with a cancer diagnosis, for example, is both useless and unnecessary. The more one tries to escape from anxiety, the more one focuses on it and the stronger it becomes.

In Japanese the word shi is a homophone for both "death" and the number four. Many Japanese won't serve four food items on a plate or give a set of four objects as a gift. In order to avoid any associations with death, there are no rooms in Japanese hotels and hospitals numbered four. There are a variety of customs aimed at avoiding even indirect mention of death in social discourse in Japan. But meaningful life therapy's theory points out that there are benefits associated with our fear of death as well. Death forces us to look at life. We take measures to preserve our safety, we use our limited time well, we may give up unhealthy habits (such as smoking) at least in part because we fear dying. The fear of death is uncomfortable, but it is both natural and beneficial. A potential problem lies not in the dread of cancer or of dying but in being obsessed with the fear that one doesn't live constructively, fully, until death occurs.

Thus, obsessive fear of cancer and dying can be seen as a kind of neurotic reaction to the circumstances of illness. To some degree we all suffer unnecessarily from our worries and obsessions, but some people seem to take life's blows harder than others. Early Morita theory held that certain personality variables increase the probability of neurotic suffering in these circumstances. Persistence/obsessiveness, a general tendency to worry, strong physical and social needs, introversion, self-centeredness, and dependency contribute to increased neurotic suffering. Therapy must aim not at overcoming the fears, but at overcoming the negative aspects of these characteristics of the moments. Depending on the circumstances of life, these traits may have positive or negative effects. But when a person is faced with a terminal illness, his neurotic tendencies must not be allowed to interfere with constructive behavior within the genuine limits imposed by the illness. Western constructive living emphasizes changeableness of humans rather than more static views of the person (e.g., personality traits).

The theory of meaningful life therapy holds that it is in control over our behavior that hope lies. In spite of our fears, in spite of our personality traits, we can take responsibility for what we do in the time remaining to us. The terminally ill patient is encouraged to behave in ways that turn focus away from ruminations, toward achieving purposes, observing and participating in external reality, and being useful to others. Notice that one need not (and, ordinarily, does not) first create some life purpose through reflection or introspection and then act to achieve them. In the actions themselves we construct our life purposes.

The cancer patients move from 1) private suffering to 2) recognition that others are suffering and fighting their cancer, too, to 3) acceptance of the reality of the illness and the fight that must be carried on to 4) an ability to live fully and deeply within the realistic limits imposed by the illness. In time, the patients come to see that their efforts not only combat their personal experience of illness but that they have impact on the larger society (other patients come to know of their fight and take hope), on the medical profession (physicians have more confidence in the strength of patients and begin to inform them of cancer diagnoses--telling patients of their cancer diagnoses is still uncommon today in Japan), and on the social sciences (new understandings of human psychological and social potentials become possible). The patients can make a contribution to others while making efforts to prolong and improve the quality of their own lives. Their final days take on increased life meaning. Again, we encounter the theme of acceptance of reality, an acceptance that carries no association of passivity. Accept cancer and fight; accept one's limits and stretch them.

The orientation toward death can be summarized in a four-part outline: 1) we must accept the inevitability of dying; 2) it is impossible to eliminate our basic dread of death; we must live alongside it; 3) behind our fear of death is the strong desire to live life fully, realistically; 4) our fear need not pressure us unnecessarily; we can live each day doing well what needs to be done.

PRACTICE

The emphasis is on group training and activities. Summer-study camps are offered for patients and their families. Exhibitions of the arts and crafts of cancer patients are held twice a year in Japan. Certainly the most celebrated media event associated with meaningful-life therapy was the assault of Mount Fuji by a group in 1984. The preparations for and climbing of Mount Fuji in the rain provided a worthy purpose and a symbolic event well covered by press and television throughout Japan. Another group climbed Mont Blanc in Switzerland in 1987.

Meaningful-life therapy also includes a visualizing meditative technique adapted from yoga, zazen, autogenic training, and Simonton's visualization technique. This meditation is carried out two or three times a day, for ten or fifteen minutes at a time. Benefits are said to be greatest when practiced on rising and just before going to bed.

A low-stimulus environment is recommended, with low light and quiet. The patient is advised to go to the bathroom beforehand and to refrain from eating a heavy meal. Clothes are loosened. The exercises can be carried out while lying on the floor or sitting in a chair.

Each set of exercises begins with preparation of the environment, preparation of the clothing and posture, and some preliminary relation exercises. These preliminary exercises involve tensing and relaxing muscle groups and ten breaths with long, quiet exhalations. Then begins the set of meditative exercises proper.

Formal exercises focus successively on total relaxation, heavy hands, warm hands, a warm abdomen, and a cool forehead. Then comes visualization of the rimpakyu cells vigorously eating up the soft conglomerates of cancer cells. Visualization is enhanced, during craft periods, by crayon drawings of the destruction of the cancer cells. Finally several termination exercises, including stretching of arms and spine, deep breaths, opening eyes and rising, finish each set of meditations. Then the set of meditations proper is begun again. The cycle is repeated for about ten or fifteen minutes, two or three times a day as noted above.

Other meaningful life therapy activities include a year-end party, a marathon event, the exhibition of arts and crafts each spring and fall, various lectures, a summer camp, educational events for health professionals, a clearinghouse for phone and mail contacts among cancer patients, media coverage of the potential and problems of cancer patients, and a variety of opportunities for cancer patients to get together and learn about constructive living in spite of their illnesses.

VALUES

The values underlying this approach to cancer treatment are worth consideration. They include a value that illness brings some loss but also some possibility of gain. The compacted life of the terminally ill patient can be rich and constructive just because of the knowledge of approaching death. Special insights become possible. Standards and priorities can be reassessed.

Another value involves fighting with the illness. One may be a patient, but one need not be a victim defeated by the cancer. While accepting the reality of themselves with their fears and limits, the patients continue to do battle with their illness. They are encouraged to make efforts not to be defeated by their illness.

There is strong desire to leave behind something for others. Shibata Hospital provides resident cancer patients the opportunity to visit elderly bedridden patients, to counsel other terminally ill patients, and to do minor tasks around the hospital. The arts- and-crafts exhibitions provide another opportunity for leaving something behind. It is said that some cancer patients are remarkably prolific and dedicated in their production of artistic works.

Another value is the group emphasis of treatment. There is communal suffering and support in the various group activities. It is important not to suffer and die alone.

A positive value is placed on knowledge of one's disease. It is unusual for physicians and families in Japan to tell cancer patients the nature of their disease. Meaningful life therapy has already done much to educate the medical profession about the positive effects of telling patients that they have cancer. At professional meetings and educational institutions, health professionals are exposed to numerous examples of MLT patients who have benefited from knowledge of their cancer's existence.

Underlying all this is the recognition that all illness carries a psychological component and that certain illnesses respond to adjunctive psychological approaches--bronchial asthma and peptic ulcer, for example. Meaningful life therapy practitioners cite the March 30, 1985 Lancet article (Pettingale, et. al.) that suggests (based on a very small study sample) that psychological attitude may be an important prognostic factor in the survival of patients with breast cancer. However, whatever effect MLT has on extending the chronological lives of patients, its value for improving the quality of their lives seems unquestionable.

This essay is an excerpt from the book A Thousand Waves, by David K. Reynolds, copyright 1990, William Morrow, Inc. The book is currently out of print but limited copies are available from the ToDo Institute's on-line bookstore.

David Reynolds can be reached at dkreynolds@juno.com or at the following address:

P.O. Box 85
Coos Bay, OR 97420