A Complex, Multi-Faceted Condition Requires a Holistic Non-Pharmacological Therapy: Making the Case for Morita Therapy in Parkinson’s Disease

Abstract

Psychotherapy has become a necessity for Parkinson’s patients suffering from anxiety disorder. There are different types of therapy; for example, Morita therapy, first proposed in 1919, is a psychological therapy. It is mainly used as an alternative therapy in Asian countries such as Japan and China. Morita therapy focuses on accepting emotions, including anxiety, rather than trying to reduce them. Although it has had an impact on treating anxiety disorder in other populations, there have been no studies to date investigating the evidence and effects of Morita therapy on anxiety disorder in Parkinson’s patients. This opinion article focuses on conducting a literature review to identify relevant studies on the applications of Morita therapy in anxiety disorders and explore the possibility of proposing it as a treatment option for Parkinson’s patients.

1. Background

Parkinson’s disease is a neurodegenerative disease characterized by motor symptoms such as resting tremors, movement disorders or bradykinesia, and muscle rigidity. In addition to motor symptoms, Parkinson’s disease includes non-motor symptoms such as sleep disorders, cognitive disorders, and anxiety disorders, which affect 40% [1] of Parkinson’s patients and alter their quality of life [2,3]. There are different scales for assessing anxiety or depression, for example, the Hamilton Anxiety Rating Scale (HAM-A), the Beck Depression Inventory (BDI), and the Parkinson Anxiety Scale (PAS).

At first, Morita therapy was practiced only in Japan. Due to its originality, this type of therapy did not initially gain international recognition but later became very widespread in various other parts of the world, including North America, Australia, China, Russia, and Rwanda. However, it is important to understand its prevalence and usefulness in the field of psychology [4]. Morita therapy is based on a specific type of therapy, namely psychological therapy. It was developed in 1919 by Shoma Morita, who was a psychiatrist and professor at Jikei Medical College (now the Jikei University School of Medicine), Tokyo. After years of work and research on various methods in psychotherapy, Morita established a type of hospital therapy for patients suffering from shinkeishitsu, a Japanese term proposed by Morita that refers to nervous and hypersensitive individuals [5], which later became known as Morita therapy [4,6,7]. Faced with obstacles during this period, Morita was not entirely systematic and scientific in his analyses of anxiety disorders. However, he later wrote several descriptive studies in Japanese, which subsequently led other researchers and psychotherapists to practice in a modified form based on different terms [5].

1.1. Description of the Intervention

Both psychological and pharmacological treatments are used for anxiety disorder in Parkinson’s patients. Pharmacological treatment includes antidepressants such as selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenergic reuptake inhibitors (SNRIs), noradrenergic and specific serotonergic antidepressants (NaSSAs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) [8,9].

A study showed that there is a relationship between buspirone and Parkinson’s disease. The authors of the study determined that the dose plays a crucial role in the appearance or absence of motor symptoms related to Parkinson’s disease. When the dose is around 60 mg per day, no problems are observed, but when the dose exceeds 60 mg and is increased to 100 mg per day, there is a deterioration affecting the physical condition of the patients, which subsequently contributes to a decrease in motor function and an increase in anxiety [10]. Indeed, the medications used to treat anxiety in patients with Parkinson’s disease, for example, monoamine oxidase inhibitors (MAOIs), are not indicated for patients who consume levodopa during treatment due to the risk of hypertensive crises. Elderly people are also more sensitive to anxiolytic medications due to the involvement of several factors related to metabolism or due to chemical reactions created by other drug treatments [11]. Psychological therapy, however, includes acceptance and commitment therapy, cognitive behavior therapy, and relaxation. Another alternative treatment for anxiety disorder is Morita therapy [10,12,13]. Morita and his colleagues in psychiatry in Japan actively practiced Morita therapy to treat generalized anxiety disorders and published numerous case studies and monographs in Japanese on its effectiveness in treating various anxiety disorders. In Japan, psychiatrists and psychologists have expressed contradictory and unfavorable views regarding the scientific foundations of Morita therapy. The therapy consists of working on behaviors, hence the name “Morita Attitudes”, which promote daily work despite anxiety disorders. Naturally, this raises the topic of anxiety adaptation, which is central to Morita treatment. However, the philosophical and cultural divide between Eastern and Western countries is a major obstacle to its wider acceptance. In contrast to the Western emphasis on control, autonomy, and emotional regulation, Morita therapy is based on Japanese philosophy and emphasizes acceptance of emotions, non-resistance, and alignment with natural life processes. In Western clinical settings, these conceptual differences can pose significant challenges to comprehending and embracing Morita therapy. The belief that this therapy is strongly associated with Zen Buddhism, a spiritual tradition that promotes mindfulness, meditation, and non-attachment, is another reason for its limited popularity. Despite not being a religious practice, Morita therapy’s philosophical connection with Zen precepts may make patients and doctors uncomfortable or suspicious of non-Western or spiritual influences in psychotherapy [6].

Morita therapy has been practiced in China since the 1990s. Its origins come from Zen Buddhism, and it is primarily used to treat various mental illnesses such as neuroses, which are characterized by obsessive disorders, shyness, hypersensitivity, and feelings of inferiority. Morita therapists have a specific goal: to help patients reconnect with nature by developing their own relationship with their true emotions. Thus, therapists facilitate their patients’ understanding of the vicious cycle by creating a close relationship between the patient, their experience of themselves or the world, and their feelings about what they have experienced, whether negative or positive, as long as they live with them and accept them as they are. However, all of this depends on their capacity and commitment [10].

1.2. Comparison Between Pharmacological Therapy and Morita Therapy (See Table 1)

In one study, two trials were conducted that compared Morita therapy with pharmacological therapy for 75 participants, with the authors using outpatient interviews and home practices. Phase 1 (bed rest) was changed to include acceptance of anxiety symptoms and comprehension of the types of Morita therapy. One of the trials continued the therapy through phase 2 (light work), phase 3 (heavier work), and phase 4 (preparation for normal life), but for the other trial, the therapy was stopped in phase 3. The control treatments in the two trials were clonazepam and alprazolam [7].

Another study compared Morita therapy plus pharmacological therapy with pharmacological therapy alone. Morita therapy was divided into four stages in each trial. In one trial, specifically in phase 1, patients focused on learning the principles of Morita therapy and accepting their anxiety disorder. Clinical dosages of citalopram, buspirone, clonazepam, fluoxetine, clomipramine, or paroxetine were the pharmacological treatments that were prescribed. In every trial, the same anxiolytics were prescribed to the experimental and control groups [7].

Table 1. Comparison between pharmacological treatment and non-pharmacological treatment (Morita therapy).

Criterion	Pharmacological Treatment	Morita Therapy
Approach	Medicine affecting the chemistry of the brain (antidepressants, anxiolytic)	Focuses on accepting suffering and engaging in action
Side Effect	Side effect risk (drowsiness, extrapyramidal effects, dependence on benzodiazepines)	Non-pharmacological approach, fewer physical side effects
Durability of Effect	Benzodiazepines have a generally transient effect and carry a dependence risk	Can result in long-term anxiety treatment
Adaptability to Parkinson’s Motor Symptoms	Possibility of interacting with anti-Parkinson’s medications, leading to, for example, worsening of motor symptoms	No interaction with motor symptoms applicable for Parkinson’s patients
Patients’ Motivation and Engagement	Personal engagement is not in high demand when only taking medication	Requires more personal work and significant patient involvement

Table 1. Comparison between pharmacological treatment and non-pharmacological treatment (Morita therapy).

Criterion	Pharmacological Treatment	Morita Therapy
Approach	Medicine affecting the chemistry of the brain (antidepressants, anxiolytic)	Focuses on accepting suffering and engaging in action
Side Effect	Side effect risk (drowsiness, extrapyramidal effects, dependence on benzodiazepines)	Non-pharmacological approach, fewer physical side effects
Durability of Effect	Benzodiazepines have a generally transient effect and carry a dependence risk	Can result in long-term anxiety treatment
Adaptability to Parkinson’s Motor Symptoms	Possibility of interacting with anti-Parkinson’s medications, leading to, for example, worsening of motor symptoms	No interaction with motor symptoms applicable for Parkinson’s patients
Patients’ Motivation and Engagement	Personal engagement is not in high demand when only taking medication	Requires more personal work and significant patient involvement

2. Why Morita Therapy Is Important for This Opinion Article

Morita therapy is an alternative therapy for patients with anxiety disorder. Today, it can be used for Parkinson’s patients suffering from psychological symptoms (anxiety disorder). A randomized controlled trial (RCT) study, which was considered the first of its kind in English-speaking countries, recruited 68 participants, representing 5.1% (95% CI 3.4% to 6.6%) of those invited (34 in the control group and 34 in the intervention group). Of these, 64 (94%; 95% CI 88.3% to 99.7%) provided follow-up data at 4 months. Participants had a mean age of 49 years and a mean baseline for the Patient Health Questionnaire-9 (PHQ-9) of 16.8; 61% were female. Out of 34 participants in the intervention group, 24 (70.6%) adhered to the minimum treatment dose. The pooled standard deviation of the follow-up for the Patient Health Questionnaire-9 (PHQ-9) was 6.4 (95% CI 5.5 to 7.8), and the correlation between baseline and follow-up for the Patient Health Questionnaire-9 (PHQ-9) was 0.42 (95% CI 0.19 to 0.61). Recovery rates were 66.7% in the intervention group and 30.0% in the control group, while response rates were 66.7% and 13.3%, respectively [11,14]. The therapy was applied at a private clinic of the University of Exeter, the AccEPT Clinic. After a discussion with their general practitioner, patients were subsequently selected to undergo Morita therapy [8].

In the aforementioned randomized controlled trial (RCT), two therapists were trained, and they were required to follow a protocol from the United Kingdom based on steps that were developed from research. Before moving on to therapy, qualitative investigations were proposed by the therapist to prepare the patient mentally. The sessions were recorded to give the patient the opportunity to see their progress and for the therapist to assess the patient’s strengths and weaknesses after each session. Among the 60 patients, 66.7% responded to the therapy compared to 13.3% with standard treatment. In light of this result, we can deduce that Morita therapy holds significant value based on other studies that have already been published with numerous participants [14]. The results of these studies will further enhance the reliability percentage of Morita therapy. In addition to the aforementioned randomized controlled trial, among the hospital clinics that have worked on this therapy are those in Japan and China [4,8]. Notably, there is only one clinic in Australia that practices this type of therapy [15]. Another randomized controlled trial and a qualitative study will be used to compare Morita therapy to other types of treatment for anxiety and depression. In another study, 60 participants were recruited to collect qualitative data on anxiety symptoms, depression, and quality of life. The authors of the study conducted qualitative interviews in parallel to explore people’s opinions of Morita therapy. The results indicated that a trial is not appropriate, as a deeper understanding of this subject is needed [16]. To date, there has been no systematic review investigating the strength of evidence for Morita therapy in anxiety disorders for Parkinson’s patients.

3. Objectives of This Therapy

The goal of this type of therapy is to alleviate negative thoughts by encouraging the patient to practice the same activity to change their point of view about their life and to encourage them to believe in themselves through constructive behaviors that we try to develop in the form of activities [10,11].

4. How the Intervention Could Proceed

Morita therapy attempts to lead people away from preoccupation with anxiety and neurotic symptoms and help them to accept their situation and achieve their life goals through the understanding that anxiety is a natural feeling, while encouraging the person to engage in constructive behaviors. This is based on four important steps [14,17,18].

4.1. First Step: Isolation from the Outside

The first step is bed rest for a duration of exactly one week, during which patients remain in their room all day with limited activities, for example, leaving only for meals and bathroom breaks, without access to other activities such as reading, listening to the radio, watching television, or using the phone. The goal of this stage is to live with anxiety, as they have no other activities to engage in. This will lead patients to turn from side to side with a sense of discomfort; some patients find that this feeling disappears after three days. During this period, there are those who can succeed in this stage and those who may give up. The only possible justification for abandoning Morita therapy in this situation is that the patient has a weak will and cannot be treated with this therapy, as they have failed at the very first stage.

4.2. Second Step: Understand Oneself

There is an option to undertake light work for four to seven days. During this time, the patient is dedicated to working under the guidance of the therapist, practicing, for example, an activity in the hospital at a gradual pace alongside daily life. For instance, one patient chose writing as a means to express his emotions: he would write in his journal about his daily activities, and later, the therapist would read what was written along with his comments, reactions, and sometimes viewpoints based on what he experienced throughout the day.

One strategy that helps manage negative thoughts is holding meetings two to three times a week with the therapist to discuss the patient’s activities without focusing on non-motor symptoms such as anxiety; instead, the focus is on managing emotions.

In addition to writing, there is the option of reading aloud for a specific period. For example, after the patient washes their face in the morning and before going to bed in the evening, they are encouraged to read the beginning of a book, just a few pages that they might not be able to read even though they are legible. One can consider their reaction to be normal because the aim of this activity is not to assess their level of comprehension but rather to stimulate their mind.

4.3. Third Step: Creativity

This step allows the patient to engage more since it is longer than the previous stages, lasting between one and two months in the form of high-intensity physical work, such as cooking or chopping wood. The work must be simple and clear, with expressions that support and value the patients’ efforts to develop psychological aspects such as self-confidence. Patients can also take advantage of this opportunity by creating things they had never previously thought of making. However, thanks to this initiation, they have already understood that through experience, what once seemed impossible can become possible, and with just one step, everything can change [10].

4.4. Fourth Step: Living Outside

To prepare for normal daily life, over a period of four weeks, patients can go out and sleep somewhere other than in the hospital, and they can also go to work, with the option to consult their doctor once a week [10].

At this stage, patients are open to the world after a long period of isolation. They are compelled to engage for various reasons that require contact with other people, and over time, anxiety may fade, depending on the patients and their willingness.

5. Conclusions and Perspectives

Anxiety disorder is a non-motor symptom that can worsen the condition of Parkinson’s patients and affect their quality of life. Morita therapy is among the various therapies used by practitioners for anxiety or sometimes depression. Practitioners can combine it with pharmacological treatments, such as benzodiazepines and antidepressants, as well as non-pharmacological methods. This will lead to further work focusing on brain imaging before and after Morita therapy to determine whether there are active areas associated with improvements in psychological symptoms, specifically anxiety disorder. It is recommended to use the Parkinson Anxiety Scale (PAS) to explain the symptoms to patients.