Shūzō Kure’s essay on psychotherapy including music in twentieth-century Japan (1916)

Music therapy in early modern and modern Japan

Music therapy is usually regarded as a relatively novel form of psychiatric treatment, theorized and systematized in the West in the twentieth century. However, if the application of sound and music is considered broadly as a form of therapy or a means of promoting and maintaining health, music therapy can be traced back to ancient times, both in the East and in the West.

In Japan, music has been closely associated with medicine for a long time, as evidenced by the long-standing use of performing arts and religious rituals for treating illness. It was first systematized as a form of medical care during the Edo period (1603–1867), when some important books of yōjō (well-being; nurturing life) explored the therapeutic effects of musical activities. Ekiken Kaibara (1630–1714), the most famous author in this genre, claimed the effectiveness of eika butō (singing and dancing) in nurturing kiketsu (vital energy and blood), which, in turn, led to better yōjō. However, it was not only Japanese and Chinese music therapy that featured in the Edo period. Under the influence of Dutch studies, Japanese scholars began to pay attention to the effects of European music on internal organs and other parts of the human body.

The situation began to change in the Meiji era (1868–1912). Since Japan established diplomatic relations with Western countries in the 1850s, the Western concepts of music therapy, particularly those of the USA, had been steadily introduced into Japan. Among the pioneers was the musicologist Kōzu Senzaburo (1852–97), who had studied in the USA and, on his return, had used his overseas experience to introduce Western music into music curricula. A hybrid form of music therapy that blended Japanese, Chinese and Western conceptions and practices was developed during the early decades of the Meiji period. Because of the enduring influence of the Edo ideas, most literature on music therapy focused on active music therapy, that is, on patients’ participation in playing music. However, from around 1884 onwards, the focus gradually shifted to receptive music therapy, emphasizing the experience of listening to music.

The late Meiji period witnessed a shift in the make-up of those interested in music therapy, from musicians and musicologists to medical professionals. Meanwhile, Western theories of music therapy became increasingly accepted in their original forms. Doctors trained in Western psychiatry began to administer music therapy. In particular, at Sugamo Hospital – the largest public mental hospital, of which Shūzō Kure was the director – both active and receptive music therapies had been offered as part of treatment since 1902. It was probably the first mental hospital in the whole of East Asia to provide music therapy systematically. Remarkably, music therapy, which had largely been a hypothetical idea and had been practised only sporadically until the early Meiji period, started to develop into a systematic and established practice.

By the 1910s, the influence of the American pragmatic approach, which had previously played an important role, had waned. Japan began to follow German, French and British medical science and theories on music therapy, which focused on experiment-based treatment and clinical research, including pathology. By the late Meiji period, there had been a growing trend to adopt an integrated approach to music therapy based on physiological, neurological and clinical experiments.

Modern Western music therapy

From around 1800 onwards, an increasing number of physicians and psychiatrists in European countries began to emphasize the close links between music and human physiology. Theories on music therapy attracted considerable attention, particularly those concerning the treatment of hypertension and gastrointestinal problems. Meanwhile, music therapy for psychological and neurological illness developed rapidly in Germany, where many psychiatrists and neurologists frequently conducted experiments and offered musical therapy in clinical settings.

One of the pioneers was Johann Christian Reil (1759–1813). Reil’s book Rhapsodieen über die Anwendung der psychischen Curmethode auf Geisteszerrüttungen (1803) contained many references to musical therapy. Another psychiatrist, Peter Lichtenthal (1778–1853), developed Reil’s ideas in his book Der musikalische Arzt (1807). He proposed a new theory claiming that each note of a musical scale produced a distinctive psychological impression. He proved this by using a piece of music that could generate a desired and appropriate response and went on to argue that music could aid in the treatment of mental disorders (Völkel, 1979: 42, 61).

Peter Joseph Schneider (1791–1871), in Die Musik und Poesie (1835: 44, 100, 256), suggested the use of music as part of occupational therapy for patients. Later, Schneider incorporated music therapy into therapeutic systems for mental illnesses and mental health programmes. The concepts of music therapy that were advocated by Lichtenthal and Schneider in the first half of the nineteenth century gradually took root in the German psychiatric care system. A mental hospital in Baden began to offer music therapy to all patients in the 1830s. Richard von Krafft-Ebing (1840–1902), the Austro-German psychiatrist and Professor of Psychiatry in Vienna, had also practised music therapy there as a staff member, and had advocated communicating with patients through musical composition (Kramer, 2000: 347).

From the 1840s onwards, with the founding of university hospitals across Germany, a transition of power occurred in psychiatry, from mentalists to physicalists. Music therapy was conceived using a different framework. Traditionally, researchers focused on the psychological effects of music and paid particular attention to the overall melody of each piece of music. This practice was based on the belief that mental illness was caused by psychological factors. However, pioneering researchers from Germany and France, two countries that had experienced rapid progress in the discipline of neurology, contributed to the emergence of a new subfield called ‘neuropsychiatry’. In this regard, an increasing number of researchers have attempted to understand how components of music produce neurological and physiological changes in the body. For example, regarding feelings such as ‘comfort’ or ‘discomfort’ induced by musical stimuli, it became increasingly popular to understand them in neurological or physiological terms by measuring blood pressure and respiration.

Moreover, medical researchers investigated various elements of music to understand the mechanism through which music affected the treatment of aphasia (Graziano and Johnson, 2014: 159–60). In particular, Hermann Oppenheim (1858–1919), at the Charité Hospital in Berlin, adopted French neurologist Jean-Martin Charcot’s (1825–1893) music therapy method to treat aphasia. In 1888, he released research findings about the processes of memorization and forgetting of musical phrases in patients (Graziano and Johnson, 2014: 160–1). A few neurologists, including August Knoblauch (1836–1919) and Richard Wallaschek (1860–1917), soon acknowledged that the recognition of language and of music were closely related. With their endorsement, Oppenheim’s ideas of music therapy were firmly entrenched in the fields of psychiatry and neurology in Germany, where music therapy based on psychotherapy or neurology was widely practised from the late 1880s to the early 1900s.

Shūzō Kure’s promotion of psychiatry and its background

Kure, a prominent psychiatrist in the late Meiji period, introduced the music therapy of Germany and other European countries into Japanese psychiatry. Kure was the third son of Kōseki Kure (1811–79), a famous Dutch-school doctor who served the lord of the Hiroshima domain. Shuzo’s mother was the eldest daughter of another renowned scholar of Dutch learning, Genpo Mitsukuri (1799–1863). Thus, he grew up in a familial environment that valued Western-style education. Under the guidance of his father, who also greatly appreciated Oriental learning, Kure mastered sinology from an early age. After finishing his study in medicine at Tokyo Imperial University in 1891, Kure worked at both the university hospital and Sugamo Hospital, before he went abroad to study in Austria, Germany and France, between 1897 and 1901. He studied psychiatry under Krafft-Ebing and Julius Wagner von Jauregg (1857–1940) in Vienna from October 1898, and neuroanatomy and neuropathology under Heinrich Obersteiner (1847–1922).

Later, Kure transferred to the University of Heidelberg in April 1899, and began to study under the German psychiatrist Emil Kraepelin (1856–1926). He learned psychiatric nosology from Kraepelin, neurology from Wilhelm Heinrich Erb (1830–1921), and the latest neuropathology techniques from Franz Nissl (1860–1919). In May 1900, Kure moved to Berlin to study under Friedrich Jolly (1844–1904) and Theodor Ziehen (1862–1950). There, he also studied clinical neurology with Oppenheim at the Charité Hospital of Humboldt University. While in Germany, Kure visited the Alt-Scherbitz asylum and was highly impressed by the staff’s approach to protecting patients’ dignity, the spirit of love and benevolence, and the open ward environment (Kure, 1902/1982: 65).

In April 1901, Kure moved to Paris to study clinical neurology under Pierre Marie (1853–1940) at the Salpêtrière Hospital, where he received first-hand experience of the humanitarian approach developed by Philippe Pinel (1745–1826). Soon after his return to Japan in October 1901, he began to draw attention to the inhumane asylum system and sought to abolish the confinement and chaining of mentally ill patients, an approach possibly affected by his visit to the Alt-Scherbitz asylum and his stint at the Salpêtrière Hospital.

Kure became director of Sugamo Hospital in 1901, and undertook to reform psychiatric care. He advocated a therapeutic approach for patients with mental and neurological diseases, which he had learned from Oppenheim and Ziehen. He also introduced into Japan the psychiatric theories of Kraepelin and Krafft-Ebing, particularly the former’s classification system of mental disorders.

Music and ‘distraction therapy’

One of Kure’s many contributions to Japanese psychiatry was introducing Ablenkungstherapie (distraction therapy), which was an important treatment in the West. In his book on Seishin Ryōhō (Psychotherapy), parts of which are translated in the Classic Text, he explained distraction therapy as a form of psychotherapy that was effective because it helped to divert patients’ attention from the complex thoughts and ideas that they could not forsake (Kure, 1916: 368). He mentioned that psychotherapy had become prominent in Germany in the late eighteenth and early nineteenth centuries, mainly because of Reil’s contribution. Reil had emphasized the importance of psychotherapy; in particular, he had regarded music as an effective tool for distracting mentally ill patients from fixed mental states, and had recommended participation in music activity, either by singing or playing musical instruments, as a psychological exercise (Reil, 1803: 142–251). Regarding Reil’s pioneering role, Kure might have been influenced by Kraepelin, who mentioned Reil in his Hundert Jahre Psychiatrie (Kraepelin, 1917/1962: 96).

Kure suggested using sound as distraction therapy to treat patients who suffered from auditory hallucinations, for which he presented Oppenheim’s method of using the ticking sound of a pocket watch for pain management as an example. Moreover, Kure noted that the German neurologist Ziehen recommended using all five senses to observe pathological conditions (Kure, 1916: 369–70). These German connections suggest that, regarding distraction therapy, Kure was mainly influenced by the clinical knowledge that he acquired at the Charité Hospital in Berlin. According to Kure, Ablenkungstherapie could be further classified into Beschäftigungstherapie (occupational therapy) and Unterhaltung oder Zerstreuung (recreational therapy). He suggested including music therapy in both of them. Thus, music therapy became an established practice at Sugamo Hospital.

In the Classic Text below, we first consider the use of music in occupational therapy, which works through patients’ psychological engagement in goal-oriented activities, rather than through a physiological effect on their bodily organs. Kure was not the first to use music for occupational therapy. In his book on the pathology and treatment of emotional and mental disorders, German psychiatrist Alezander Haindorf (1782–1862) claimed that regularly playing musical instruments was an effective occupational therapy (Haindorf, 1818: 65–70, 81, 132–54). Schneider, another German psychiatrist, claimed, in Music and Poetry, that musical activities such as singing and playing instruments had therapeutic effects (Schneider, 1835: 352). Kraepelin (1917/1962: 96, 98, 112) proposed a similar idea in his Hundert Jahre Psychiatrie, and was at the forefront of research on music therapy, along with other prominent contemporary psychiatrists and neurologists, such as Oppenheim, Krafft-Ebing, and Erb. Undoubtedly, in developing his own ideas about music therapy, Kure learned from these previous studies, and built on his German experience to promote the inclusion of musical activities as part of occupational therapy. Instead of focusing on the physiological benefits of music, Kure emphasized its psychological effects, particularly on how it could help patients’ psychological engagement in goal-oriented activities.

Secondly, we consider Kure’s ideas about the role of music in recreational therapy. He defined this as a purely mental distraction method intended to comfort and entertain patients in distress. He was probably influenced by the various practices and facilities that he observed in mental hospitals in Germany and France. In 1902, Kure wrote a paper on the Alt-Scherbitz Asylum, describing how it was equipped with facilities for music and dance to soothe and entertain patients (Kure, 1902/1982: 65). Kure recommended cheerful and pleasant music pieces and theatrical plays. He also proposed holding concerts for parents and advised doctors to select carefully the appropriate type of music and length of performance. Indeed, from 1902 onwards, Kure began to hold regular concerts called igaku (consolation music) as part of his recreational therapy programme.

Interestingly, the music played at these igaku concerts was mainly Japanese, and Western music was never included. One form of modern Japanese music performed at the concerts was Chikuzen-biwa, a novel style of biwa music originating in the Chikuzen region of northern Kyushu. It arrived in Tokyo around 1898 and was a new and fashionable style of music at the time. Jōruri (a form of narrative music accompanied by the shamisen, a type of lute) and Naniwa Bushi (a popular form of narrative music also with the shamisen, and originating in the late Edo period) were other new styles performed at these concerts. Kure also organized gramophone concerts on public holidays.

Thus, Kure appears to have favoured music genres that were fashionable in contemporary culture, although he had due regard for patients’ preferences in his selection. The igaku concerts were held at the auditorium of Sugamo Hospital, organized by Seishinbyōsya-Kyūchikai (The Charitable Society for the Protection of the Mentally Ill), which was founded through Kure’s initiative. One of the society’s many undertakings was visiting mental hospitals in the Tokyo region, including Sugamo Hospital, to comfort mentally ill patients, particularly by holding concerts and distributing sweets. The society donated equipment that was lacking in those hospitals, offered medical advice to outpatients who were referred by society members, and provided care and medication for patients in need. The society held regular concerts every two to three months and invited musicians to deliver ‘receptive music therapy’.