Japanese Kampo

1. Introduction

Version followed: Kampo as practised inside Japan's national health insurance system, meaning prescription ("ethical") extract formulations prescribed by medically licensed physicians, as described by Japanese physician-researchers, the Japan Society for Oriental Medicine's ICD-11 work and Japanese regulatory labelling (PMDA); the psychotherapist's own work alongside it follows the DSM-5-TR Cultural Formulation Interview (CFI). Kampo practice outside Japan (by herbalists, acupuncturists or TCM practitioners, or as imported over-the-counter products) is not covered by these sources and is marked [uncertain] where it comes up.

What it is. Kampo (漢方) is Japan's traditional herbal medicine. It derives from Chinese herbal medicine, which reached Japan in 552 AD by one account, and was the backbone of Japanese medicine for more than 1,500 years [source: Arai et al. 2020]. Dates for its arrival differ between accounts (a 7th-century date is also given in summaries) [uncertain]. Because identical herb species were hard to obtain and trade was limited, Kampo developed its own path, so Japanese and Chinese formulas now differ markedly [source: Kono et al. 2015]. After the 1868 Meiji Restoration the government adopted the German medical system and excluded Kampo as pre-modern; it regained official attention around 1970 [source: Arai et al. 2020]. Four extract formulas were first listed for national health insurance reimbursement in 1967 (「初めて4処方の漢方エキス剤が薬価収載され」) [source: Yakuji Nippo 2024; Kono et al. 2015], and medical Kampo products entered routine practice from 1976 [source: Watanabe 2018]. About 148 prescription extract formulations are now reimbursed [source: Arai et al. 2020; Kono et al. 2015]; one 2024 trade-press source gives 147 [source: Yakuji Nippo 2024] [uncertain: count differs by source and date]. Kampo is not a folk or alternative practice in Japan: it is dispensed as prescription drugs in university, national and foundation hospitals, often alongside Western drugs [source: Kono et al. 2015], and about 90% of Japanese physicians reportedly use it in daily practice [source: Watanabe 2018].

Who holds authority. In Japan, Kampo is prescribed within ordinary medical licensure: physicians who prescribe it must hold Western medical training, a requirement traced back to the Meiji era [source: Watanabe 2018], and one Japanese physician-educator states that only doctors and pharmacists trained in Western medicine practise it [source: Arai M 2017]. Specialist-physician (漢方専門医) and certified Kampo pharmacist systems exist; there are about 2,000 Kampo specialists [source: Watanabe 2018; Arai M 2017]. The Japan Society for Oriental Medicine (日本東洋医学会) is the professional society; its terminology and disease-classification committee led Japan's work on the ICD-11 traditional medicine chapter [source: Watanabe 2018]. Product safety labelling is issued through Japan's Pharmaceuticals and Medical Devices Agency (PMDA) [source: PMDA label]. Who may prescribe Kampo outside Japan, and how, varies by jurisdiction [uncertain: not verified].

Core idea of how change happens (as the tradition holds it). Kampo practitioners describe health as a balanced state of ki (vital energy), ketsu (roughly, blood) and sui (roughly, body fluids), read through the dichotomies yin–yang, kyo–jitsu (deficiency–excess, "hollow–full") and netsu–kan (heat–cold) [source: Arai et al. 2020]. The clinician identifies the patient's sho (証, the pattern of signs, symptoms and constitution at a given time) and chooses a formula to fit that pattern, so different formulas may be used for the same disease when the sho differs [source: Arai et al. 2020; Watanabe 2018]. Kampo holds mind and body to be one (心身一如), so emotional and bodily symptoms are treated on the same level [source: Arai M 2017]. These are the tradition's concepts, described here as practitioners hold them.

The psychotherapist's place. A psychotherapist does not diagnose sho or prescribe Kampo. Your work is to understand what Kampo means to the client, assess with the CFI, coordinate with the prescribing physician or pharmacist with consent, notice safety signals and route them to the prescriber, and keep psychological treatment and Kampo care from working at cross-purposes [synthesis].

2. Framework

Kampo is a codified medical system, not a psychotherapy; there is no Kampo "protocol" for therapists. Below are (a) the clinical process as Kampo sources describe it, so you can follow what your client is going through, and (b) a framework for your own parallel work [synthesis for (b)].

(a) The Kampo clinical process (for orientation only).

Western diagnosis plus pattern. Japanese practice combines a Western diagnosis with a sho; one leading author argues Kampo treatment decisions need both [source: Watanabe 2018]. Japan's classification uses only the pattern category of the ICD-11 traditional medicine chapter, not its "disorders" [source: Watanabe 2018].
The four examinations. Visual observation; listening to body sounds and smelling; touching; and the patient's own account. Abdominal examination (腹診, fukushin) and tongue examination (舌診, zesshin) are the principal techniques [source: Arai et al. 2020].
Formula selection and review. A formula is chosen to fit the sho; the sho can change, so formulas are reviewed over time [source: Arai et al. 2020; Watanabe 2018]. Under national insurance, patients can receive Western and Kampo care at the same institution, with extract and crude-herb treatments both covered [source: Arai et al. 2020; Arai M 2017].
ICD-11. Chapter 26 (Traditional Medicine Conditions, Module 1), released with ICD-11 in 2018, classifies traditional medicine disorders and patterns from East Asian medicine, including Japanese Kampo, Chinese and Korean medicine. It is a tool for classification, statistics and research, and it does not certify efficacy or safety [source: Watanabe 2018].

(b) The psychotherapist's parallel phases [synthesis].

Engagement and assessment (sessions 1–3, inside your normal intake). Goals: learn whether the client uses Kampo, who prescribed it and why, and what it means to them; complete the CFI core (16 questions) and any supplementary modules that fit [source: APA CFI for the instrument; synthesis for timing]. Move on when you have the client's explanatory model, a full list of medicines and Kampo products (to pass to the prescriber, not to judge yourself), and consent decisions about contact with the prescriber.
Formulation and coordination (sessions 2–5). Goals: write a cultural formulation that holds both the client's Kampo understanding and your psychological formulation; agree with the client what you will share with the prescribing physician or pharmacist. Move on when roles are clear: the prescriber handles Kampo and medicines, you handle psychological treatment.
Psychotherapy alongside Kampo (the length of your usual treatment). Goals: deliver your usual evidence-based therapy, using the client's own terms where helpful; check in briefly about Kampo care at reviews; route any physical or medication concern to the prescriber.
Review and ending. Goals: review outcomes with the client; make sure Kampo and medicine questions stay with the prescriber after you finish; share an ending summary only with consent.

Session counts are not set by any Kampo source; they follow your own modality [synthesis].

3. Guiding principles

Kampo is mainstream medicine in Japan. Treat it as part of the client's medical care, not as "alternative" [source: Kono et al. 2015; Watanabe 2018]. Practical meaning: ask about it the way you ask about any prescription.
Authority sits with the licensed prescriber. In Japan this is a physician, and a pharmacist dispenses [source: Watanabe 2018; Arai M 2017]. Practical meaning: every question about starting, stopping or changing a Kampo product or a medicine goes to the prescriber; you never advise on it.
Do not let Kampo replace other treatment, or the reverse. A Japanese physician-educator states that Western drugs should not be reduced quickly when Kampo is started, and that Kampo is not a substitute for them [source: Arai M 2017]. Practical meaning: if a client plans to drop an antidepressant because they are "on Kampo now", route this to the prescriber promptly.
Attribute the concepts. Ki, ketsu, sui, sho and 心身一如 are the tradition's concepts; describe them as Kampo holds them, neither as fact nor as superstition [synthesis]. Practical meaning: "In Kampo terms, your doctor sees this as…", not "your ki is stagnant".
Respect individualised pattern-based care. Kampo chooses by pattern, so two people with the same diagnosis may take different formulas [source: Arai et al. 2020; Yakuji Nippo 2024]. Practical meaning: never compare a client's formula with someone else's or suggest one.
"Natural" does not mean risk-free. Japanese labelling carries boxed warnings for some formulas, such as interstitial pneumonia with shosaikoto [source: PMDA label]. Practical meaning: take new cough, breathlessness, fever, swelling or jaundice seriously and send the client to the prescriber the same day.
Evidence status is mixed and should be stated plainly. Some mental-health uses have small trials (e.g. yokukansan for behavioural and psychological symptoms of dementia), and ICD-11 inclusion is not evidence of efficacy [source: Matsuda et al. 2013; Watanabe 2018]. Practical meaning: when asked "does it work?", say what is known and refer the decision to the prescriber.
Mind–body unity can be a bridge. Kampo's 心身一如 view [source: Arai M 2017] fits the biopsychosocial model. Practical meaning: use it to legitimise talking about stress and emotion without dismissing bodily complaints [synthesis].
Cultural humility. The client, their family and the prescriber know the client's Kampo care better than you do [synthesis]. Practical meaning: ask, do not assume, and check how much the client identifies with Kampo at all.
Consent and confidentiality govern every contact. [synthesis] Practical meaning: written consent before speaking to the prescriber, limited to what the client agrees to share.
Work within your scope. [synthesis] Practical meaning: no tongue or abdominal examination, no pattern diagnosis, no herbal advice, no touch.

4. Intervention inventory

These are the psychotherapist's own interventions alongside Kampo care. None of them is a Kampo procedure: the four examinations, sho diagnosis and formula choice belong to the licensed prescriber [source: Arai et al. 2020; Watanabe 2018]. Steps are [synthesis] unless a source is given. Example language is illustrative throughout.

4.1 Cultural humility and self-examination

Purpose / when: Before and during work with any client who uses Kampo, to notice your own assumptions (e.g. "herbal = placebo", or "Eastern = holistic and better") [synthesis].
Steps: (1) Before the first session, write down what you believe about Kampo and where that belief comes from. (2) Note that in Japan Kampo is prescription medicine used by most physicians [source: Watanabe 2018; Kono et al. 2015], which may differ from the herbal market where you work. (3) After sessions where Kampo comes up, check whether you steered, dismissed or over-endorsed it. (4) Take questions about your bias to supervision.
Example language (illustrative): "I know Kampo is part of ordinary medical care in Japan, but I don't know how it fits into your life. Could you help me understand?"
Watch for: Your tone shifting to sceptical or to enthusiastic; offering opinions about formulas; the client going quiet after you mention it. It is working when the client brings up Kampo and their prescriber without being asked.

4.2 Asking about Kampo use without judgement

Purpose / when: At intake and at every medication review, because clients often do not mention herbal products unless asked [synthesis].
Steps: (1) Ask about all medicines, then separately about Kampo, other herbal products and supplements. (2) Ask who prescribed each (physician in Japan, physician or herbalist elsewhere, self-bought) and what it is for, in the client's words. (3) Ask whether the client's other doctors know about it. (4) Record the names as the client gives them; do not interpret them.
Example language (illustrative): "Some people take Kampo or other herbal medicines alongside their other treatment. Do you take anything like that? Who suggested it, and what is it meant to help with?"
Watch for: Embarrassment or defensiveness (normalise and move on); products the client's psychiatrist or GP does not know about (raise coordination, 4.8). It is working when the client gives a full list and says who prescribes what.

4.3 DSM-5-TR Cultural Formulation Interview (core)

Purpose / when: Early in assessment, to understand the problem from the client's own perspective and their social network's. The CFI is a 16-question semi-structured interview, meant to inform clinical understanding, not to be the sole basis for diagnosis [source: APA CFI].
Steps: (1) Introduce it with a brief explanation of why you are asking. (2) Cover its four domains in order: cultural definition of the problem; cultural perceptions of cause, context and support; cultural factors affecting self-coping and past help seeking, which explicitly includes folk, traditional and alternative healing alongside medical care; and cultural factors affecting current help seeking, which includes the clinician–patient relationship [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. (3) Use the interviewer probes in the published form; do not modify it, since modification needs APA permission [source: APA CFI]. (4) Write the answers into your formulation in the client's words.
Example language (illustrative): "I'd like to understand how you see what's been happening, including any help you've already tried, Kampo or otherwise."
Watch for: The client giving "textbook" answers to please you; Kampo appearing under past help seeking while a Western diagnosis appears under the problem, which is common and not a contradiction [synthesis]. It is working when the client's own explanation shapes your treatment plan.

4.4 CFI supplementary modules

Purpose / when: When a core domain needs depth. The published modules include explanatory model, social network, older adults, caregivers, religion and spirituality, immigrants and refugees, and children and adolescents; an informant version also exists [source: APA CFI].
Steps: (1) Use the explanatory-model module if the client frames distress in Kampo terms (see 4.5). (2) Use the immigrants and refugees module for clients who moved from Japan, or whose Kampo care was in Japan and is now unavailable. (3) Use the older adults and caregiver modules where a parent with dementia is taking Kampo (see 4.13). (4) Use the informant version with a family member, with consent.
Example language (illustrative): "You mentioned your doctor in Japan prescribed Kampo. What has it been like to manage your health since you moved here?"
Watch for: Loss of a trusted Kampo physician after migration as a source of grief or of self-treatment with imported products (see 4.14). It is working when you can name what care the client had, what was lost and what they want now.

4.5 Working with the client's Kampo explanatory concepts

Purpose / when: When a client describes their distress in Kampo terms. Kampo describes ki deficiency (気虚) with low energy and lack of motivation, stagnant ki (気うつ) with low mood, rebellious ki (気逆) with sudden anger, and links blood stasis (瘀血) to premenstrual irritability and anxiety and fluid disturbance (水毒) to headache before rain; it holds that the seven emotions (七情), when disturbed, affect the five organs and can cause illness [source: Arai M 2017].
Steps: (1) Ask what the term means to the client and who used it (their physician, family, themselves). (2) Reflect it back as the client's or the prescriber's view: "in Kampo terms…". (3) Find the overlap with your formulation (e.g. low energy and withdrawal, anger, sleep). (4) Use the client's term in goal setting if it helps engagement. (5) Never diagnose ki, ketsu or sui patterns yourself, and never suggest a formula.
Example language (illustrative): "Your doctor described this as your ki being stuck. In our work we can look at the same heaviness from another angle: what drains you, and what gives you a little energy back."
Watch for: Over-adopting the vocabulary so it sounds as if you diagnose sho; the client feeling their bodily experience is being turned into "just stress". It is working when the client feels both frameworks are respected.

4.6 Cultural concepts of distress and somatic expression

Purpose / when: When distress is expressed mainly through the body, or through a culturally specific idiom. Taijin kyofusho ("interpersonal fear disorder"), a Japanese concept, is in the DSM-5 appendix Glossary of Cultural Concepts of Distress [source: Cummings 2015, Foundation for Psychocultural Research], and a DSM-5-TR training source lists it among the DSM-5-TR cultural concepts of distress [source: UNMC BHECN slides] [uncertain: secondary, unverified for DSM-5-TR].
Steps: (1) Do not treat bodily complaints as "resistance" to psychological talk; Kampo's 心身一如 view treats them on the same level as emotion [source: Arai M 2017]. (2) Ask what the symptom means socially and for the family. (3) Make sure physical complaints have been medically assessed. (4) Check whether a cultural concept of distress better explains the presentation than a disorder category, or sits alongside one.
Example language (illustrative): "When the tension is in your chest and stomach like this, what do you think it is telling you? And has your doctor been able to check it over?"
Watch for: Missing a medical cause by assuming somatisation; or pathologising a culturally normal way of talking about distress. It is working when the client can talk about body and feeling together.

4.7 Handing over a full medicines and products list

Purpose / when: Whenever the client takes Kampo with other medicines, or more than one Kampo product. Of 148 prescription extract formulas, 109 contain glycyrrhiza (licorice) [source: Arai et al. 2020], so combined products can add up. Labels also restrict some combinations with Western drugs; the shosaikoto label, for example, contraindicates use with interferon [source: PMDA label]. Labels for licorice-containing formulas list precautions for combined use with other licorice- or glycyrrhizin-containing products and with loop and thiazide diuretics, because potassium loss adds up (risk of pseudoaldosteronism and low-potassium muscle problems) [source: PMDA label, Tsumura shakanzoto]. A laboratory study of five common formulas (including yokukansan) found only weak inhibition of the P-glycoprotein drug transporter, which its authors judged a low interaction risk; it was not a clinical study [source: Matsumoto et al. 2018]. These are examples, not a complete list: the prescriber and pharmacist must judge interactions, not you.
Steps: (1) Ask the client to bring all packages or a photo list to the next session, or to their pharmacist. (2) Encourage the client to tell every prescriber and pharmacist about every product. (3) With consent, include the list in your letter to the prescriber. (4) Do not comment on interactions yourself.
Example language (illustrative): "Could you bring photos of all your medicine packets, including Kampo? I won't judge them, but your doctor and pharmacist should see the whole picture."
Watch for: Products from more than one prescriber; imported products with labels the client cannot read. It is working when a pharmacist or prescriber has reviewed everything.

4.8 Collaboration and referral with the Kampo prescriber

Purpose / when: When the client agrees and the care overlaps (e.g. a Kampo formula prescribed for anxiety, irritability or sleep while you treat the same problems). Kampo is used alongside Western drugs in Japanese hospitals [source: Kono et al. 2015].
Steps: (1) Obtain written consent naming the prescriber and what may be shared. (2) Send a short letter: your role, the problem you are treating, the client's goals, any safety concerns. (3) Ask the prescriber what they would like you to watch for and how to reach them. (4) Agree roles: they handle Kampo and medicines; you handle psychological treatment. (5) If the client has no prescriber (self-bought products), suggest they see a physician or pharmacist, ideally one trained in Kampo (in Japan, a 漢方専門医 exists [source: Watanabe 2018]).
Example language (illustrative): "Would it be all right if I wrote to Dr. ___ so we're not working at cross-purposes? I'd only share what we agree on."
Watch for: The client fearing the prescriber will disapprove of therapy, or the reverse; prescribers who are hard to reach. It is working when both clinicians know about each other and roles are clear.

4.9 Recognising and routing physical safety signals

Purpose / when: Throughout treatment, whenever a client on Kampo mentions new physical symptoms. Among adverse events reported for Kampo medicines, the most frequent categories were liver injury (28.2%), lung injury (27.8%), pseudoaldosteronism (21.0%), mesenteric phlebosclerosis (5.3%) and drug eruption (4.4%); toxicity can occur at any time, not only early [source: Arai et al. 2020]. Pseudoaldosteronism (oedema, low potassium, high blood pressure) is linked to glycyrrhiza-containing formulas [source: Arai et al. 2020]. Japanese labelling for shosaikoto carries a warning that interstitial pneumonia can occur and can be fatal without prompt treatment, and tells patients to stop and contact their clinician at once if cough, breathlessness or fever appear; it also lists pseudoaldosteronism, myopathy and rhabdomyolysis, and liver dysfunction with jaundice as serious adverse reactions, and contraindicates use with interferon and in liver cirrhosis or liver cancer [source: PMDA label].
Steps: (1) Learn the warning signs as patient-level symptoms: new cough, breathlessness or fever; swelling, weight gain or new high blood pressure; muscle weakness or pain; yellow skin or eyes, dark urine; new rash. (2) If any appear, tell the client to contact their prescriber or urgent care the same day; for marked breathlessness, emergency care now. (3) Do not tell the client to stop or keep taking the product; the label instructions and the prescriber govern that. (4) Document what you advised and, with consent, inform the prescriber.
Example language (illustrative): "A new cough with breathlessness is something your doctor needs to know about today, especially with a new medicine. Can you call them now, from here?"
Watch for: The client minimising symptoms because Kampo is "natural"; symptoms attributed to anxiety without medical review. It is working when the client contacts the prescriber promptly and reports back.

4.10 Discussing evidence when the client asks

Purpose / when: When a client or family member asks whether Kampo works for a mental-health problem. Kampo clinicians describe use of formulas for anxiety, irritability, depression, insomnia and other stress-related presentations, chosen by pattern [source: Arai M 2017; Arai et al. 2020]. Independent trial evidence is limited: one meta-analysis of four randomised trials (236 participants) found yokukansan reduced behavioural and psychological symptoms of dementia more than usual care, with no difference in discontinuation [source: Matsuda et al. 2013]; an updated meta-analysis was published in 2016 [source: Matsunaga et al. 2016] but its findings are [uncertain: not verified]. ICD-11 classification does not certify efficacy or safety [source: Watanabe 2018].
Steps: (1) Ask what the client has heard and hopes for. (2) Say briefly what is known, attributing it. (3) Say that the decision belongs to the client and the prescriber. (4) Offer to note the question in your letter to the prescriber.
Example language (illustrative): "There are some small studies on Kampo for problems like this, but the evidence isn't settled. Whether it's right for you is a question for your doctor; I'm happy to help you list what to ask."
Watch for: Being drawn into recommending or discouraging a formula; the client hearing "not proven" as "you're foolish". It is working when the client goes to the prescriber with clear questions.

4.11 Keeping Kampo and other treatment from replacing each other

Purpose / when: When a client plans to stop an antidepressant, antipsychotic or other medicine, or psychotherapy, because they now take Kampo; or wants to stop Kampo because therapy is helping. A Japanese physician-educator states that Western drugs should not be reduced quickly when Kampo is started and that Kampo is not a substitute [source: Arai M 2017].
Steps: (1) Ask about intentions to change any medicine. (2) Explain that changes need the prescriber, without giving your own view on the medicine. (3) Help the client plan the conversation with the prescriber. (4) Review risk if a psychiatric medicine is being stopped without advice (relapse, withdrawal, suicide risk) and follow your standard risk assessment.
Example language (illustrative): "It makes sense to want fewer tablets. Changing any of them, including Kampo, is something to plan with your doctor so it's safe. Shall we write down what you want to ask?"
Watch for: Abrupt stopping; relapse signs; family pressure for or against Kampo. It is working when medicine changes happen only through the prescriber.

4.12 Interpreters and cultural brokers

Purpose / when: With clients whose first language is Japanese, or whose Kampo care and records are in Japanese [synthesis].
Steps: (1) Use a professional interpreter, not a family member, for assessment and safety discussions. (2) Brief the interpreter that Kampo terms (証, 気うつ, formula names) should be kept as the client says them, not paraphrased. (3) With consent, a bilingual pharmacist or physician familiar with Kampo can help translate product labels for the prescriber. (4) Check understanding of safety advice by asking the client to explain it back.
Example language (illustrative): "Please keep any Kampo words as Ms. ___ says them, and tell me if a term has no easy English equivalent."
Watch for: Interpreters adding their own views on Kampo; labels mistranslated. It is working when the client's own terms reach your notes and the prescriber.

4.13 Working with families and caregivers

Purpose / when: When a family member manages Kampo for a dependent adult, e.g. a parent with dementia given yokukansan, a formula studied for behavioural and psychological symptoms of dementia [source: Matsuda et al. 2013; Kono et al. 2015].
Steps: (1) Use the CFI caregiver and older-adult modules [source: APA CFI]. (2) Ask about caregiver stress and how decisions about medicines are made. (3) Encourage the caregiver to keep one list of all products and share it with every prescriber. (4) Teach the caregiver the safety signals in 4.9 and to call the prescriber. (5) Offer your usual caregiver support interventions.
Example language (illustrative): "You're managing a lot of medicines for your mother. Who do you call if something changes, and does everyone have the same list?"
Watch for: Caregiver burnout; disagreement in the family about Kampo; the person with dementia unable to report symptoms. It is working when there is one list and one point of contact.

4.14 Products obtained outside regulated prescribing

Purpose / when: When a client buys Kampo or similar products over the counter, online or by import. In Japan, prescription Kampo is made under legally required GMP plus industry standards, and top-selling products are tested for heavy metals, pesticide residues, aflatoxin and microbes [source: Kono et al. 2015]. Quality controls for products sold elsewhere vary and are not described here [uncertain].
Steps: (1) Ask where the product comes from. (2) Without judging, suggest the client show it to a pharmacist or physician. (3) Treat any physical symptom as in 4.9.
Example language (illustrative): "Products from different places are made under different rules. A pharmacist can tell you more about this one; would you be willing to show it to them?"
Watch for: Products sold with claims to treat serious illness; no prescriber involved at all. It is working when a pharmacist or physician knows about the product.

4.15 Safeguarding where care is delayed

Purpose / when: When reliance on any herbal product delays urgent medical care, for the client or a dependent child or adult [synthesis]. Kampo is not presented here as a treatment for cancer or other serious physical disease.
Steps: (1) Assess urgency. (2) Encourage immediate medical review. (3) For a child or dependent adult whose urgent care is being withheld, follow your local safeguarding procedures. (4) Document and consult.
Example language (illustrative): "I respect that Kampo matters to your family. These symptoms still need a doctor today, and Kampo physicians in Japan work alongside other doctors too."
Watch for: Escalating symptoms; isolation from medical care. It is working when medical review happens.

4.16 Writing the cultural formulation and plan

Purpose / when: After assessment, to hold the client's Kampo understanding and your psychological formulation together [synthesis].
Steps: (1) Summarise the client's explanatory model in their words (from 4.3–4.5). (2) Record all care: prescriber, Kampo, other medicines, psychotherapy. (3) State roles and the agreed communication plan. (4) Note safety signals to monitor and who acts on them. (5) Review the formulation at each treatment review.
Example language (illustrative): "So in your words, the stress has 'got stuck' and shows up in your stomach and your temper. Your doctor treats that with Kampo; here we'll work on the stress and the anger directly. Does that fit?"
Watch for: A formulation that silently drops the Kampo view. It is working when the client recognises themselves in it.

5. Handling problems

Kampo sources do not address psychotherapy problems directly; all responses below are [synthesis] unless a source is given.

The client asks you which formula to take, or whether to change one. Decline warmly and redirect: "That's your doctor's call, because Kampo is chosen by your individual pattern." Pattern-based choice is how Kampo describes itself [source: Arai et al. 2020]. Offer to help the client prepare questions.
The client wants to stop psychiatric medication for Kampo. Do not argue for or against. Route to the prescriber promptly, review relapse and suicide risk with standard risk assessment, and, with consent, inform the prescriber. One Japanese physician-educator states that Western drugs should not be reduced quickly when Kampo is started [source: Arai M 2017].
The client feels dismissed ("you think it's just herbs"). Repair the rupture: name it, apologise for any implied judgement, and restate that Kampo is part of mainstream medical care in Japan [source: Kono et al. 2015; Watanabe 2018]. Return to the client's explanatory model (4.5).
The client over-idealises Kampo against "Western" therapy and disengages. Use the CFI's help-seeking domains to explore what has and has not helped [source: APA CFI]; frame psychotherapy as compatible with Kampo's mind–body unity view [source: Arai M 2017]; agree a time-limited trial with review points.
Stuck: only bodily complaints, no access to emotion. Stay with the body (4.6), check medical review is done, and introduce emotion through the client's own idiom (e.g. stagnant ki, anger "rising") before psychological terms.
Overwhelm during assessment. Shorten the CFI to the core domains over two sessions; postpone modules. The CFI is a guide, not a required sequence of all supplementary modules [source: APA CFI on purpose; synthesis on pacing].
Non-adherence to therapy tasks attributed to Kampo ("the medicine will fix it"). Explore hopes and timeframes; agree that both can work together; reduce task size.
Physical symptoms during treatment. Follow 4.9: same-day prescriber contact for cough, breathlessness, fever, swelling, jaundice or muscle symptoms [source: PMDA label; Arai et al. 2020]; emergency care for marked breathlessness. Never interpret the symptom as anxiety without medical review.
The prescriber does not respond or refuses contact. Respect it, document it, ask the client's pharmacist or GP to coordinate instead, and keep encouraging the client to tell every clinician about every product.
Disagreement in the family about Kampo. Use the CFI informant version and social-network module [source: APA CFI]; keep your role neutral on the medicine; focus on communication and on one shared medicines list.
The client cannot access their Japanese Kampo physician after migrating. Treat as a loss; help the client find a physician or pharmacist locally and tell them about the previous treatment. Who may prescribe Kampo formulas outside Japan depends on local licensing [uncertain].
Products of unknown origin or with disease-cure claims. Raise concern gently, suggest pharmacist review (4.14), and apply safeguarding procedures if a dependent's urgent care is being delayed (4.15).
Your own scepticism or enthusiasm leaking into sessions. Take it to supervision; return to 4.1.
Touch. Kampo diagnosis uses abdominal and tongue examination [source: Arai et al. 2020]. These are for the prescriber only. Do not perform or imitate them, and if a client asks you to, explain that it is outside your role.

Sources

Web sources:

Books cited: none. The DSM-5-TR cultural concepts of distress (Section III) are referred to in 4.6 [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]; taijin kyofusho's place in the DSM-5-TR list rests on secondary sources [uncertain: secondary, unverified].

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