When the Therapist’s Thoughts Change, the Patient Changes: An Intervention for Adolescent Patients Who Discontinue Psychotherapy Based on a Buddhist Concept

Adolescent patients with psychiatric problems often refuse psychotherapy. Therapists can have difficulty contacting such patients and feel perplexed. We cannot diagnose the patient unless they are present, and it is difficult to continue treatment in such cases. I previously reported a case study of family therapy based on a Buddhist concept.¹ Buddhism highlights the importance of cause- and-effect relationships and promotes the idea that direct causes (hetu in Sanskrit) and conditions (pratyaya) work together to produce effects (vipāka). We can use these concepts to solve impasses in such complicated cases.

Case Report

The patient was a 14-year-old girl with autism spectrum disorder (ASD) (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision criteria)² who refused personal psychotherapy. In the initial stages of this case, the patient’s state of withdrawal persisted, and she had low self-esteem. I thought she had social anxiety disorder due to tension and anxiety in social situations and ASD due to communication difficulties, inflexibility, and hypersensitivity to sound. Schizophrenia was also considered due to the rigidity of interpersonal relationships, but it was ruled out because there were no pathological experiences of hallucinations or delusions. I could not fully understand the patient’s confused thoughts and gradually became pessimistic and perplexed. Therefore, I changed the treatment plan and treated the patient based on a Buddhist concept.

In Japan, these concepts are often expressed using the Buddhist terms In-Ga (in Japanese, the relationship between cause and effect) and In-En-Kahoh (in Japanese, the relationship among direct causes, conditions, and results), respectively.^3,4 Takahashi⁴ advocated the Buddhist concept of In-En-Kahoh, which indicates that good results come not from linear cause- and-effect relationships but from multifactorial cause- and-effect relationships, in which the direct cause and conditions interact to produce a result. When facing a therapeutic impasse like that described in this case, the most important thing is for the therapist to change their way of thinking. Positive results can be achieved by reexamining and changing the causes of the problem (the therapist’s thoughts) and influencing the patient’s environment. Despite increasing evidence suggesting that patients’ internalized models can affect therapeutic relationships, few previous studies have discussed therapists’ attitudes, interpersonal skills, thoughts, and characteristics.^5,6

First, we should reflect on the cause of the problem (the therapist’s thoughts) and transform it. I checked my initial ideas about the patient and continued to challenge myself to believe that she wished to improve her situation. Next, we can influence and support the family and their circumstances (conditions). If done effectively, this process may ultimately lead to a positive outcome (good effects/results). I continued to support her family (mother) to form a family-therapist alliance. The patient’s family was suffering and faced conflict and frustrated situations.⁷ Ensuring that parents internalize psychotherapy may also be important for improving treatment outcomes.

One of the basic tenets of Buddhism is the concept of interdependence, which says that all things exist only in relation to others and that nothing can have an independent and autonomous existence.⁸ According to the In-En-Kahoh principle, all phenomena are seen as results (Kahoh) produced by a combination of causes (In) and conditions (En).⁴ From the perspective of In-En-Kahoh, the notion of “In” within this system refers to the direct cause of something, while “En” refers to the indirect causes of something (the environmental conditions that give rise to it). Finally, “Kahoh” is the resultant reality (the result).³ In the present case, the patient started to participate in activities step by step over about 5 years.

To summarize the 5-year timeline of treatment, the first third was a period of unclear diagnosis and fluctuating treatment plans. The middle third was a period of engagement based on the Buddhist concept. After shifting my own perspective and continuing family therapy focused on supporting the mother, the patient began attending the outpatient clinic. The latter third was a period when the patient began trial and error in aiming for social reintegration.

Conclusion

There are no reports, to my knowledge, about psychotherapeutic treatment based on this Buddhist concept. These interactions may help to solve patients’ difficulties and therapists’ confusion in such cases and may be applicable to systemic family therapy.

Article Information

Published Online: October 1, 2026. https://doi.org/10.4088/PCC.26cr04227
© 2026 Physicians Postgraduate Press, Inc. Prim Care Companion CNS Disord 2026;28(5):26cr04227
Submitted: March 12, 2026; accepted May 27, 2026.
To Cite: Inagaki T. When the therapist’s thoughts change, the patient changes: an intervention for adolescent patients who discontinue psychotherapy based on a Buddhist concept. Prim Care Companion CNS Disord 2026;28(5):26cr04227.
Author Affiliation: Department of Nursing, Faculty of Medicine, Shimane University, Izumo, Shimane, Japan.
Corresponding Author: Takuji Inagaki, MD, PhD, Department of Nursing, Faculty of Medicine, Shimane University, Izumo, Shimane 693-8501, Japan ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Patient Consent: The patient and guardian provided consent to publish the case report, and information has been de-identified to protect patient anonymity.