Conservative Psychotherapy: A Detailed Exposition — 2026-3-8

Conservative Psychotherapy: A Detailed Exposition — 2026-3-8

Conservative Psychotherapy — Biological and Ethical Justification Through the Integrated MAD·SB Theory —
DATE 2026-03-08
Author :Kon Tadashi :Shinagawa Psychosomatic Clinic

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Abstract

This paper connects the “Conservative Psychotherapy” proposed by the author to the integrated framework of MAD Theory (M·A·D Unit Model) and Sickness Behavior (SB) Theory, and argues for its biological grounding and ethical justification. Conservative Psychotherapy is named by analogy with “organ-conserving surgery” in the surgical field, and aims to systematize a non-invasive, expectant, and accompanying psychiatric practice. As the integrated MAD+SB theory has clarified, depression is a “state of awaiting biological regeneration” following injury to the M-Unit (the source of activity, optimism, and the sleep-inducing component), and the SB of D-Unit dominance functions as a “scab” protecting that regeneration. From this understanding, the conservative attitude — prioritizing “not violating the regenerative process” over “doing something” — becomes not an emotionally motivated gentleness but an actively chosen medical intervention grounded in neurobiology. This paper presents four ethical axes — the principle of non-maleficence, respect for autonomy, the principle of proportionality, and temporal justice — and argues that Conservative Psychotherapy constitutes a practical framework integrating all four.

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Introduction: The Question of “Not Trying Too Hard to Cure”

In psychiatric practice, the attitude of “not trying too hard to cure,” “not rushing the patient,” and “not disrupting the patient’s life” has long existed. Yet this attitude was never systematized as a formal “technique,” never appeared in treatment manuals, and was rarely transmitted in educational settings. On the contrary, with the rise of evidence-based medicine (EBM), this attitude has frequently been subjected to criticism as “unprofessional,” “unscientific,” and “merely waiting.”

The question this paper poses is: is this criticism justified?

To state the conclusion in advance: it is not. The attitude of “not trying too hard to cure” is neither an emotionally motivated consolation nor a passive resignation; it is an actively chosen medical intervention grounded in neurobiology, and the product of a high-order ethical judgment. In order to make this clear, this paper constructs the theoretical and ethical foundation of “Conservative Psychotherapy” while drawing on the integrated framework of MAD Theory and SB Theory.

The word “Conservative” derives from “breast-conserving surgery” and “organ-conserving therapy” in the surgical field. It is an attempt to transplant into the context of psychotherapy the surgical philosophy in which radical resection (Radical) is not the only correct answer, and in which preserving the patient’s bodily function and quality of life is respected as a more sophisticated medical judgment. Just as surgery conserves the function of organs, the psychiatrist conserves the continuity of the patient’s life, their defensive structure, and the form in which they have lived. This stance is called “Conservative Psychotherapy.”

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Chapter One: The Background of the Question — Why Articulate This Now?

1-1 The Pressure That Performativity Exerts on Psychiatric Medicine

The wave of “performativity” that pervades contemporary society exerts a tacit pressure on psychiatric medicine as well — the pressure for “recovery as quickly as possible.” Evidence-based short-term intervention models, the introduction of the “Recovery Model,” the demand for quantified outcomes such as number of outpatient visits, rates of improvement, and rates of return to employment — while these have brought many benefits, they have simultaneously driven those patients who “do not change” into the categories of “treatment resistance” and “lack of motivation.”

The same internalization occurs on the side of clinicians. The compulsive drive to cure — “I must make them better,” “Why aren’t they improving?”, “Is there not some other intervention needed?” — exhausts the clinician and introduces unnecessary tension into the relationship with the patient. A culture that cannot tolerate “waiting” injures those patients who need to wait.

1-2 The “Quiet Practice” Sedimented in Japanese Psychiatric Clinics

However, at the deep stratum of Japanese psychiatric practice, a serene and resilient attitude, entirely different from the above, has long been shared. The attitude expressed in such words as “Well, let’s take it slowly,” “There’s no need to hurry,” and “You don’t have to do anything right now” is a clinical culture that has been transmitted implicitly from senior to junior clinicians, without ever being organized as a methodology.

Morita Therapy’s “arugamama” (accepting things as they are), the practice of long-term supportive psychotherapy, the withholding of interpretation as “not unnecessarily touching,” the respect for silence that refuses to “allow recovery to be narrativized” — these all share a single root. It is “skepticism toward controllability” and “trust in the regenerative process.” This paper aims to integrate these under the name “Conservative Psychotherapy” and to render their logical, neurobiological, and ethical foundations visible.

1-3 The Task of Connecting These to the MAD+SB Integrated Theory

Conservative Psychotherapy has until now been discussed primarily in the context of clinical philosophy and psychotherapy theory. The novel undertaking of this paper is to connect it to the integrated framework of MAD Theory (the M·A·D Unit Model) and SB (Sickness Behavior) Theory.

What is gained by this connection? First, a neurobiological explanatory basis — transcending emotionalism and philosophical argument — is obtained for the question “why is the conservative attitude therapeutic?” Second, the precision of clinical judgment is heightened by mapping the boundary between “what to do and what not to do” in Conservative Psychotherapy onto the concrete biological event of the M-Unit regeneration process. Third, it becomes possible not only to demonstrate that the attitude of “not trying too hard to cure” is ethically justified, but also to show that “trying too hard to cure” may be neurobiologically harmful.

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Chapter Two: The Key Points of the MAD+SB Integrated Theory — The Biological Basis of Conservative Therapy

2-1 What Is Depression? — “A State of Awaiting Regeneration After M-Unit Injury”

The core proposition of the MAD+SB integrated theory, which constitutes the biological basis of this paper, is re-presented below (detailed argument is deferred to the previously published paper).

Depression is “a state in which the M-Unit — the functional unit that integrally supplies the drive of optimism and activity along with the sleep-inducing component — has sustained injury and is awaiting its physical regeneration.” When the M-Unit ceases function (freezes) due to crisis response (infection, overload, chronic stress), the D-Unit (responsible for pessimism, social withdrawal, self-reproach, and the implementation of SB), which had previously been in a counterbalancing relationship, becomes exposed. This is the clinical state of depression.

There are three most important points in this model.

First, the regeneration of the M-Unit requires a biological period of time (two to four months), and this time cannot be shortened — not by improvements in the environment, not by force of will. Second, the SB brought about by the D-Unit (withdrawal, rest, social retreat) is an adaptive program that functions as a “protective scab” for the M-Unit during this regeneration period. Third, there exists a diurnal cycle in which “the M-Unit is whittled down by the disposal program during the night and gradually recovers through external stimulation during the day,” which constitutes the mechanism of diurnal variation: the worst feeling in the morning and relative recovery in the evening.

2-2 The D-Unit as “Scab” — The Paradox of Protection

The most clinically important proposition in this understanding is the paradoxical recognition that “SB by the D-Unit is a scab protecting the regeneration of the M-Unit.”

The scab is a source of suffering for the patient. The desire to withdraw, the inability to move, the absence of pleasure in anything, the sense of guilt — these sufferings are products of the D-Unit, and the patient experiences them as “symptoms to be cured.” Clinicians too tend to treat them as “pathological states to be eliminated.”

However, applying the surgical metaphor: a scab is not “something to be removed” but “something to be protected.” When a scab is forcibly peeled away, the regenerating tissue is exposed and the damage spreads. Interventions that forcibly strip away the D-Unit scab in depression — compelled rapid return to social functioning, forced activation, the pressure of “you should be able to try harder” — may function as direct impediments to the regenerating M-Unit.

Here lies the first biological basis of Conservative Psychotherapy. “Protecting the scab” is protecting the regenerative environment of the M-Unit, and this is a medically rational choice.

2-3 The Risk of Invasive Intervention — Interaction with the M-Unit Disposal Program

A further important point that must be considered is the risk that excessive psychological intervention may enhance the “nocturnal M-Unit disposal program.” The brain disposes of excessive and unnecessary M-cells during sleep. In the process of recovery under MAD Theory, it is possible for M-cells to be disposed of in excess. In such cases, the sleep-promoting component held by the M-Unit is lost, and nocturnal insomnia results.

In healthy individuals, this program — by which “excess M-Unit is disposed of during sleep” — functions in depressive patients not as “repair” but as “the continuation of destruction.” The activation of this disposal program is closely linked to the quality of sleep (particularly the excess of REM sleep).

Active interventions such as depth-psychological excavation, interpretations that evoke strong negative emotion, confrontation with past trauma, and emphasis on “reasons to recover” may, through the patient’s increased level of arousal, emotional activation, and increased REM sleep, actually enhance the nocturnal M-Unit disposal program.

To put it simply: the hypothetical risk that “excessive intervention makes the patient’s nights more agonizing” is derived from this model. The non-invasiveness of Conservative Psychotherapy — “not rushing toward meaning-making,” “not compelling insight” — can be understood as a rational choice that avoids this potential harmfulness.

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Table: Types of Intervention — Conservative Psychotherapy’s Evaluation and Interpretation from MAD Theory

Type of Intervention	Evaluation by Conservative Psychotherapy and Interpretation from MAD Theory
Depth interpretation · Confrontation with trauma	As a general rule, withheld during the acute and intermediate phases of depression. Risk of enhancing the “M-Unit disposal program.” Selective use in the stable recovery phase is possible.
Active cognitive restructuring (CBT)	The framework of “correcting distorted thinking” itself carries the risk of treating the D-Unit’s protective function as an enemy called “symptom.” Not pressing too hard on the “meaning” of symptoms is the conservative attitude. Preventive use after recovery is effective.
Behavioral activation · Early return to social functioning	Risk equivalent to forcibly peeling off the scab. Moderate daytime external stimulation (light, meals, brief conversation) is recommended, but the quantitative demand for activation — “move more” — is dangerous. Gradual, patient-led return is the principle. Danger of manic-depressive mixed state.
Narrativizing recovery · Goal-setting	Questions such as “why do you want to recover?” and “what do you want to do after recovery?” — in the absence of the M-Unit — become the task of “compelling the patient to perform optimism in place of the M-Unit.” This increases exhaustion.
Maintaining “being together”	The most reliable conservative intervention. The clinician’s continuous presence supplies the suicide-stop signal as a substitute for the M-Unit, and suppresses the activation of the D-Unit’s self-elimination program (suicidal ideation).
Prescribing daytime external stimulation	An active, low-invasiveness intervention that promotes daytime recovery of the M-Unit. Light, meals, brief conversation, a short walk. Provided not as “activity that must be done” but as “stimulation that can be passively received.”

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Chapter Three: The Ethical Structure of Conservative Psychotherapy

3-1 Four Ethical Principles and Their Integration

The four principles (respect for autonomy, beneficence, non-maleficence, justice) presented by Beauchamp & Childress (1979) as the basic framework of medical ethics have been widely referenced. In constructing the ethical foundation of Conservative Psychotherapy, this paper re-interprets these four principles in the context of psychotherapy, and then adds a unique fifth axis — “Temporal Justice” — for discussion.

Ethical Principle	Concrete Meaning in Conservative Psychotherapy
① Non-maleficence	“Not causing secondary damage through excessive intervention.” Not forcibly stripping away the scab. Not enhancing the “M-Unit disposal program.” Protecting the patient from the runaway of the drive to cure.
② Respect for Autonomy	“Respecting the fact that the patient has their own pace of regeneration.” Not prescribing the speed, direction, or form of recovery from outside. Conserving the patient’s own defensive structure — “how they have survived until now.”
③ Beneficence	“Preparing the regenerative environment and assisting the cultivation of the M-Unit through external stimulation.” The clinician actively does what can be done (promotion of daytime stimulation, preparation of the sleep environment, external protection against suicidal ideation) — but non-invasively. Not “doing nothing,” but “actively choosing not to violate.”
④ Justice	“Not biasing treatment resources and time toward those patients who recover quickly.” Maintaining a structure in which patients with chronic conditions and long-term outpatient treatment are not excluded from the system. Maintaining a fair relationship in which patients are not evaluated by their speed of recovery.
⑤ Temporal Justice	“All patients should be socially and institutionally guaranteed the time biologically necessary for recovery from their illness” — this is the unique ethical axis of this paper. The two-to-four month regeneration time of depression is a biological constraint that cannot be shortened, and medical institutions and social environments that do not respect it are ethically problematic.

3-2 The Deepening of the Principle of Non-Maleficence — The Concept of “Professional Non-Action”

The ethical core of Conservative Psychotherapy lies in the thorough internalization of the principle of non-maleficence. And its practical expression is the concept of “Professional Non-Action.”

The word “non-action” is frequently misunderstood as “doing nothing,” “laziness,” or “avoidance of responsibility.” However, non-action in Conservative Psychotherapy is entirely different.

“Professional Non-Action” in its true sense is the choice to “deliberately not intervene precisely because one knows the power of intervention,” and this choice is the integration of judgments at the following three levels.

Level 1: The Neurobiological Level

The judgment not to obstruct the regenerative process of the M-Unit. A consideration for the possibility that excessive emotional activation, depth interpretation, and forced cognitive restructuring may enhance the “nocturnal M-Unit disposal program” and delay regeneration. This is based on a neurobiological recognition that there are situations in which “not intervening” is equivalent to “not causing harm.”

Level 2: The Psychological and Relational Level

The judgment to respect the defensive structure, lifestyle, and interpersonal patterns that the patient has built over many years. In the psychoanalytic context, a defense is, before it is a “symptom,” evidence of having survived. Hastily removing a defense adopted for the sake of survival carries the danger of exposing the patient, defenselessly, to the unprocessed material behind it. The question “is it truly beneficial to strip away this patient’s defenses now?” must be continuously asked.

Level 3: The Social and Cultural Level

The judgment to temporarily release the patient from the social demands of “recovering,” “working,” and “narrativizing.” The framework presupposed by the Western Recovery Model — “the autonomous subject reconstructs their own life” — is not applicable to all patients. For those patients who are injured by speaking, who are overwhelmed by being asked about goals, who do not currently have the capacity to construct a narrative of recovery, the attitude of “you don’t need to speak now,” “goals can come later,” “it is enough just to be here” is the product of a high degree of cultural sensitivity and clinical judgment.

3-3 The Psychotherapeutic Redefinition of Respect for Autonomy

“Respect for Autonomy” in medical ethics is usually understood as “respecting the patient’s right to consent to or refuse treatment on the basis of sufficient information (informed consent).” In Conservative Psychotherapy, however, respect for autonomy carries a deeper meaning.

When the M-Unit of a depressive patient has ceased to function, the patient’s capacity for judgment and decision-making is temporarily impaired. In a state in which the optimism, future prospects, and self-affirmation supplied by the M-Unit have been lost, it is impossible to accurately judge “what will have value for oneself after recovery.” “Consent” in this state may not express the patient’s authentic autonomy.

True respect for autonomy involves not following “the judgment in the current D-Unit-dominant state,” but rather caring for a judgment that has a temporal horizon: “how will the patient, after the M-Unit has regenerated, evaluate this treatment choice?”

In this sense, Conservative Psychotherapy is one that attends not only to “the expressed will of the patient in the present” but also to “the presumed will of the patient after regeneration.” For example, the statement “I don’t want to receive treatment anymore” from a patient in acute depression may be related to the D-Unit’s self-elimination program, and treating this directly as “autonomous will” may instead undermine the patient’s long-term autonomy.

However, here lies the greatest point of tension in Conservative Psychotherapy. The question of where to stand between “the patient’s present will” and “their presumed future will” is by no means self-evident. The boundary between overprotective paternalism and respect for the patient must be continuously re-examined.

3-4 The Ethics of “Permitting Chronicity” — Connecting Non-Maleficence and Harm Reduction

In Conservative Psychotherapy, the choice to “permit chronicity” is not laziness or resignation, but an active ethical judgment. This judgment connects to the logic of “harm reduction.”

The philosophy of harm reduction, established in the field of substance dependence, is the ethical stance of “prioritizing the minimization of realistic harm over compelling an idealized state (complete abstinence, complete recovery).” The application of this philosophy in psychotherapy is also meaningful.

The list of secondary damage that can be caused by active interventions based on the supremacy of cure — “you should be getting better” — is long. Collapse of self-esteem (“it’s my own fault I’m not getting better”), loss of trust in treatment (“this doctor doesn’t understand me”), rupture of the therapeutic relationship (“I’m going to stop coming”), relapse through overactivity (“being told to try harder made me worse”), enhancement of suicidal ideation (“I’m never going to get better, it would be better if I were gone”) — all of these can be understood as “side effects of excessive intervention.”

Avoiding these secondary injuries can, in some cases, improve long-term prognosis more effectively than the primary “promotion of recovery.” “Actively permitting” chronicity can in certain cases become a “protective treatment choice” that avoids the worst outcomes (suicide, rupture of relationships, irreversible social collapse).

In this sense, “permitting chronicity” is not “giving up on recovery,” but “preventing the catastrophic outcome that comes from rushing toward recovery.” Holding this distinction clearly is a demonstration of the ethical maturity of Conservative Psychotherapy.

3-5 Temporal Justice — The Unique Ethical Axis of This Therapy

The fifth ethical axis proposed in this paper, “Temporal Justice,” is a concept that has no equivalent in the existing framework of medical ethics, and represents a contribution unique to Conservative Psychotherapy.

“Temporal Justice” means: the ethical proposition that all patients should be socially and institutionally guaranteed the time biologically necessary for recovery from their illness.

The MAD+SB integrated theory has shown that recovery from depression involves a “biological time required for the physical regeneration of the M-Unit” of two to four months. This time cannot be shortened. It cannot be exceeded through willpower, the addition of antidepressants, or the intensive administration of psychotherapy (ECT and ketamine partially challenge this limit, but are not omnipotent).

However, many contexts in contemporary society (the workplace, the family, the insurance system, medical evaluation) treat this biological time as “an unreasonably long period.” “You’ve been resting for three months,” “why aren’t you better yet?”, “when will you be able to return?” — these questions are expressions of temporal injustice that ignores biological constraints.

One important role that the clinician bears in Conservative Psychotherapy is to resist this “temporal injustice” as the patient’s representative. To speak on behalf of the fact that “this illness has a biologically necessary period of time” to the workplace, the family, and society — to function as a buffer that protects the patient from unjust temporal pressure — is part of the ethical mission of medicine.

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Chapter Four: The Practical Structure of Conservative Psychotherapy

4-1 The Boundary Between “What to Do” and “What Not to Do”

Conservative Psychotherapy is not a “therapy that does nothing.” This is an important correction of a misunderstanding. Conservative Psychotherapy is an active therapeutic stance with clear principles regarding both “what not to do” and “what to do.”

Domain	“What to Do” (Active Conservative Action)	“What Not to Do” (Protective Non-Action)
Cognition and Interpretation	Provide a structural explanation of the pathological state (MAD theory-based psychoeducation) to help the patient understand that “their suffering has a structure.”	Do not perform hasty meaning-making or interpretation of symptoms. Do not engage in inductions such as “might this symptom have its origin in childhood trauma?”
Emotional Processing	Receive what the patient voluntarily expresses — without denial, without rushing, without excessive reaction.	Do not force the patient to speak. Do not encourage “delving deeper” into emotions. Refrain from prompting such as “please tell me more.”
Behavior and Activity	Prescribe passive daytime external stimulation (light, meals, brief conversation, walks) without pressure.	Do not compel the quantitative activation of “you should be more active.” Do not rush early return to employment or social functioning.
Goal-Setting	Share the minimal goal of “not destroying today.”	Do not have the patient speak at this stage about medium- to long-term recovery goals or the “design of a life after recovery.”
Maintenance of the Relationship	Maintain the therapeutic relationship over the long term through the continuation of regular consultations and outpatient visits. The presence of the clinician at a fixed place in a fixed rhythm functions as a secure base.	Do not bring the pressure of measuring and evaluating the “outcomes” of treatment into the relationship. Do not excessively ask “have you been doing better than last time?”
Suicide Risk Management	Supply the suicide-stop signal in substitution for the M-Unit. Repeatedly provide the recognition that “the assessment that you are a cost to the group is a judgment made in the absence of the M-Unit, and is not your true evaluation in your present state.” Hospitalization and the involvement of the family as necessary.	Do not treat the activation of the D-Unit’s self-elimination program as “a matter of will.” Do not offer the ineffective encouragement: “let’s try not to feel like dying.”
Integration with Pharmacotherapy	Position antidepressants as the preparation of the regenerative environment for the M-Unit (increase in BDNF, normalization of the HPA axis, improvement of sleep), and explain their biological role to the patient.	Before rapid drug escalation or polypharmacy, secure space to evaluate “whether the current administration is functioning adequately.” Consider the effect on the M-Unit disposal program of excessive medication.

4-2 The Conservative Design of Psychoeducation — How to Convey MAD Theory

Psychoeducation in Conservative Psychotherapy aims not at “motivation to hasten recovery” but at “existential stabilization through giving structure to suffering.”

This distinction is important. Ordinary psychoeducation has the purpose of “understanding the illness in order to recover quickly.” Conservative psychoeducation has the purpose of “knowing that one’s present suffering is not meaningless hell but has a structure that can be explained.” The purpose is not “acceleration of recovery” but “acquisition of a way of enduring suffering.”

When conveying MAD Theory to the patient, the following framework is useful:

“In your brain there is an engine (M-Unit) that generates optimism, activity, and sleep. That engine has been injured by the overloads you have borne until now. An injured engine takes time to repair — just as it takes time for skin that has been injured to form a scab and for new skin to grow. That repair period is two to four months.”

“The fact that mornings are the worst is not because your will is weak. Because the engine is gradually whittled down during the night, the morning is the time when the engine is at its most depleted.”

“The feeling of wanting to die that arises is not because you genuinely want to die — it is an old program that starts running when the engine is gone. When the engine is repaired, that program will stop.”

“What I (the physician) am bearing now is this: while the engine is being repaired, to keep pressing the stop button of that program on your behalf.”

This explanation — without “unnecessarily frightening the patient” — answers the three most urgent questions: “why am I suffering now?”, “why don’t I get better immediately?”, and “why do suicidal thoughts arise?” — while at the same time conveying “the meaning of the clinician’s continued presence here.” This is the core of conservative psychoeducation.

4-3 The Technique of the Clinician’s “Co-Presence” — Bearing Time Together

In Conservative Psychotherapy, the most important function of the clinician is “continuing to be there (co-presence).” This is not a passive “looking on from the sidelines,” but a highly active technical act.

The reason “co-presence” is a technique is that it is a sustained, active choice in which the clinician continues to resist, within themselves, the very impulse to “want to do something.” In the time during which the patient does not improve, the clinician is constantly subjected to the internal pressure: “shouldn’t I be doing more?” To continue to maintain the position of “enduring the present state together with the patient” — without surrendering to this pressure and rushing toward excessive intervention — is a highly specialized professional act requiring training and determination.

In a psychoanalytic context, Winnicott’s (1960) “holding environment” is the concept closest to this function. The clinician does not “do something,” but functions as a “background that does not collapse” in the moments when the patient is about to fall apart. In the framework of MAD Theory, this function can be understood as the “substitute stabilizing device for the M-Unit.” While the M-Unit is absent, the external structure of the therapeutic relationship functions as “the minimum substitute for optimism” and “the minimum source of the sense of safety.”

The clinician’s attitude of “enduring time without change” continuously sends the patient the message: “even if you do not change, I am here.” This message is the most effective counterargument to the D-Unit’s assessment that “I am an excessive cost to the group.” The continuous presentation of the fact “you are not a cost, because I am not treating you as a cost” becomes the most important deterrent to suicidal ideation.

4-4 The Technique of Silence — Not Making the Patient Speak Is Protecting Them

In Conservative Psychotherapy, “silence” is not an absence but a technique. Not making the patient speak, withholding meaning-making, not pressing questions too deep — these create a unique therapeutic space called “shared silence.”

In Western psychotherapy, particularly in the contexts of Narrative Therapy and CBT, “speaking, meaning-making, and narrativizing” are placed at the center of recovery. However, as Japanese clinical experience demonstrates, no small number of patients are injured by speaking.

“Speaking” in a state in which the M-Unit is absent is reprocessed through the pessimistic filter of the D-Unit. When past events are spoken of, there is the danger that they will be reinterpreted by the D-Unit as evidence that “I was defective” and “nothing is ever going to change.” Speaking may leave the patient in a worse state than before.

The attitude of “you don’t need to speak now” and “meaning can come later” is a protection against this danger. At the same time, the fact that “even without speaking, the clinician is here” communicates to the patient the message that “having words that can be articulated is not the condition for existence.” This is also an important condition for patients who “carry suffering they cannot adequately put into words” to remain within the therapeutic relationship over the long term.

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Chapter Five: Conservative Practice by Pathological Type — For Whom, What, and How

5-1 Melancholic Depression — The Best Indication for Conservative Therapy

The best indication for Conservative Psychotherapy is melancholic depression (endogenous depression). There are three reasons.

First, melancholic type represents “the most deeply frozen state of the M-Unit,” with the scab (SB from the D-Unit) most thickly formed. Active intervention in this state carries the greatest risk of secondary damage. Second, cortisol toxicity from HPA axis overactivation obstructs the regeneration of the M-Unit, and this time axis cannot be shortened from outside. Third, diurnal variation (worsening in the morning, recovery in the evening) is clear, and the temporally conservative strategy of “not performing depth intervention in the morning” can be clearly applied.

The concrete framework of conservative practice for melancholic type is: maintaining regular short consultations, appropriate use of antidepressants (SNRI, tricyclics, etc. for their effects on the HPA axis and NE system), preparation of the sleep environment, prescribing passive daytime external stimulation, explanation of “not seeking meaning in the worst feeling in the morning,” continuous supply of stop signals against suicidal ideation, and sharing of the time axis of “two-to-four months of regeneration time.”

In conservative practice for melancholic type, the avoidance of “psychotherapeutic deep excavation” is especially important. In this condition, questioning “insight” and asking “why did you become depressed?” are both, as a general rule, withheld during the acute and intermediate phases. The answers to these questions carry meaning for the first time in the stable phase following regeneration of the M-Unit.

5-2 Atypical and Inflammatory Depression — Direct Application of the SB Model

Atypical depression (hypersomnia, hyperphagia, mood reactivity, sickness behavior type) is the condition to which SB Theory can be most directly applied. In this condition, the primary mechanism is the activation of the D-Unit by inflammatory cytokines, and the first priority of treatment is the reduction of the inflammatory burden.

In the context of Conservative Psychotherapy, “non-invasive anti-inflammatory interventions” for this condition — anti-inflammatory diet (Mediterranean diet), moderate aerobic exercise (mitochondrial function improvement), improvement of sleep, care for the gut microbiome — are positioned as “conservative modification of lifestyle.”

Especially important in atypical depression is the understanding of such symptoms as “why is the body so heavy?” and “why do I keep wanting to sleep?” Explaining these on the basis of SB Theory as “an adaptive rest program when the immune system is fighting” allows the patient to gain the recognition “I am not being lazy.” This shift in recognition itself reduces a part of the D-Unit’s “sense of worthlessness and self-reproach.”

5-3 Bipolar Disorder — The Special Logic of Manic Switch Risk and Conservation

The application of Conservative Psychotherapy to bipolar disorder (BD) partially overlaps with its application to depression, while also requiring its own logic.

In the depressive phase of BD, basically the same conservative practice as for melancholic type can be applied. However, what is particularly important in BD is “consideration for the manic switch.” In the framework of MAD Theory, manic switch is “the phenomenon in which the M-Unit in the midst of regeneration ignites in a runaway fashion,” with external stimulation (strong light, sleep deprivation, overactivity, strong emotional experiences) serving as triggers.

Conservative Psychotherapy for BD patients necessarily has the aspect of “stimulation management for the prevention of manic switch.” The conservative principle for BD is: “precisely when recovery seems to be coming into sight (when the M-Unit is beginning to regenerate) is when one must be most cautious.” During periods of high manic switch risk (spring, periods of rapidly increasing activity, periods when sleep is beginning to shorten), the conservative strategy of “deliberately limiting external stimulation” and “reliably continuing mood stabilizers” — a “re-ignition prevention” approach — becomes necessary.

Careful attention to mixed manic-depressive states is helpful for suicide prevention and is therapeutically valuable.

5-4 Long-Term Outpatient and Chronic Cases — The True Value of Conservative Therapy

It is in long-term outpatient and chronic cases that Conservative Psychotherapy most distinctively demonstrates its value. Cases that in conventional psychotherapy models tend to be treated as “chronicity = treatment failure” are positively redefined in Conservative Psychotherapy as “cases requiring continuous protection.”

Many chronic cases possess the following characteristics. Environmental triggers continue (structural problems in the workplace and family relationships have not been resolved). Re-injury is repeatedly incurred before complete M-Unit regeneration has been achieved. The pressure to “have to recover” itself becomes a factor in re-injury to the M-Unit. The treatment distrust and self-reproach generated by conventional treatment models become an additional burden.

What Conservative Psychotherapy provides to such cases is: a shift in recognition — “your chronicity is the inevitable consequence of the structural problems in your environment and the repeated injury to your M-Unit, and is not a problem of your will”; a resetting to the minimal goal of “accumulating small stabilities”; a redefinition of the therapeutic relationship as “continuing to come here without getting better itself has meaning”; and a shift in evaluative criteria — “continuing to avoid the worst outcome is itself therapeutic success.”

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Chapter Six: The Limits of Conservative Psychotherapy and Response to Criticism

6-1 Response to the Misunderstanding of “Doing Nothing”

The most common criticism of Conservative Psychotherapy is: “isn’t this simply justifying doing nothing?” This criticism must be taken seriously.

The response is as follows. Conservative Psychotherapy does not “do nothing”; it “actively chooses what not to do.” This distinction is decisively important. Just as “organ-conserving surgery” in the surgical field is not “not performing surgery” but “a highly sophisticated technical choice that conserves organ function,” Conservative Psychotherapy is not “lazy inactivity” but “an accumulation of non-invasive choices made after precisely evaluating the harmfulness of intervention.”

There are things that Conservative Psychotherapy “does.” It provides psychoeducation. It continues to meet regularly. It prescribes daytime stimulation. It prepares the sleep environment. It continues to supply stop signals against suicidal ideation. It functions as a stabilizing device serving as a substitute for the M-Unit. It advocates on behalf of the patient to the family and workplace. It appropriately manages pharmacotherapy. All of these are “things to do.” “What not to do” is the invasive intervention that obstructs the regeneration of the M-Unit.

6-2 Relationship with EBM — Is There No Evidence?

The criticism that “Conservative Psychotherapy has no evidence from RCTs” is also to be anticipated. This is true, and must be honestly acknowledged. Conservative Psychotherapy is, by its nature (its non-invasiveness, individualization, and long-term character — “choosing what not to do”), structurally difficult to verify through RCTs.

However, this difficulty does not mean that Conservative Psychotherapy is not evidence-based. As shown in this paper, each component of Conservative Psychotherapy has a neurobiological basis. The hypothesis that “invasive intervention enhances the M-Unit disposal program” is verifiable. The proposition that “daytime external stimulation promotes M-Unit recovery” is consistent with existing research (evidence from light therapy and exercise therapy). Multiple evidence bases exist for the proposition that “long-term maintenance of the therapeutic relationship contributes to improved prognosis” (Firth et al., 2017; Norcross & Lambert, 2019).

Conservative Psychotherapy is not “without evidence”; it is “difficult to verify through conventional evidence-generation models.” For verification of this therapy, not RCTs but long-term cohort studies, therapeutic relationship research, patient-reported outcome research (PROM), and qualitative research methods are appropriate.

6-3 The Ethical Limits of “Permitting” Chronicity

The position of “permitting chronicity” has ethical limits. It is necessary to discuss these honestly.

“Permitting chronicity” minimizes harm only when a therapeutic relationship is maintained and the worst outcomes (suicide, social collapse) are being prevented. Chronicity in which the relationship is not maintained (abandonment of outpatient treatment, dropout from support) is not harm reduction but “mere neglect.”

Furthermore, “permitting chronicity” must never become a pretext for justifying “therapeutic laziness” or “avoidance of growth” on the part of the clinician. Conservative Psychotherapy does not mean “it’s all right to do nothing.” The clinician bears the ongoing obligation to ask “is the present conservative attitude the best possible approach?” Regular supervision, case discussions with colleagues, and revision of treatment strategy as necessary are all essential in Conservative Psychotherapy as well.

Furthermore, in some cases (particularly moderate-to-severe bipolar disorder, psychotic depression, and severe suicide risk), a conservative attitude alone is insufficient, and active intervention (ECT, hospitalization, intensification of pharmacotherapy) becomes necessary. Conservative Psychotherapy is not “a universal therapy applicable to all mental illnesses” but “a selective strategy whose application is judged according to condition, pathological type, and phase.”

6-4 The Context-Dependency of Japanese Psychotherapy

Since Conservative Psychotherapy claims to inherit the tradition of “Japanese psychotherapy,” its context-dependency must also be honestly discussed.

As shown in this paper, Conservative Psychotherapy has aspects that are constituted upon the institutional and social infrastructure of “the anonymity of the city” and “the Japanese medical system (free access, acceptance of long-term outpatient treatment, low co-payment).” In contexts where these conditions are different (rural areas, the American insurance model, institutional environments that mandate short-term intensive intervention), the practical feasibility of Conservative Psychotherapy is limited.

In this sense, Conservative Psychotherapy is better understood as an “attitude” than a universal “technique.” As Japan’s infrastructure erodes (restriction of free access, reduction in medical remuneration for long-term outpatient treatment), the “institutional foundation” of Conservative Psychotherapy may also be lost. Another significance of systematizing Conservative Psychotherapy is that it provides grounds for rendering visible the value of this institutional foundation and making a social claim for its protection.

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Chapter Seven: Ethical Integration — A Position Statement for Conservative Therapy

7-1 A Summary of the Core Ethical Propositions of Conservative Psychotherapy

The content discussed throughout this paper is organized below as the “core ethical propositions” of Conservative Psychotherapy.

Core Proposition	Summary of Content
Proposition 1: The Ethics of Biological Time	Recovery from depression takes a biologically necessary period of time. Interventions that attempt to shorten this time may obstruct the M-Unit’s regenerative process and be harmful. Clinicians must hold “respect for biological time.”
Proposition 2: The Obligation to Protect the Scab	The SB of the D-Unit is a scab protecting the regeneration of the M-Unit. Forcibly stripping away this scab is iatrogenic injury. The clinician has “the obligation to protect the scab.”
Proposition 3: The Activeness of Non-Action	“Not intervening” is not passivity; it is an active medical choice made after evaluating the harmfulness of intervention. Professional non-action is a technical act requiring advanced knowledge and training.
Proposition 4: The Protective Function of the Therapeutic Relationship	The ongoing relationship with the clinician functions as a substitute stabilizing device for the M-Unit and suppresses the activation of the D-Unit’s self-elimination program. The maintenance of the therapeutic relationship is itself a therapeutic act.
Proposition 5: Respect for the Patient’s Own Way of Having Survived	The defensive structure and lifestyle through which the patient has survived until now is, before being a “symptom” of illness, a “technique of survival” of that person. Removing it carelessly is to dismantle the technique of survival.
Proposition 6: The Demand for Temporal Justice	Society, institutions, and the family do not have the right to criticize the biological recovery time of depression as “unreasonably long.” The clinician bears the role of claiming temporal justice as the patient’s representative.
Proposition 7: Active Acceptance of Chronicity	Chronicity is not treatment failure; it is an active choice of awaiting biological regeneration while avoiding the worst outcomes. However, this presupposes the maintenance of the therapeutic relationship and is strictly distinguished from abandonment.

7-2 Redefining the “Professional Stance” of Conservative Psychotherapy

The most fundamental question that emerges throughout this paper is: “what is the expertise of the psychiatrist and psychotherapist?”

In the model of modern medicine, the role of the expert has been defined as a “Director” — one who “makes a diagnosis, performs interventions, and improves symptoms.” In this definition, “doing nothing” signifies the abandonment of expertise.

Conservative Psychotherapy questions this definition at its foundation. It argues that the most important role of the expert lies not in “directing” but in “bearing time together (time-bearer).” And “bearing time together” is not “doing nothing” but “protecting the biological regenerative process without violating it, and enduring together with the patient the time until that process is complete.”

In this sense, Conservative Psychotherapy is a proposal to shift the center of gravity of the psychiatrist’s expertise — from “mastery of the techniques of intervention” to “the technique of non-invasive protection and the patience of waiting.” This shift signifies not the “diminishment” of expertise but its “deepening.”

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Concluding Remarks: The Ethical Declaration — “It Is Permissible to Exist Without Being Cured”

“Conservative Psychotherapy” converges on a single proposition:

It is permissible to exist without being cured.

This proposition is not a helpless resignation. It is the expression, as an ethical declaration, of the biological facts revealed by the MAD+SB integrated theory — “the regeneration of the M-Unit takes time,” “protecting the scab makes regeneration possible,” “forcibly stripping away the D-Unit’s scab expands the damage.”

Just as surgery protects the patient’s bodily self by conserving the breast, the psychiatrist protects the psychological and existential self of the patient by conserving the form in which they have survived until now. This “protecting” is not passive. Respecting biological time, sustaining the protection of the scab, continuing to maintain the therapeutic relationship, resisting temporal injustice, continuing to supply stop signals to the self-elimination program — all of these are active medical acts.

When the outcome-driven medical evaluation of contemporary society measures patients by “speed of recovery,” the psychiatrist has a role as a cultural and ethical resister — one who “evaluates patients not by speed but by continuity.” “Curing as quickly as possible” is not always the good; “taking the biologically necessary time, avoiding catastrophe, and accumulating small stabilities” may be the good. Protecting this “slow good” is the final mission of Conservative Psychotherapy.

Recovery is not advancing in a straight line toward the light. That medicine acknowledges time spent pausing, retreating, taking the long way around, and continuing to circle the same place as “time in which it is permissible to live” — that practice of acknowledgment is the quiet question that Conservative Psychotherapy poses to contemporary psychiatric medicine, and its answer.

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Theoretical Annotations and Supplementary Notes

Note 1: The Distinction Between “Professional Non-Action” and Non-Action in Medical Ethics

In medical ethics, “omission” tends generally to be treated more leniently than “harm by commission,” on the grounds that “no harm has been inflicted.” However, “Professional Non-Action” in Conservative Psychotherapy is not a question of ethical superiority or inferiority; it is the choice of non-action “as the result of the best therapeutic choice,” and is fundamentally different from “non-action due to laziness or indifference.” The question of “the moral status of omission” discussed by Quinn & Shue (1989) and others needs, in the context of psychotherapy, to be reinterpreted as “active non-action with a therapeutic purpose.”

Note 2: Similarities and Differences with Morita Therapy

Conservative Psychotherapy resonates with Morita Therapy in the “ethics of non-manipulation,” but the two are not identical. Morita Therapy primarily targets neurosis (anxiety, compulsion) and aims at “arugamama” as a specific attitudinal change. Conservative Psychotherapy targets a broader range of conditions (depression, bipolar disorder, chronic illness in general) and, in the sense that it “refrains from compelling attitudinal change itself,” possesses a more thoroughgoing non-directiveness. In addition, Conservative Psychotherapy, in possessing the neurobiological basis of MAD+SB Theory, stands in a complementary relationship to the philosophical and phenomenological foundation of Morita Therapy.

Note 3: Similarities and Differences with Supportive Psychotherapy

On the relationship with supportive psychotherapy (Rockland, 1992; Gabbard, 2004): Supportive psychotherapy aims at active “strengthening” — reinforcing the patient’s defenses and supporting ego functions. Conservative Psychotherapy aims at “preservation” — not violating the patient’s existing defenses, lifestyle, and the form in which they have survived. Strengthening and preservation are different: strengthening means “making it better,” while preservation means “not destroying the present state.” If supportive psychotherapy is “promotion in an upward direction,” Conservative Psychotherapy is “the active choice of maintaining the current state.”

Note 4: Critical Dialogue with the Recovery Model

The framework emphasized by the “Recovery Model” (Anthony, 1993; Slade, 2009) — “the reconstruction of one’s own life by the autonomous subject” — has provided hope and direction to many patients. Conservative Psychotherapy does not negate this model. However, it points out the fact that the specific practices of “having the patient speak,” “having the patient narrativize,” and “giving the patient goals” can be harmful to some patients (particularly those in the acute phase of depression, chronic cases, and those who are injured by speaking). The two have different ranges of application in terms of “the patients, periods, and conditions to which they are applied,” and their relationship is not one where one is right and the other is wrong.

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