Chapter 1
Rather than “Curing,” “Do Not Destroy”
— The path to the birth of Preservational Psychotherapy
1. From a Single Failure
When I first became a psychiatrist, I believe I was a rather “argumentative” doctor.
If a patient said they couldn’t sleep, I would explain the mechanism of sleep. If they said they wanted to die, I would attempt to analyze why they felt that way. If they said they didn’t want to take medication, I would try to logically convey the necessity of the medicine. None of this was incorrect. And yet, for some reason, there were times when the treatment simply did not go well.
Even now, I am haunted by the memory of a female patient in her fifties who visited me for chronic insomnia and depression.
She was meticulous and devoted to her family. Using a psychological approach known as “Cognitive Behavioral Therapy,” I carefully analyzed her “habits of thought” and repeatedly told her, “Let us try to value yourself more.” Logically, this was sound. However, after three months, she said to me:
“I try to do exactly what you tell me, Doctor, but it only makes me feel more exhausted. I think I really am no good after all.”
Those words stung. In my attempt to “cure” her, I had instead driven her into a corner.
What she needed was not a correction of her cognition. Perhaps all she needed was for someone to tell her, “You are fine just as you are.”
This experience changed something within me. The “good intentions” of the practitioner—the desire to “make things better” or “change things”—can sometimes become a heavy burden for the patient. If that is the case, then what is “treatment” in the first place? I was forced to rethink everything from that starting point.
2. The Harder You Try to “Change,” the More They Stiffen
In the world of psychotherapy, the prevailing idea for a long time was that “the therapist changes the patient.”
Psychoanalysis, founded by Freud, sought to remove the roots of symptoms by exploring the patient’s unconscious and “interpreting” childhood experiences and repressed emotions. Cognitive Behavioral Therapy, which appeared later, aimed to correct the patient’s “distorted thinking.” Many modern therapies, such as Motivational Interviewing and Dialectical Behavior Therapy, are also predicated on the idea of the “patient changing.”
Each of these is a respectable and effective therapy. However, the paradox I repeatedly faced in clinical practice was this:
“The harder you try to change someone through reason, the more the patient stiffens.”
Why is this?
When told to “change,” human beings naturally become defensive. This resistance is particularly strong in those who have spent many years building their own way of living; to be told to change feels like a denial of that life. Even if the person says they “want to change,” there is a force deep within them that says, “I want to protect my current self.”
In psychiatry, this “force to protect oneself” is called a “Defense Mechanism.”
◆ What is a Defense Mechanism?
A defense mechanism is an unconscious psychological process that works to protect the mind from being hurt or overwhelmed by anxiety. For example, “repression” makes painful memories “disappear,” “displacement” redirects anger toward something else, and “humor” laughs away anxiety. Everyone, even healthy individuals, uses these daily.
The problem is that for a long time in the history of psychotherapy, defense mechanisms were viewed as “things to be removed.” Approaches such as “releasing repression” or “breaking down defenses” seek to change the patient’s inner self more deeply. However, doing so can sometimes destroy the “delicate equilibrium” the patient has managed to maintain.
This is especially problematic for patients whose hearts are in an extremely fragile state. For someone who has experienced years of abuse, someone with schizophrenia, or someone with profound trauma—for them, defense mechanisms are not “weaknesses,” but the “wisdom to survive.” Attempting to forcibly remove them is tantamount to tearing down the very walls that have protected them.
3. A Lesson from History: The Limits of “Design by Reason”
When I think about this problem, a story from history always comes to mind.
The French Revolution at the end of the 18th century was a grand experiment to “illuminate society with the light of reason.” It sought to overthrow the authority of the monarchy and religion and “design” a new society based on the ideals of liberty, equality, and fraternity. The result, however, was a reign of terror and mass slaughter.
Why did it fail? One answer was provided by the British thinker Edmund Burke (1729–1797).
Burke argued that society is not something that can be “designed by reason.” He believed that society is an accumulation of customs, traditions, and the wisdom of people built up over a long period. To abruptly destroy these and try to remake society into something “rational” is bound to fail. This is because human beings are not made of reason alone.
“Individual reason is often limited, and when an individual relies solely on his own reason, he is prone to prejudice and error. However, the collective reason of the species is the wisdom accumulated across the ages.” (Edmund Burke, 1790)
The Soviet-style socialism of the 20th century was the same. It attempted to plan and manage society perfectly through scientific reason, but the “impurities”—human irrationality, emotions, indigenous cultures, and customs—flowed in from outside the plan, eventually leading to the collapse of the system.
If we apply this to psychotherapy, the idea that “we can change a patient according to theory” seems to me to have the same structure as the design philosophy of the French Revolution.
A patient’s heart is the accumulation of the time they have lived. Their relationship with their parents, scarred memories, years of habits, and the reactions their body has learned—these are not “distortions,” but evidence of how that person has survived their life until now. Is trying to “correct” them from the outside truly an act of healing?
4. The Meaning of the Word “Preservation”
If I were to sum up the philosophy I have arrived at in one word, it would be “Preservation” (Onzon).
Preservation—it is perhaps not a very common word in this context. To “preserve” means to keep something precious as it is for the sake of the future. It is also used in games like chess or shogi, as in “preserving one’s pieces.”
I named this “Preservational Psychotherapy” because I liked the nuance this word carries.
Preservation does not mean simply leaving things alone. It means actively protecting the current state.
In psychotherapy, “preservation” means not rushing to change the things the patient currently possesses—their own way of seeing the world, their sense of time, their coping mechanisms, or their sense of distance from others. Instead, it involves respecting those things and creating a “margin” (yohaku) where the person can change at their own pace.
◆ What is “Margin” (Yohaku)?
In the Japanese language, there is a unique concept called Ma (the space or interval between). It is the sense of seeing musical rests, empty spaces in architecture, or silences in conversation not as an “absence” (nasu), but as something that carries active meaning.
In Noh theater, it is said that the Ma between actions determines the depth of the performance. There are forms to follow, but it is not enough to perform them mechanically. By finely adjusting the “space” while feeling the atmosphere of the moment, a truly living performance is born.
The “margin” in Preservational Psychotherapy is similar to this Ma. The time when the therapist does nothing, the silence without interpretation, the atmosphere that does not rush for an answer—these are not a “lack” of treatment, but the “active space” required for the patient to begin moving at their own pace.
5. From “Curing” to “Nurturing”
The shift in thinking at the heart of Preservational Psychotherapy is a move from “curing” (cure) to “nurturing” (nurture), or from “changing” (change) to “not destroying” (do not destroy).
Medicine generally aims to “cure.” A fracture is set, an infection is defeated with antibiotics, and cancer is excised. This is natural. However, in the field of psychiatry, the word “cure” does not always carry the same meaning as it does in physical medicine.
What does it mean for depression to be “cured”? What does it mean for schizophrenia to be “cured”? What does it mean for years of trauma to be “cured”?
It does not mean “I no longer need to take medicine.” It does not mean “I no longer feel anything.” It does not mean “I have returned to exactly who I was before.”
My simplest definition of “recovery” is this:
“Recovery is not about getting better; it is about reclaiming time in which it is acceptable even if one does not get better.”
The person who taught me this most deeply was the work of the Japanese psychiatrist Hisao Nakai (1934–2022).
◆ A Psychiatrist Named Hisao Nakai
Hisao Nakai was one of Japan’s leading psychiatrists in the latter half of the 20th century, known for his deep insights into the long-term treatment of schizophrenia. His clinical practice focused on “protecting the patient’s living world” rather than merely “curing.”
He left behind the words: “To heal is to survive.” This was not a statement of resignation. It was a statement that fully accepted the weight of “survival.” It was a declaration that the essence of psychiatric care is to support a person so they can continue to live within their own time, no matter what illness they carry.
A patient’s psychological equilibrium is sometimes unbelievably fragile. If a therapist steps in too far with the intent to “change” or “cure,” they may inadvertently destroy that balance. “Not destroying” is not a passive attitude; it is one of the most difficult clinical judgments to make.
6. “Error-Correcting Intelligence”: From Reason to Reality
I once aspired to be an “intellectual and rational doctor.”
I had an image of accurately analyzing a patient’s problems, applying the most effective theory, and leading them to recovery via the shortest route. But that was a kind of “design philosophy,” and it held the same pitfalls as the French Revolution or Soviet socialism.
As I gained more clinical experience, I came to value a different kind of intelligence. I call it “Error-Correcting Intelligence” (Gosa Shusei Chisei).
◆ What is Error-Correcting Intelligence?
“A Priori Reason” refers to an intellect that brings in a theory as something already correct and tries to fit reality into that theory. This is close to the universal and absolute reason described by Kant in his philosophy.
In contrast, “Error-Correcting Intelligence” is the intellect that continuously picks up feedback from reality—”The patient seems energetic today,” “Yesterday’s intervention was a bit too strong,” “These words did not resonate”—and uses it to finely correct one’s own judgments and techniques.
In computer terms, it is not executing a pre-written program exactly as is, but rather a process of constantly rewriting parameters according to the environment during execution. Or, it is like a master craftsman adjusting the angle of his tools while feeling the texture of the material.
This “Error-Correcting Intelligence” is born from humility. It is an attitude of constantly asking, “What does this patient need right now?” rather than “My theory is correct.”
From this stance, the therapeutic attitude of “let us try not to destroy” emerges naturally over “let us change them.” This is because once you destroy what a patient currently has, the repair often exceeds the therapist’s power.
7. About the Name “Preservational Psychotherapy”
When I gathered these ideas under a single name, I chose the term “Preservational Psychotherapy.”
Initially, I called it “Japanese Psychotherapy,” referring to the accumulation of practices that naturally grew in the clinical fields of Japanese psychiatry. However, the adjective “Japanese” is prone to the misunderstanding that it “would not work abroad,” and more importantly, the essence of this idea lies not in cultural particularity, but in an insight into humanity in general.
Next, I considered the English name “Conservative Psychotherapy.” I thought of this because it overlaps with Burke’s conservative philosophy in the sense of “valuing maintenance over reform.” However, this word carries political nuances and risks giving a passive impression of “changing nothing.”
Finally, I settled on “Preservational Psychotherapy.” The verb “preserve” has active meanings: “to protect,” “to save,” and “to keep something precious.” In English, making jam is also called “preserving”—taking ripe fruit and adding just enough care to keep it from rotting so its flavor can be maintained for a long time. This is exactly the image of treatment that I envision.
Though the name has changed, the core idea remains consistent:
Rather than manipulating symptoms or narratives, protect the “margin” (yohaku) so that the person may reclaim their own time.
This is the simplest definition of Preservational Psychotherapy.
8. Summary of This Chapter—and Toward the Next
In Chapter 1, I have shared the path that led me to this way of thinking.
The paradox that a therapist’s “good intentions” to “cure” can sometimes become a burden. The “failure of rational design” repeated throughout history. The Japanese sense of space known as Ma. And the humble intellectual stance of “Error-Correcting Intelligence” that continues to learn from reality.
By weaving these together, the concept of “Preservational Psychotherapy” was born.
But how does one actually practice “not destroying,” “waiting,” and “protecting the margin”? How is it different from “doing nothing”?
In Chapter 2, after clarifying how Preservational Psychotherapy differs from “Supportive Psychotherapy” or “Do-Nothing Psychotherapy,” I will explore its ideological roots within the traditions of Western philosophy and psychiatry.
Column ①: What is Psychotherapy in the First Place?
Psychotherapy (psychological therapy, or counseling) is a general term for mental care provided primarily through “words” and “relationships” without the use of medication. Specifically, there are various types, such as counseling, Cognitive Behavioral Therapy, psychoanalytic therapy, family therapy, and group therapy.
In Japanese psychiatric outpatient clinics, it is common to combine pharmacotherapy (medication) with psychotherapy. The act of “talking with a doctor in the consultation room” is itself psychotherapy in a broad sense.
“Preservational Psychotherapy,” as discussed in this book, is not the name of a specific technique, but rather the “attitude and stance of the therapist” that permeates all forms of psychotherapy. Regardless of the method used, the primary concern of Preservational Psychotherapy is the manner in which the therapist faces the patient.
(End of Chapter 1)—
