こちらが提供された第4章の全文翻訳です。
これまでの章の流れを汲み、社会的な視点を含んだ思慮深いトーンを維持し、洗練された英語で表現いたしました。
Chapter 4
In a Society That Says “Heal Quickly”
— What a Practitioner Can Do in an Age of Rushed Recovery
1. A Certain Patient’s Words
Several years ago, a male patient in his forties who had been visiting me over a long period for depression said something that stayed with me:
“I feel such a sense of relief when I come to see you, Doctor. Everywhere else, I feel this constant pressure that I have to ‘get well soon.'”
I was somewhat surprised. His condition was by no means severe; he was employed and managed his daily life reasonably well. Yet, in the world outside the consultation room, he felt a relentless, invisible pressure.
Upon further inquiry, I learned that colleagues at work would ask, “Are you still taking medication?” His family would ask, “When will you be back to your old self?” Even his primary physician (myself) would ask every time, “How have you been lately? Are you getting better?”
Every word surrounding him demanded that he be “faster” and “better.”
I realized later that his sense of “relief” came from the fact that I had, perhaps unconsciously, refrained from such inquiries. Instead of asking “Are you getting better?” I would ask “What has been happening lately?” Instead of “Is the medicine working?” I would ask “What was most difficult for you this week?” Choosing these questions was likely an expression of the “preservational” sensibility within me.
However, this experience posed a fundamental question to me: No matter how much I practice “not rushing” and “not destroying” within the confines of a private consultation room, what can a practitioner do if the very society in which the patient lives continues to demand “heal quickly”? How should we address this contradiction?
2. For Whom is the Concept of “Recovery”?
the word “recovery” (kaifuku) is used very frequently in psychiatric care. In the field of psychiatric rehabilitation, the English term “Recovery” is often used as is.
However, this concept requires re-examination. From what, and toward what, is one “recovering”? Who determines that a person has “recovered”?
In a medical sense, “recovery” often refers to a state where symptoms are alleviated, medication is reduced, and social life is resumed. These are undoubtedly important goals. Yet, therein lies a pitfall.
What kind of society is this “social life” that is being resumed?
The society the patient belonged to before falling ill was often the very environment that drove them to the breaking point. If “recovery” means returning to an environment of long working hours, interpersonal pressure, competition, and isolation, then “recovery” is simply sending the patient back to the same place that harmed them.
Alternatively, we might ask: Does “recovery” mean the patient adapting to society? Or does it mean creating a society in which the patient can truly live?
This is not merely a medical issue; it is a question of social design. Yet, psychiatry cannot escape this question, for the very definition of “recovery” is co-authored by the “complicit relationship” between medicine and society.
3. The Meaning of Being “Chronic”
Many psychiatric conditions follow a chronic course.
Depression is prone to relapse. Schizophrenia often requires long-term management. Individuals with personality issues may require years of engagement. Developmental disabilities are not something to be “cured,” but rather something that requires one to continuously find ways to live alongside their specific traits.
In other words, for many psychiatric patients, the ending where one is “completely cured and stops attending the clinic” is often not a realistic prospect. There is a possibility that they will require some degree of support over a long period, or even a lifetime.
However, modern medical systems are primarily designed around the model of “acute phase — treatment — recovery — termination of care.”
Outpatient consultation times are short. There is a tendency to view a decrease in the frequency of visits as a sign of “recovery.” Long-term outpatient care is sometimes even viewed negatively as “dependence.” The duration of hospital stays continues to be shortened.
While this model suits fractures or infectious diseases, it is fundamentally ill-suited to chronic psychiatric distress.
◆ Is “Chronicity” a Bad Thing?
The word “chronic” (manseika) often carries a negative nuance. It implies a problem: that something “will not heal” or is “dragging on.” Yet, perhaps this perspective itself needs to be questioned.
If a person lives their life in their own way—engaging with others, laughing at times, and crying at others—while continuing to visit a clinic chronically, is this a “failed treatment”? Or is it a “way of life” that the person has found?
It is within these chronic outpatient relationships that much of the practice of Preservational Psychotherapy resides. Rather than dramatic changes in an acute phase, a person slowly reclaims their own time within a trusting relationship nurtured over many years.
4. The Context of the City
The clinic where I work is located in Shinagawa, Tokyo. An urban outpatient clinic occupies a unique position within psychiatric care.
Cities are where people gather. And yet, cities are filled with loneliness.
In old rural communities, those who were mentally unstable were often “somehow” included within the collective. People accepted them with the thought that “that person is a bit eccentric.” The gaze of the community was both a form of surveillance and a form of support.
Cities lack this kind of communal inclusion. One might not even know who lives next door. Relationships at work are superficial; if one is deemed even slightly “useless,” they lose their place. Reasons to seek psychiatric care abound in the city.
Yet, at the same time, the city offers the gift of “anonymity.” In small towns or rural communities, many fear it becoming known that they are “attending a psychiatric clinic.” In the city, the chance of anyone knowing which clinic you visit is far lower. This anonymity lowers the threshold for seeking help.
An urban outpatient clinic is like a small “island of existence” floating within this anonymity. A patient visits this island once a week or once a month, shares their story, and then returns to the anonymous flow of the city.
I have witnessed many times how much the simple fact that “there is a place where one can stop by” supports a person.
For a patient, the consultation room being a “place where it is acceptable just to be”—that alone means treatment has already begun.
5. Institutional Time and Human Time
In modern psychiatry, there is “Institutional Time.”
Insurance-based medical care has “points” (fees). Hospital stays have upper limits on days. The renewal of certificates for the mentally disabled has a set period. Employment support programs have goals and deadlines. Appointments are filled weeks in advance.
These are all mechanisms created for the sake of “efficiency” and “fairness.” I do not intend to deny them. However, “Institutional Time” and the time required for a human being to recover are often profoundly out of sync.
One patient was deemed “recovered” after three months of hospitalization and was discharged. However, his true recovery took five years. During those five years, what supported him was a monthly outpatient visit. To the eyes of the “system,” those five years looked like “chronicity and prolongation.” To him, however, they were a necessary five years to slowly reclaim his own time.
Another patient was encouraged to participate in an employment support program. A schedule was designed as “steps toward recovery.” However, she could not keep up with the pace and fell into deeper despair, thinking, “I am a failure.” In this case, the support became a wound.
“Institutional Time” is not synchronized with the patient’s time. The system assumes an “average recovery curve,” but human recovery does not follow an average.
◆ The Concept of “Prescribing Time”
A phrase I value in my clinical practice is the “Prescription of Time.” Just as one prescribes medicine, a therapist should explicitly tell the patient: “This is a time when it is okay to go slowly,” or “This is a time when there is no need to rush.”
Patients often harbor an internal impatience, feeling they “must heal quickly.” For a therapist to say “there is no need to rush right now” is to grant “permission” to that impatience. The simple words “Take your own time” can bring immense relief to a patient.
6. The Spell of “Productivity”
Modern society has a strong tendency to measure human beings by their “productivity.”
Can you work? Can you earn? Can you contribute to society? Can you be useful? These questions have become the yardstick for determining human value.
This “productivity-ism” (seisansei-shugi) directly strikes psychiatric patients.
If they take leave for depression, they fear their evaluation at work will drop. Even after returning, they blame themselves if they feel they cannot perform as they once did. They struggle to take pride in working while living with a mental disability, constantly asking themselves, “Why can’t I do things normally?”
This “productivity-ism” is not just something imposed from the outside. It is deeply rooted within the patients themselves. “I must be useful,” “I must not be a burden,” “I must recover quickly and return to society”—these are voices from within.
Preservational Psychotherapy confronts this “internalized productivity-ism.”
For a therapist to be able to say, “You don’t have to produce anything right now” or “It is enough just to exist,” the therapist themselves must be free from productivity-ism. They must not harbor impatience that “this patient is not recovering very quickly” and must not succumb to the pressure to “get them back to work quickly.”
This is not an easy task. Therapists, too, exist within the pressures of the system and society.
Unless the therapist truly believes the words “It is enough just to exist,” those words will never reach the patient.
7. Regarding the “Right Not to Recover”
Let me put this in a somewhat provocative way: perhaps people have a “right not to recover.”
This is slightly different from the “right to refuse treatment.” It is the question of whether we can recognize as a right the state of receiving treatment but not reaching the “recovered state” that society expects—or even choosing not to reach it.
Of course, this does not mean “it is okay for the patient to suffer.” Alleviating suffering is the fundamental mission of medicine.
However, a “state of alleviated suffering” and the “recovered state as defined by society” are not always the same.
One person might not be able to work but has become able to spend their daily life peacefully. Is this “recovery”?
Another person might still have auditory hallucinations but has learned to live alongside them successfully. Is this “recovery”?
Another person might not have their depression vanish entirely but has come to feel that they “can still go on living.” Is this “recovery”?
I would like to call all of these “recovery.” Yet, institutionally, they are often viewed as “incomplete recovery” or “chronicity.”
◆ A New Meaning of “Recovery”
In recent years, the concept of “Recovery” in the world of psychiatric rehabilitation has undergone a significant shift. In addition to traditional “clinical recovery” (the disappearance of symptoms and restoration of function), the idea of “Personal Recovery” has gained ground.
Personal Recovery refers to a state where, even if symptoms remain, the individual feels they are “living a meaningful life.” Practices that place the patient’s own voice at the center, such as “User-Led Research” (Tojisha-Kenkyu) or “Open Dialogue,” are part of this movement.
Preservational Psychotherapy resonates deeply with this idea of Personal Recovery.
8. The Concept of a “Clinical Ecosystem”
There is a limit to what an individual therapist can achieve in practicing Preservational Psychotherapy. An “environment” that makes it possible is required. I call this the “Clinical Ecosystem.”
An ecosystem refers to a biological community. For a tree to grow in a forest, soil, water, light, microorganisms, and relationships with other plants are all necessary. You cannot successfully “grow” a tree by pulling it out in isolation.
The recovery of a psychiatric patient is the same. it is not something completed solely within the consultation room. What is needed for a patient to feel safe enough to reclaim “their own time”?
First is a “long-term outpatient relationship.” The ability for a patient to build a relationship with the same therapist over a long period is the foundation of Preservational Psychotherapy. However, modern medical systems threaten this long-term relationship through doctor rotations, clinic closures, and insurance restrictions.
Next is “institutional temporal margin.” For patients not to feel rushed, the system itself must be designed not to rush them. Flexibility regarding the upper limits of hospital stays, accommodating long-term outpatient care, and individualizing employment support—this kind of institutional margin is necessary at the clinical front.
Finally, there are “community connections.” Not just the clinic, but day care, home-visit support, peer support (mutual aid among those with similar experiences), and local “places to be”—this network functions as a “holding environment” for the patient’s entire life.
Preservational Psychotherapy does not end within the consultation room. It can only be practiced when there is a social and institutional “ecosystem” to support it.
9. “Preserving” the Practitioner
Finally, I would like to speak from a slightly different angle.
Preservational Psychotherapy is not only for the sake of the patient. It is also for the sake of the practitioner.
The front lines of psychiatric care place a heavy burden on the practitioner. Continuously receiving the suffering of patients affects the practitioner’s heart as well. “Burnout” is a serious issue among psychiatric professionals.
Why does burnout occur? One major reason is the pressure that “I must make them better” or “Why are they not getting well?” The impatience to “heal them quickly” drives the practitioner into a corner.
When one applies the ideas of Preservational Psychotherapy to the practitioner themselves, it looks like this:
The practitioner, too, can tell themselves: “There is no need to rush.” “I don’t have to solve everything today.” “If the patient doesn’t change, it is not my failure.” “Simply being there is already a part of treatment.”
This mindset protects the practitioner from burnout.
Furthermore, when a practitioner can value themselves, they can maintain the quality of care for the patient. An exhausted practitioner loses the sensitivity required to perceive subtle changes in a patient. Only a “practitioner with margin” can create a “consultation room with margin.”
A practitioner “preserving” themselves is not a selfish attitude; it is a part of their responsibility to the patient.
10. Summary of This Chapter—and Toward the Next
In this chapter, we have considered the meaning of Preservational Psychotherapy from the context outside the consultation room—society, institutions, and culture.
The question of for whom “recovery” exists. The meaning of chronicity. Loneliness and anonymity born from the context of the city. The gap between Institutional Time and Human Time. The spell of “productivity-ism” from within. The “right not to recover.” The necessity of a Clinical Ecosystem. And the preservation of the practitioner themselves.
These are not issues limited to the interior of psychiatric care. They are directly connected to the question: “In what kind of society do we want to live?”
In the final chapter, I would like to look back on what I have sought to convey throughout this book and reflect once more on “another form of treatment” that Preservational Psychotherapy points toward.
Column ④: What is Open Dialogue?
“Open Dialogue” is a psychiatric treatment approach born in Finland. It was developed in the 1980s by Jaakko Seikkula and others at Keropudas Hospital.
At its core is a simple principle: when a patient experiences a crisis, the patient, their family, and supporters all gather together to continue a “dialogue.” They do not rush a diagnosis, they do not rush medication, and above all, they listen. The therapist does not provide “answers”; the process of dialogue itself becomes the treatment.
In the Western Lapland region of Finland, there are reports that this approach dramatically reduced the rate of long-term hospitalization for schizophrenia.
While not identical to Preservational Psychotherapy, it is an approach that resonates deeply in its stance of “not rushing,” “not imposing interpretations,” and “maintaining a space for dialogue.”
(End of Chapter 4)
