Chapter 5
Still, I Am Here
— What Preservational Psychotherapy Points Toward
1. Reflecting on the Journey Thus Far
Through these five chapters, I have taken a long and winding path.
In Chapter 1, I spoke of my failure as a young doctor who believed that “patients could be changed through reason.” Drawing on the setbacks of the French Revolution and the collapse of Soviet-style socialism as examples, I considered the limits of “design thinking.” I also described my own epistemological shift—a turning away from the radical toward a more conservative approach.
In Chapter 2, I carefully unraveled the definition of “Preservational Psychotherapy”: not manipulating symptoms; not rewriting narratives; and protecting the “margin” (yohaku) so that a person may reclaim their own inherent rhythm of time. I confirmed that Shoma Morita’s Aruga mama (as it is), Hisao Nakai’s “sitting beside,” and the Japanese concept of Ma (space/interval) all point in this same direction.
In Chapter 3, we turned our gaze toward Western psychiatry and philosophy. We looked at Winnicott’s “Holding Environment,” Bion’s “Container,” and the paradox taught by the clinical treatment of schizophrenia: “existence over interpretation.” We saw how Levinas’s philosophy of the Other, Gilligan’s ethics of care, and the existentialist “freedom not to change” all converge at the single point of the “self-restraint of power.”
In Chapter 4, we stepped outside the consultation room to consider the social pressures that demand one “heal quickly,” the meaning of chronicity, and the loneliness and anonymity of the city. We discussed the gap between Institutional Time and Human Time, and the necessity for the practitioner to “preserve” themselves.
Now, in this final chapter, I would like to speak once more, with great care, about what I truly wished to convey through all of this.
2. The Weight of the Word “Treatment”
More than thirty years have passed since I became a psychiatrist. As I continue this work, I feel that the weight of the word “treatment” (chityo) has changed year by year.
When I was young, the word carried a proactive and powerful resonance. To cure. To fix. To restore. As a doctor, I believed my job was to “do” something.
But now, it is different. I have come to feel a certain tension within the word “treatment.”
To treat is to intervene in another person’s life. Using words, using relationships, and using medication, one touches the patient’s inner world. This is an extremely delicate act and—as I have repeatedly stated—it is also an exercise of power.
The grammatical subject of the verb “to cure” (naosu) is always the practitioner. The patient becomes the object who is “cured” (naosareru).
Yet, if we are to speak the truth, when a person recovers, the source of that power lies, in almost every case, within the patient themselves. The practitioner does no more than arrange the “conditions” so that this power can be manifest.
A therapist does not grow the plant. They only tend the soil, the light, and the water so that the plant may grow of its own accord.
This realization is the bedrock of Preservational Psychotherapy. Rather than “curing,” one “protects the place where growth can occur.” This shift does not diminish the practitioner’s role; rather, it demands a role that is deeper and more nuanced.
3. The Strength of Not Having “Correct Answers”
As one works long as a psychiatrist, the number of things one “does not know” increases.
When I was young, I believed in what was written in textbooks. If a diagnosis was made, the treatment was decided. If the correct medicine was prescribed, symptoms would improve. If the appropriate psychotherapy was performed, the patient would recover.
But actual clinical practice is not so simple. Even with the same diagnosis, a medicine that worked for Patient A may not work for Patient B. An approach that was effective for Patient C may have the opposite effect on Patient D. If you ask “why,” there are countless answers—or perhaps, there is no answer at all.
“Not knowing” is a state that invites anxiety for a doctor. To say “I don’t know” to a patient can feel like a “failure” as a professional. Therefore, doctors often pretend to understand.
However, I now believe that “not having the correct answer” is not a weakness, but a kind of strength.
◆ The Concept of “Negative Capability”
The English Romantic poet John Keats (1795–1821) used the term “Negative Capability” in a letter written in 1817. He defined it as the ability to be “in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.”
Wilfred Bion cited this as a vital quality for a psychoanalyst: the ability for a therapist to let go of the impatience to “understand” and simply receive the patient’s narrative. This, he argued, is the quality of a therapist that truly “reaches” the patient.
“Not having the correct answer.” “Simply being there, while not knowing.” I believe this is deep wisdom, not only in psychiatric care but in all human relationships.
A practitioner who can admit “I don’t know” in front of a patient grants the patient permission to also “not know.”
Before a therapist who “has the answers,” a patient may feel the pressure to “provide the correct answer.” However, before a therapist who “does not know alongside them,” the patient can feel that “it is okay to be here even if I don’t understand.”
This sense that “it is okay to be here” is exactly what Preservational Psychotherapy aims for.
4. The Depth of “Waiting”
If I were to rephrase Preservational Psychotherapy in a single phrase, I believe it is the “art of waiting.” Yet, how profound a word “waiting” is.
There are at least three layers to “waiting.”
The first layer is temporal: waiting in time. It is the capacity to say: you don’t have to change right now. You don’t have to have the answer today. I can wait until next year, or even five years from now. This “temporal patience” is necessary for both the therapist and the patient.
The second layer is waiting on interpretation. It is the act of not rushing to provide meaning. One does not immediately provide an answer to the question “why?” Instead, one receives the patient’s silence as an internal movement occurring before it can become words. This “suspension of interpretation” enables the patient to discover their own meaning.
The third layer is more fundamental: waiting for the patient’s very existence. It is not waiting for a “future patient who has changed,” but simply receiving the existence of the person who is “here now.”
I believe this is the deepest form of “waiting” in human relationships.
To “wait” is not to endure the present while expecting change. it is to accept the existence of the other person exactly as they are in the present.
Those who have raised children may know this. It is the act of not viewing a child’s “now” as mere preparation for the future, but receiving the “now” as an end in itself. Not rushing, not comparing—simply trusting in that child’s time.
The therapeutic relationship in psychiatry is, in the best sense, similar to this.
5. The Book of Job
While writing this book, a certain story was always in the back of my mind: the Book of Job from the Old Testament.
Job was a man of great faith, yet he was beset by one misfortune after another as a trial from God. He lost his wealth, his children, and was struck with a painful illness. His friends came to visit him and said, “You are suffering because you have sinned,” and “You must beg God for forgiveness.”
But Job rejected this. He continued to insist: “I have done nothing wrong. There is no reason for this suffering.”
The “explanations” offered by his friends seemed rational on the surface. “There is a cause for suffering; remove the cause and the suffering will vanish.” This is similar to a medical mindset.
However, Job intuitively felt that accepting these “rational explanations” would be to deny his own suffering. He felt there was something in his pain that his friends’ words could not reach.
Finally, God appeared before Job. But God did not give Job an “answer.” Instead, God spoke from the whirlwind, asking: “Where were you when I laid the foundations of the earth?” God spoke only of the vastness of the universe and the depth of a world that exceeds human understanding.
And through that “answerless address,” Job reclaimed something. This story seems to me to overlap with Preservational Psychotherapy.
His friends are like the therapist. Out of good intentions, they try to provide an “answer.” “This is the cause of your suffering,” “If you do this, you will get better.” But those “answers” do not reach the core of the person who is suffering.
God’s “answerless address” is a response close to silence. Yet that silence leaves Job’s suffering as it is—as something “un-understandable.” That is “respect for the un-testifiable.”
To not attempt to explain all of suffering. To let the un-understandable remain beside one. That is, at times, the most profound response.
6. Why I Continue This Work
Why do I continue to be a psychiatrist? The answer is simple. Because being with the patient is the core of this work.
Not to do something for them, not to change them, and not even to cure them—but simply to be with them.
This is not “doing nothing.” It is maintaining the place of the consultation room. It is protecting the space where the patient can speak. Not rushing, not hurrying for an interpretation, but simply receiving. These are quiet, yet highly active deeds.
And I have witnessed many times how much this “being together” means to a patient.
A patient who has visited for many years says, “Just talking with you, Doctor, somehow makes me feel calm.” Nothing special has been done. Yet, the accumulation of “time simply spent talking”—dozens or hundreds of times—is what supports that person.
This is Preservational Psychotherapy. It is not dramatic. It is difficult to see. But it is something that is certainly, undeniably there.
7. To the Readers—Those I Hope This Book Reaches
Whoever you are reading this book, there is something I want to tell you.
If you are attending a psychiatric clinic as a patient:
If you feel that you are “not getting better easily,” please know that this is not your failure. Recovery takes time. And the form of recovery is your own. There is no need to compare yourself with someone else’s “recovered state.” Please try, just for a moment, to set aside the pressure to “heal quickly.” If you are being told that you “must change,” there is a reason for your current state that only you can understand. You do not have to make anyone understand that reason immediately. Please trust in your own time.
If you work in the field of psychiatry or psychology:
If you feel the impatience that you “must make things better,” please pause for a moment. The fact that you are “simply there” is already a part of treatment. You do not have to have the answers. You do not have to understand everything. You do not have to rush. I ask that you ask yourself if you are exhausted. For a practitioner to “preserve” themselves is a responsibility to their patients.
If you are the family or friend of a patient:
Your desire for them to “get well soon” comes from love. However, that feeling can inadvertently become a pressure. I hope you can occasionally create moments where you can say, “You are fine as you are.” Your presence by their side is already a great support.
And to the readers who have no direct connection to psychiatric care:
Preservational Psychotherapy is not just a story about psychiatry. This way of thinking applies to every situation where human beings interact. In education, in the workplace, and within the family—it is the sense of pausing for a moment before the impulse to “change” or “hurry” someone. It is the sense of trusting another person’s time. The sense that simply being there is already a form of support. I believe this is something that lies at the very root of how human beings relate to one another, even before it is a technique of psychotherapy.
8. As an Unfinished Project
This book is not a finished product. The idea of “Preservational Psychotherapy” is something I have nurtured little by little over thirty years of clinical practice, but it is still in the middle of its development.
While writing this book, I felt many times that “there are still things I do not understand.” Application to disorders other than schizophrenia. The relationship with pharmacotherapy. Situations where Preservational Psychotherapy is not suited. What kind of training is necessary to acquire this stance—I do not yet have sufficient answers to these questions.
But I believe that is fine.
“Remaining in a state of not knowing” is at the very core of this philosophy. For me to remain “not knowing” is to be faithful to Preservational Psychotherapy.
I lack presentation skills, and to be honest, I am not confident whether my words will reach my contemporaries. However, I wrote this in the hope that these words might reach someone in the distant future—be they a psychiatrist or a patient—who holds an interest in this question.
The “me” of the past always seems young and embarrassing. Reading this back in a few years, I will likely think, “I was so immature back then.” But I believe that beyond that accumulation of years, a certain “depth” is born, however slight. It is something that is transmitted not through words, but “vertically”—within the time spent silently facing a patient in the consultation room.
9. Finally — “Still, I Am Here”
I chose the words “Still, I am here” as the title of this chapter. These are the words of the practitioner. Even if the patient does not change. Even if the same story is repeated over and over. Even if I think “I’ve reached my limit.” Still, I am here.
But at the same time, these are the words of the patient. No matter how painful it is. Even on nights when they think “I want to disappear.” Still, they are here.
The fact of “being here”—that is what supports everything in Preservational Psychotherapy.
By the therapist “being here,” the patient feels “it is okay to be here.” By the patient “being here,” the therapist finds the reason to “continue this work.” I believe that in this reciprocity, the deepest essence of psychiatric care resides.
Please, I hope that you, too, will be here. You don’t have to rush. You don’t have to change. You don’t have to have the answers. Simply being here is already the beginning.
(March 2026, at Shinagawa Psychosomatic Clinic — Tadashi Kon)
In Place of a Postscript — How This Book Came to Be
The basis of this book is a series of blog posts I have written over many years. In that blog, titled “Shinagawa Psychosomatic Clinic Freedom Memo,” I accumulated countless fragments: thoughts from daily clinical practice, reflections on books I read, points of contact with philosophy and history, and snippets born from conversations with patients.
It was many years ago that I first used the term “Japanese Psychotherapy.” Later, I changed the name to “Conservative Psychotherapy,” and finally settled on “Preservational Psychotherapy.” The name has changed, but the inquiry has not.
In re-compiling those blog posts into a single book, I did not merely collect them; I re-read them, filled in what was missing, and re-organized them into a single flow. What I realized in the process of writing is that what I have been thinking about for over thirty years has, in the end, been circling around a single question.
That question is: Is the resilience of the human heart located outside the bounds of our intervention? And is protecting that “outside” the deepest responsibility of the therapist?
The answer to this question has not yet emerged. It likely never will in my lifetime. But I believe that continuing to hold this question is the very reason I continue to be a psychiatrist.
To everyone who has read this book, I offer my heartfelt gratitude.
Column ⑤: Hints for Practitioners to Practice Preservational Psychotherapy
Finally, for those working on the front lines of psychiatry and psychology, I will list a few concrete attitudes that lead to the practice of Preservational Psychotherapy.
【Things to keep in mind in the consultation room】
- Choose the question “What was most on your mind this week?” rather than “How have you been? Are you getting better?”
- Try, just once, to let go of the impulse to fill the patient’s silence.
- Instead of asking “Why is there no change?”, ask “What is supporting you in remaining here?”
- View a patient’s defenses not as “resistance,” but as “wisdom.”
- Consciously let go of the pressure that “I must solve something in today’s session.”
【Regarding yourself】
- Quiet the voice of self-criticism that says “I should have done better.”
- Do not fear admitting “I don’t know” in front of the patient.
- When you are tired, do not force yourself to play the role of the “capable therapist.”
- Knowing your own limits constitutes sincerity toward the patient.
These are not so much “techniques” as they are “stances.” They are not something to be mastered in a single day, but something I believe is nurtured little by little through the accumulation of clinical practice.
(End of Chapter 5)
