This is a complete, unabridged English translation of the provided manuscript, formatted to maintain the structure and academic tone of the original psychiatric journal article.
A Detailed Treatise on “Conservative Psychotherapy” (2026-3-8)
Date: March 8, 2026
Subject: Conservative Psychotherapy
Subtitle: Biological and Ethical Justification via the Integrated MAD/SB Theory
Manuscript for: Journal of Psychiatric Medicine
Author: Tadashi Kon, Shinagawa Psychosomatic Internal Medicine
[Abstract]
This paper connects the author’s proposed “Conservative Psychotherapy” to the integrated framework of the MAD theory (M-A-D Unit Model) and Sickness Behavior (SB) theory, arguing for its biological basis and ethical justification. Conservative Psychotherapy—named in analogy to “organ-sparing surgery” in the field of surgery—aims to systematize a non-invasive, expectant, and concomitant psychiatric practice. As clarified by the integrated MAD+SB theory, depression is a state of “waiting for biological regeneration” following an injury to the M-unit (the source of activity, optimism, and sleep-inducing components), while the sickness behavior dominated by the D-unit functions as a “biological scab” to protect that regeneration. From this perspective, the conservative stance of the therapist—prioritizing “not violating the regeneration process” over “doing something”—is not merely emotional kindness but an active medical choice backed by neurobiology. This paper presents four ethical pillars—Non-maleficence, Autonomy, Beneficence, and Justice—along with a fifth original pillar, “Temporal Justice,” arguing that Conservative Psychotherapy is a practical framework that integrates these principles.
Introduction: The Question of “Not Trying Too Hard to Heal”
In psychiatric clinical practice, the attitudes of “not trying too hard to heal,” “not rushing the patient,” and “not destroying their life” have long existed. However, these have never been systematized as formal “techniques,” appeared in manuals, or been frequently transmitted in educational settings. On the contrary, with the rise of Evidence-Based Medicine (EBM), these attitudes have often faced criticism as being “unprofessional,” “unscientific,” or “merely waiting.”
The question this paper asks is: Is this criticism justified?
To state the conclusion first: No. The attitude of “not trying too hard to heal” is neither emotional consolation nor passive resignation; it is an active medical choice backed by neurobiology and the product of high-level ethical judgment. To clarify this, this paper constructs the theoretical and ethical foundation of “Conservative Psychotherapy” while employing the integrated framework of the MAD and SB theories.
The term “Conservative” originates from “breast-conserving surgery” or “organ-conserving therapy” in the field of surgery. It represents an attempt to transplant into the context of psychotherapy the surgical philosophy that radical resection is not the only correct answer, and that preserving the patient’s physical functions and Quality of Life (QOL) is a superior medical judgment. Just as a surgeon conserves the function of an organ, a psychiatrist conserves the continuity of the patient’s life, their defense structures, and the shape of the life they have lived. This stance is called “Conservative Psychotherapy.”
Chapter 1: Background of the Inquiry—Why Verbalize This Now?
1-1 Pressure of Meritocracy on Mental Healthcare
The wave of “meritocracy” covering modern society exerts silent pressure on mental healthcare for “the earliest possible recovery.” The introduction of short-term intervention models based on evidence, the “Recovery Model,” and the demand for quantified results—such as number of visits, improvement rates, and return-to-work rates—have brought many benefits. However, they have also driven “patients who do not change” into categories like “treatment-resistant” or “lacking motivation.”
A similar internalization has occurred on the side of therapists. The compulsive urge to heal—”I must make them better,” “Why aren’t they improving?”, “Is another intervention necessary?”—exhausts clinicians and introduces unnecessary tension into the relationship with the patient. A culture that cannot tolerate “waiting” harms patients who need time.
1-2 “Quiet Practice” Precipitated in Japanese Clinical Work
However, at the base of Japanese psychiatric practice, a quiet yet resilient attitude has long been shared. Expressed in phrases like “Let’s take it slowly,” “There’s no need to rush,” or “You don’t have to do anything right now,” this attitude has been a clinical culture transmitted implicitly from seniors to juniors without being organized as a methodology.
Morita Therapy’s “Aruga-mama” (acceptance of reality), the practice of long-term supportive psychotherapy, the suspension of interpretation as “not touching unnecessarily,” and the respect for silence as “not forcing recovery into a narrative”—these all share the same root. They represent a “skepticism toward controllability” and a “trust in the regeneration process.” This paper aims to integrate these under the name “Conservative Psychotherapy” and visualize its logical, neurobiological, and ethical foundations.
1-3 Connection with the Integrated MAD+SB Theory
Conservative Psychotherapy has previously been discussed mainly in the context of clinical philosophy and psychotherapeutic theory. The new attempt of this paper is to connect it to the integrated framework of the MAD Theory (M-A-D Unit Model) and Sickness Behavior (SB) theory.
What is gained from this connection? First, we obtain a neurobiological explanation for the question “Why is a conservative attitude therapeutic?” beyond emotional or philosophical arguments. Second, we can improve clinical judgment by mapping the boundary between “what to do” and “what not to do” onto the specific biological phenomenon of the M-unit regeneration process. Third, we can show that not only is “not trying too hard to heal” ethically justified, but “trying too hard to heal” may be neurobiologically harmful.
Chapter 2: Key Points of the Integrated MAD+SB Theory: Biological Basis of Conservative Therapy
2-1 What is Depression? “A State of Waiting for Regeneration after M-unit Injury”
The core proposition of the MAD+SB theory (detailed in previous reports) is as follows:
Depression is a state of “waiting for physical regeneration” after the M-unit (the functional unit responsible for optimism, driving activity, and supplying sleep components) has been injured. When the M-unit enters a functional stop (freeze) due to an emergency response (infection, overload, chronic stress), the D-unit (responsible for pessimism, social withdrawal, self-reproach, and SB implementation), which was previously in an antagonistic relationship, is laid bare. This is the clinical state of depression.
There are three most important points in this model:
- The regeneration of the M-unit requires biological time (2–4 months). This time cannot be shortened by willpower or environmental improvement.
- The SB (withdrawal, rest, social retreat) brought by the D-unit functions as a “protective scab” for the M-unit during this regeneration period.
- There is a diurnal cycle where the M-unit is “scrapped” by a disposal program at night and recovers slightly via daytime external stimuli. This is the mechanism for morning dread and relative evening recovery.
2-2 The D-unit as a “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.”
A scab is a source of distress for the patient. The desire to withdraw, the inability to move, the lack of pleasure, the sense of guilt—these are products of the D-unit, and the patient experiences them as “symptoms to be cured.” Therapists also tend to treat them as “pathological states to be removed.”
However, applying a surgical analogy, a scab is not “something to be removed” but “something to be protected.” Forcibly peeling off a scab exposes the regenerating tissue and spreads the damage. In depression, interventions that forcibly peel the D-unit’s scab—forcing rapid social return, unreasonable activation, or pressure that “you should be able to try harder”—may act as direct obstacles to the regenerating M-unit.
The first biological basis of Conservative Psychotherapy is here. “Protecting the scab” means protecting the regeneration environment of the M-unit, which is a medically rational choice.
2-3 Risks of Invasive Intervention: Interaction with the M-unit Disposal Program
Furthermore, it is crucial to consider the risk that excessive psychological intervention may enhance the “nighttime disposal program of the M-unit.” The brain disposes of excess and unnecessary M-cells during sleep. In the recovery process of MAD theory, “over-disposal” of M-cells can occur. In that case, the sleep-promoting components of the M-unit are lost, resulting in nighttime insomnia.
In healthy individuals, this program disposes of surplus M-units during sleep. In depressed patients, it functions as “continuity of destruction” rather than “repair.” The activation of this disposal program is closely related to the quality of sleep (especially the over-activation of REM sleep).
Active interventions—such as deep psychodynamic digging, interpretations that evoke strong negative emotions, confronting past traumas, or emphasizing “reasons to recover”—may actually increase the nighttime M-unit disposal program through the patient’s level of arousal, emotional activation, and increased REM sleep.
Briefly put, the hypothetical risk is that “excessive intervention makes the patient’s night more painful.” The non-invasiveness of Conservative Psychotherapy—”not rushing to give meaning” and “not forcing insight”—can be understood as a rational choice to avoid this potential harm.
| Type of Intervention | Evaluation in Conservative Psychotherapy and Interpretation from MAD Theory |
|---|---|
| Deep Interpretation / Trauma Confrontation | Generally avoided in the acute and middle phases of depression. Risk of enhancing the “M-unit disposal program.” Selective use possible after stable recovery. |
| Active Cognitive Correction (CBT) | The framework of “correcting distorted thoughts” itself carries the risk of viewing the D-unit’s protective function as a “symptom” to be attacked. A conservative attitude avoids asking the “meaning” of symptoms too deeply. Effective for preventive use after recovery. |
| Behavioral Activation / Early Social Return | Corresponds to the risk of forcibly peeling off a scab. While moderate daytime external stimuli (light, food, short conversation) are encouraged, quantitative activation demands like “move more” are dangerous. Gradual, patient-led return is the principle. Risk of mixed manic-depressive states. |
| Narrative Construction of Recovery / Goal Setting | Questions like “Why recover?” or “What do you want to do after recovery?” force the patient to “act out optimism in place of the M-unit” while the M-unit is absent. This increases exhaustion. |
| Maintenance of “Being With” | The most reliable conservative intervention. The therapist’s continuous presence acts as a substitute for the M-unit, supplying a suicide-stop signal and suppressing the D-unit’s self-elimination program (suicidal ideation). |
| Prescription of Daytime External Stimuli | An active but low-intensity intervention to promote daytime recovery of the M-unit. Light, food, short conversations, light walks. Provided as “stimuli to be received passively” rather than “activities that must be done.” |
Chapter 3: Ethical Structure of Conservative Psychotherapy
3-1 Integration of the Four Ethical Principles
The four principles presented by Beauchamp & Childress (1979)—Autonomy, Beneficence, Non-maleficence, and Justice—have been widely referenced as the basic framework of medical ethics. In constructing the ethical foundation of Conservative Psychotherapy, this paper reinterprets these four principles within the context of psychotherapy and adds a fifth axis: “Temporal Justice.”
| Ethical Principle | Specific Meaning in Conservative Psychotherapy |
|---|---|
| ① Non-maleficence | “Do not cause secondary damage through excessive intervention.” Do not forcibly peel the scab. Do not enhance the “M-unit disposal program.” Protect the patient from the runaway of the “urge to heal.” |
| ② Autonomy | “Respect the patient having their own pace of regeneration.” Do not define the speed, direction, or form of recovery from the outside. Conserve the defense structures unique to the patient and how they have survived. |
| ③ Beneficence | “Prepare the regeneration environment and assist the growth of the M-unit through external stimuli.” The therapist actively does what they can (promoting daytime stimuli, organizing the sleep environment, external protection against suicidal ideation) without being invasive. Choosing “not to violate” rather than “doing nothing.” |
| ④ Justice | “Do not bias treatment resources and time toward fast-recovering patients.” Protect structures so that patients with chronic or long-term conditions are not excluded from the system. Maintain a fair relationship that does not judge the patient by the speed of recovery. |
| ⑤ Temporal Justice | “Every patient should be guaranteed the time biologically necessary for their recovery.” This is an original ethical axis of this paper. The 2–4 month regeneration time for depression is an irreducible biological constraint; a medical system or social environment that does not respect this is ethically problematic. |
3-2 Deepening 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. Its practical expression is the concept of “Professional Non-Action.”
The term “Non-Action” is often misunderstood as “doing nothing,” “laziness,” or “evasion of responsibility.” However, non-action in Conservative Psychotherapy is entirely different. “Professional Non-Action” in the true sense is the choice to “daringly not intervene because one knows the power of intervention.” This choice integrates judgments across the following three levels:
- Level 1: Neurobiological Level: The judgment not to interfere with the M-unit regeneration process. Consideration for the possibility that excessive emotional activation, deep interpretation, or forced cognitive correction may enhance the “nighttime M-unit disposal program” and delay regeneration. This is based on the neurobiological recognition that “not intervening” is equivalent to “doing no harm.”
- Level 2: Psychological and Relational Level: The judgment to respect the defense structures, lifestyle, and interpersonal patterns the patient has built over many years. In a psychoanalytic context, defense is a “proof of survival” before it is a “symptom.” Removing a defense adopted for survival too quickly carries the risk of exposing the patient to unprocessed material behind the defense without protection. The question “Is peeling this patient’s defense right now truly beneficial?” must be constantly asked.
- Level 3: Socio-Cultural Level: The judgment to temporarily release the patient from social demands such as “recovering,” “working,” or “forming a narrative.” The framework where an “autonomous subject reconstructs their own life,” which the Western recovery model assumes, is not applicable to all patients. For patients who are hurt by speaking, overwhelmed by being asked for goals, or who currently lack the energy to construct a recovery narrative, the attitude of “it’s okay not to speak now,” “goals can come later,” or “it’s enough just to be here” is the product of high-level cultural sensitivity and clinical judgment.
3-3 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 based on sufficient information (Informed Consent).” However, in Conservative Psychotherapy, autonomy carries a deeper meaning.
When the M-unit of depression has ceased to function, the patient’s judgment and decision-making capacity are temporarily impaired. In a state where one has lost the optimism, future prospects, and self-esteem supplied by the M-unit, one cannot accurately judge “what will be valuable to my future self after recovery.” “Consent” in this state may not express the patient’s essential autonomy.
True respect for autonomy involves not just following “judgments in the current D-unit-dominant state” but including consideration for “how the patient will evaluate this treatment choice after the M-unit has regenerated”—a judgment with a temporal perspective. In this sense, Conservative Psychotherapy practices care not only for the “patient’s currently expressed will” but also for the “presumed will of the patient after regeneration.” For example, a statement by an acute-phase depressed patient that they “no longer want to receive treatment” may be related to the D-unit’s self-elimination program; respecting this as “autonomous will” might actually damage the patient’s long-term autonomy.
However, here lies the greatest point of tension for Conservative Psychotherapy. Where to stand between the “patient’s current will” and their “presumed future will” is never self-evident. The boundary between overprotective paternalism and respect for the patient must be constantly questioned.
3-4 The Ethics of “Permitting Chronicity”: Connecting Non-maleficence and Harm Reduction
In Conservative Psychotherapy, the choice to “permit chronicity” is neither laziness nor resignation, but an active ethical judgment. This judgment connects with the logic of “Harm Reduction.”
The philosophy of harm reduction, established in the field of drug addiction, is an ethical position that prioritizes “minimizing realistic harm” over “demanding an ideal state (complete abstinence/complete recovery).” The application of this thought is also significant in psychotherapy.
The list of secondary injuries that active intervention based on a “healing-above-all” mindset can cause is long: collapse of self-esteem (“It’s my fault I’m not getting better”), distrust of treatment (“This doctor doesn’t understand me”), severance of the therapeutic relationship (“I’m going to stop coming here”), relapse due to overactivity (“I got worse after being told to try harder”), and enhancement of suicidal ideation (“I won’t get better anyway, I should be gone”). These can all be understood as “side effects of excessive intervention.”
Avoiding these secondary injuries may improve the long-term prognosis more than a primary “promotion of recovery.” “Permitting chronicity actively” can be a “protective treatment choice” that avoids the worst outcomes (suicide, severance of relationships, irreversible social collapse). In this sense, “permitting chronicity” is not “giving up on healing” but “preventing catastrophic outcomes caused by rushing to heal.” Maintaining this distinction clearly shows the ethical maturity of Conservative Psychotherapy.
3-5 Temporal Justice: An Original Ethical Axis of This Therapy
The fifth ethical axis proposed in this paper, “Temporal Justice,” is a concept not found in existing frameworks of medical ethics and is a unique contribution to Conservative Psychotherapy.
“Temporal Justice” is the ethical proposition that: Every patient should be guaranteed the time socially and institutionally necessary for the biological recovery of their disorder.
The integrated MAD+SB theory showed that there is a “biological time required for the physical regeneration of the M-unit” in the recovery from depression, which is 2–4 months. This time cannot be shortened. Neither willpower, the addition of antidepressants, nor the intensive implementation of psychotherapy can exceed this biological constraint (though ECT or ketamine partially challenge those limits, they are not omnipotent).
However, many contexts of modern society (workplace, family, insurance systems, medical evaluation) treat this biological time as “unjustifiably long.” “You’ve been resting for three months,” “Why aren’t you better yet?”, “When can you return?”—these questions are expressions of temporal injustice that ignore biological constraints.
One of the important roles therapists play in Conservative Psychotherapy is to resist this “temporal injustice” as the patient’s representative. Advocating to the workplace, family, and society the fact that “this illness requires a biologically necessary amount of time” and functioning as a buffer to protect the patient from unjust temporal pressure is part of the ethical mission of medicine.
Chapter 4: Practical Structure of Conservative Psychotherapy
4-1 The Boundary between “Doing” and “Not Doing”
Conservative Psychotherapy is not a “do-nothing therapy.” This is a correction of an important misunderstanding. Conservative Psychotherapy is an active therapeutic position 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 / Interpretation | Provide a structural explanation of the condition (MAD theory psychoeducation) to help the patient understand that “there is a structure to my suffering.” | Avoid hasty attribution of meaning or interpretation of symptoms. Do not lead the patient with questions like “Is this symptom caused by childhood trauma?” |
| Emotional Processing | Accept what the patient says spontaneously without denial, without rushing, and without overreacting. | Do not force the patient to speak. Do not encourage “deep digging” into emotions. Refrain from urging “Please tell me more.” |
| Behavior / Activity | Prescribe passive daytime external stimuli (light, food, short conversation, walks) without pressure. | Do not demand quantitative activation like “You should be more active.” Do not rush early employment or social return. |
| Goal Setting | Share minimal goals like “not destroying today.” | Do not force the patient to speak about medium-to-long-term recovery goals or “designing life after recovery” at this stage. |
| Relationship Maintenance | Maintain the therapeutic relationship long-term through regular consultations and visits. The therapist’s existence at a fixed place and rhythm functions as a secure base. | Do not bring pressure to measure or evaluate the “results” of treatment into the relationship. Do not excessively ask, “Are you better than last time?” |
| Suicide Risk Management | Supply a suicide-stop signal as a substitute for the M-unit. Repeatedly provide the recognition that “your evaluation that you are a cost to the group is a judgment made while the M-unit is absent, not a true evaluation of you.” Hospitalization and family involvement as needed. | Do not treat the activation of the D-unit’s self-elimination program as a “matter of will.” Do not give ineffective encouragement like “Let’s try hard not to want to die.” |
| Integration with Pharmacotherapy | Position antidepressants as “preparing the regeneration environment for the M-unit” (increasing BDNF, normalizing HPA axis, improving sleep) and explain their biological role to the patient. | Before rapid dose increases or polypharmacy, leave room to evaluate “is the current dose functioning sufficiently?” Consider the impact of over-medication on the M-unit disposal program. |
4-2 Conservative Design of Psychoeducation: How to Convey MAD Theory
Psychoeducation in Conservative Psychotherapy is not a “motivation to rush recovery” but aims for “existential stability by giving structure to suffering.”
This difference is important. Normal psychoeducation has the purpose of “understanding the illness to get better quickly.” Conservative psychoeducation has the purpose of “knowing that the current suffering is not an inexplicable hell, but has an explainable structure.” The goal is not “acceleration of recovery” but “acquisition of the ability to endure suffering.”
When conveying MAD theory to patients, the following framework is useful:
“In your brain, there is an engine (the M-unit) that creates optimism, activity, and sleep. That engine has been injured by previous overloads. An injured engine takes time to repair—just as an injured skin takes time for a scab to form and new skin to grow. That repair period is 2 to 4 months.”
“The reason mornings are the worst is not because your will is weak. It’s because the engine is slightly chipped away during the night, so morning is the time when the engine is at its lowest.”
“The feeling of wanting to die is not because you truly want to die; it’s an old program that starts running when the engine is absent. Once the engine is repaired, that program will stop.”
“What I (the doctor) am doing now is continuing to press the stop button for that program until your engine is repaired.”
This explanation answers the three most urgent questions—”Why is it so painful now?”, “Why won’t it heal immediately?”, and “Why do I have suicidal thoughts?”—without unnecessarily scaring the patient, while simultaneously conveying the “meaning of the therapist’s continued presence.” This is the core of conservative psychoeducation.
4-3 The Technique of “Co-presence”: Accepting Time
In Conservative Psychotherapy, the most important function of the therapist is “to continue to be there (co-presence).” This is not passive “bystanding” but a highly active technical act.
The reason “co-presence” is a technique is that it is a continuous, active choice where the therapist themselves continues to resist the impulse to “do something.” In the time when the patient does not improve, the therapist is constantly exposed to internal pressure: “Shouldn’t I do something more?” Staying in the position of “enduring the current state together with the patient” without succumbing to this pressure and rushing into excessive intervention is a high-level professional act that requires training and will.
In a psychoanalytic context, Winnicott’s (1960) “holding environment” is the concept closest to this function. The therapist does not “do something” but functions as a “non-collapsing background” at the moment the patient seems about to collapse. This function can be understood in the context of MAD theory as a “substitute stabilizer for the M-unit.” While the M-unit is absent, the external structure of the therapeutic relationship functions as a “minimum substitute for optimism” and a “minimum source of a sense of safety.”
The therapist’s stance of “enduring the time of no change” continuously sends the message to the patient: “Even if you don’t change, I am here.” This message is the most effective rebuttal to the D-unit’s evaluation that “I am an excessive cost to the group.” The continuous presentation of the fact that “you are not a cost, because I am not treating you as a cost” becomes the most important deterrent against suicidal ideation.
4-4 The Technique of Silence: Protection through Not Speaking
In Conservative Psychotherapy, “silence” is a technique, not a lack. Not forcing the patient to speak, withholding meaning, and not deepening inquiries creates a unique therapeutic space called “shared silence.”
In Western psychotherapy, especially in the context of Narrative Therapy or CBT, “speaking, giving meaning, and narrating” are placed at the heart of recovery. However, as Japanese clinical experience shows, not a few patients are hurt by speaking.
“Speech” in a state where the M-unit is absent is reprocessed through the D-unit’s pessimistic filter. Telling past events carries the risk of them being reinterpreted by the D-unit as evidence that “I was no good” or “nothing will change anyway.” Speaking can make the condition worse than before speaking.
The attitude of “you don’t have to talk now” or “the meaning can come later” is a protection against this danger. At the same time, the fact that “the therapist is here even if I don’t speak” conveys the message to the patient that “having words to speak is not a condition for existence.” This is also an important condition for “patients with suffering that cannot be well verbalized” to remain in a long-term therapeutic relationship.
Chapter 5: Conservative Practice by Pathology: To 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 for this.
First, the melancholic type is the “deepest frozen state of the M-unit,” where the scab (SB by the D-unit) is formed most thickly. Active intervention in this state carries the greatest risk of secondary damage. Second, cortisol toxicity due to HPA axis overactivity is inhibiting M-unit regeneration, and this timeline cannot be shortened from the outside. Third, diurnal variation (morning worsening/evening recovery) is clear, and the conservative measure of “not performing deep intervention in the morning” can be clearly applied.
The specific framework of conservative practice for the melancholic type is: maintaining regular short consultations, appropriate use of antidepressants (action on the HPA axis and NE system like SNRIs or tricyclics), organizing the sleep environment, prescribing daytime passive external stimuli, explaining “not to seek meaning in morning dread,” continuously supplying stop signals for suicidal ideation, and sharing the “2–4 month regeneration time” timeline.
In conservative practice for the melancholic type, avoiding “psychotherapeutic deep digging” is particularly important. In this pathology, asking for “insight” or “why I became depressed” should, in principle, be avoided in the acute and middle phases. The answers to these questions only gain meaning during the stable period after the M-unit has regenerated.
5-2 Atypical and Inflammatory Depression: Direct Application of the SB Model
Atypical depression (oversleeping, overeating, mood reactivity, sickness behavior type) is the pathology where the SB theory can be most directly applied. In this pathology, the activation of the D-unit by inflammatory cytokines is the primary mechanism, and the first priority of treatment is reducing the inflammatory load.
In the context of Conservative Psychotherapy, “non-invasive inflammatory reduction interventions”—anti-inflammatory diet (Mediterranean diet), moderate aerobic exercise (improving mitochondrial function), improving sleep, and attention to gut microbiota—are positioned as “conservative modifications of lifestyle.”
What is particularly important in atypical depression is the understanding of symptoms like “why my body is heavy” or “why I get sleepy.” Explaining these based on SB theory as an “adaptive rest program when the immune system is fighting” gives the patient the recognition that “I am not being lazy.” This change in recognition itself alleviates part of the D-unit’s “sense of worthlessness and guilt.”
5-3 Bipolar Disorder: Manic Switch Risk and the Special Logic of Conservation
The application of Conservative Psychotherapy to Bipolar Disorder (BD) partially overlaps with its application to depression but requires its own logic.
In the depressive phase of BD, conservative practices similar to those for the melancholic type can basically be applied. However, what is particularly important in BD is “consideration for manic switching.” In the framework of MAD theory, a manic switch is a “phenomenon where the regenerating M-unit runaway ignites,” triggered by external stimuli (strong light, sleep deprivation, overactivity, strong emotional experiences).
Conservative Psychotherapy for BD patients necessarily has the aspect of “stimulus management for preventing manic switches.” The conservative principle of BD is: “Be most cautious exactly when recovery starts to be seen (when the M-unit starts to regenerate).” In periods of high manic switch risk (spring, periods of rapidly increasing activity, when sleep starts to shorten), “conservative measures to prevent re-ignition” become necessary, such as intentionally limiting external stimuli and ensuring the continuation of mood stabilizers.
Paying attention to mixed manic-depressive states is helpful for suicide prevention and is therapeutic.
5-4 Long-term Consultations and Chronicity Cases: The Pinnacle of Conservative Therapy
Conservative Psychotherapy demonstrates its most unique value in cases of long-term consultation and chronicity. In conventional psychotherapeutic models, these cases tend to be treated as “failures of treatment,” but in Conservative Psychotherapy, they are positively redefined as “cases requiring continuous protection.”
Many chronic cases have the following characteristics: environmental triggers are continuing (structural problems in workplace or family relationships are not resolved). Re-injury is repeated before complete M-unit regeneration is achieved. The pressure to “must recover” itself has become a factor for M-unit re-injury. Distrust of treatment and self-reproach created by previous treatment models have become an additional load.
What Conservative Psychotherapy offers to these cases is: a change in recognition that “your chronicity is a necessary consequence of structural problems in the environment and repeated injury to the M-unit, not a problem of your will,” a resetting of goals to “accumulating small stabilities,” a redefinition of the therapeutic relationship as “continuing to come here without being cured has meaning in itself,” and a shift in evaluation criteria to “continuing to avoid the worst outcomes is itself a success of treatment.”
Chapter 6: 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 that “isn’t this just justifying doing nothing?” This criticism must be taken seriously.
The response is as follows: Conservative Psychotherapy is not “doing nothing” but “actively choosing what not to do.” This distinction is critically important. Just as “organ-conserving surgery” in surgery is not “not performing surgery” but a “high-level technical choice to conserve organ function,” Conservative Psychotherapy is not “doing-nothing laziness” but a “stacking of non-invasive choices based on a sophisticated evaluation of the harmfulness of intervention.”
There are things “to do” in Conservative Psychotherapy. Perform psychoeducation. Continue to meet regularly. Prescribe daytime stimuli. Organize the sleep environment. Continue to supply stop signals for suicidal ideation. Function as a stabilizing device as a substitute for the M-unit. Advocate to family and workplaces. Appropriately manage pharmacotherapy. These are all things “to do.” “What not to do” are invasive interventions that interfere with M-unit regeneration.
6-2 Relationship with EBM: Is There No Evidence?
The criticism that “there is no evidence for Conservative Psychotherapy through RCTs” is also expected. This is a fact and must be honestly acknowledged. Conservative Psychotherapy, by its nature (choosing what not to do, non-invasiveness, individuality, long-term nature), is structurally difficult to verify through RCTs.
However, this difficulty does not mean that Conservative Psychotherapy is not based on evidence. 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 testable. The proposition that “daytime external stimuli promote M-unit recovery” is consistent with existing research (evidence for light therapy and exercise therapy). Multiple pieces of evidence exist showing that “long-term maintenance of the therapeutic relationship contributes to improved prognosis” (Firth et al., 2017; Norcross & Lambert, 2019).
Conservative Psychotherapy does not “lack evidence”; rather, it is “difficult to verify with conventional evidence-generation models.” For the verification of this therapy, rather than RCTs, long-term cohort studies, therapeutic relationship studies, Patient-Reported Outcome (PROM) studies, and qualitative research methods are appropriate.
6-3 Ethical Limits of “Permitting Chronicity”
There are ethical limits to the position of “permitting chronicity.” It is necessary to discuss this sincerely.
“Permitting chronicity” “minimizes harm” only when the therapeutic relationship is maintained and the worst outcomes (suicide, social collapse) are prevented. Chronicity where the relationship is not maintained (dropping out of treatment/support) is not harm reduction but “mere abandonment.”
Furthermore, “permitting chronicity” must not become an excuse to justify “therapeutic sloth” or “avoidance of growth” on the part of the therapist. Conservative Psychotherapy is not “anything goes.” Therapists have an obligation to constantly ask, “Is the current conservative attitude best?” Regular supervision, case reviews with colleagues, and re-evaluating treatment strategies as needed are essential even in Conservative Psychotherapy.
Furthermore, in some cases (especially moderate-to-severe Bipolar Disorder, psychotic depression, and serious suicide risk), a conservative attitude alone is insufficient, and active intervention (ECT, hospitalization, strengthening pharmacotherapy) becomes necessary. Conservative Psychotherapy is not a “universal therapy applicable to all psychiatric disorders” but a “selective strategy to judge application according to the state, pathology, and period.”
6-4 Context-Dependence as a Japanese Psychotherapy
Since I claim that Conservative Psychotherapy inherits the tradition of “Japanese psychotherapy,” I must also sincerely discuss its context-dependence.
As shown in this paper, Conservative Psychotherapy has aspects established on top of institutional and social infrastructures like “urban anonymity” and the “Japanese medical system (free access, acceptance of long-term visits, low out-of-pocket costs).” In contexts where these conditions differ (rural areas, US-style insurance systems, institutional environments that mandate short-term intensive intervention), the practical feasibility of Conservative Psychotherapy is limited.
In this sense, Conservative Psychotherapy should be understood as an “attitude” rather than a universal “technique.” Along with the erosion of Japanese infrastructure (limitations on free access, reduction of medical fees for long-term visits), there is a possibility that the “institutional foundation” of Conservative Psychotherapy will also be lost. Another significance of systematizing Conservative Psychotherapy is to visualize the value of this institutional foundation and provide a basis for socially advocating for its protection.
Chapter 7: Ethical Synthesis: Position Statement for Conservative Therapy
7-1 Organizing the Ethical Core Propositions of Conservative Psychotherapy
The content discussed throughout this paper is organized below as the “Ethical Core Propositions” of Conservative Psychotherapy.
| Core Proposition | Summary of Content |
|---|---|
| Proposition 1: Ethics of Biological Time | There is a biologically necessary time for recovery from depression. Interventions that try to shorten this time interfere with the M-unit regeneration process and can be harmful. Therapists must have “respect for biological time.” |
| Proposition 2: Duty to Protect the Scab | SB by the D-unit is a scab protecting M-unit regeneration. Forcibly peeling this scab is an iatrogenic injury. Therapists have a “duty to protect the scab.” |
| Proposition 3: Positivity of Non-Action | “Choosing not to intervene” is not passivity but an active medical choice based on an evaluation of the harmfulness of intervention. Professional non-action is a technical act requiring high-level knowledge and training. |
| Proposition 4: Protective Function of the Therapeutic Relationship | A continuous relationship with a therapist functions as a substitute stabilizer for the M-unit and suppresses the D-unit’s self-elimination program. Maintaining the therapeutic relationship itself is a therapeutic act. |
| Proposition 5: Respect for the Patient’s Unique Way of Surviving | The defense structures, lifestyles, and interpersonal patterns through which a patient has survived so far are a person’s “technique for survival” before they are “symptoms” of a disorder. Removing these easily is to dismantle the technique for survival. |
| Proposition 6: Requirement for Temporal Justice | Society, institutions, and families have no right to criticize the biological recovery time of depression as “unjustifiably long.” Therapists play the role of advocating for temporal justice as the patient’s representative. |
| Proposition 7: Active Permission of Chronicity | Chronicity is not a failure of treatment but an active choice to wait for biological regeneration while avoiding the worst outcomes. However, this is predicated on maintaining the therapeutic relationship and is distinguished from abandonment. |
7-2 Redefining the “Professional Stance” of Conservative Psychotherapy
The most fundamental question arising through this paper is: “What is the professionalism of psychiatrists and psychotherapists?”
In the model of modern medicine, the role of the professional has been defined as the one who “makes a diagnosis, performs an intervention, and improves symptoms”—the Director. In this definition, “doing nothing” implies a renunciation of professionalism.
Conservative Psychotherapy fundamentally questions this definition. It argues that the most important role of the professional is not “directing” but “taking on time together (time-bearer).” And the role of “taking on time” is not “doing nothing” but “enduring the time together with the patient until the process is complete, while protecting the biological regeneration process without violating it.”
In this sense, Conservative Psychotherapy is a proposal to shift the weight of psychiatric professionalism from “mastery of intervention techniques” to “non-invasive protective techniques and the patience of waiting.” This shift means “deepening” rather than “shrinking” professionalism.
Conclusion: An Ethical Declaration: “You May Exist While Remaining Unhealed”
“Conservative Psychotherapy” converges into a single proposition:
You may exist while remaining unhealed.
This proposition is not powerless resignation. It is an expression as an ethical declaration of the biological facts shown by the integrated MAD+SB theory: “M-unit regeneration takes time,” “protecting the scab makes regeneration possible,” and “forcibly peeling the D-unit’s scab expands the damage.”
Just as a surgeon spares a breast to protect the patient’s physical self, a psychiatrist spares the shape through which a patient has survived so far to protect their psychological and existential self. This “protecting” is not passive. Respecting biological time, defending the scab, continuing to maintain the therapeutic relationship, resisting temporal injustice, and continuing to supply stop signals to the self-elimination program—these are all active medical acts.
When meritocratic medical evaluations measure patients by “speed of recovery,” psychiatrists have a role as cultural and ethical resistors who “evaluate patients not by speed but by continuity.” There are cases where “healing as quickly as possible” is not the good, but “stacking small stabilities while avoiding catastrophe over biologically necessary time” is the good. Protecting this “slow good” is the ultimate mission of Conservative Psychotherapy.
Recovery is not a straight line toward the light. Acknowledging the time spent stopping, returning, taking detours, and circling the same spot as “time when it is okay to live”—the practice of that acknowledgment is the quiet question and answer that Conservative Psychotherapy throws toward modern psychiatry.
Theoretical Notes and Supplements
Note 1: Distinction between “Professional Non-Action” and Non-Action in Medical Ethics
In medical ethics, “omission” is generally treated more lightly than “harm by action (commission)” as “not causing harm.” However, “Professional Non-Action” in Conservative Psychotherapy is not a matter of ethical superiority but choosing non-action as the result of the best therapeutic choice, fundamentally different from “non-action due to laziness or indifference.” The problem of the “moral status of omission” discussed by Quinn & Shue (1989) and others needs to be reinterpreted in the context of psychotherapy as “active non-action with a therapeutic purpose.”
Note 2: Differences and Similarities with Morita Therapy
Conservative Psychotherapy resonates with Morita Therapy in the “ethics of non-manipulation,” but they are not the same. Morita Therapy mainly targets neuroses (anxiety/obsessions) and aims for a specific change in attitude called “Aruga-mama.” Conservative Psychotherapy targets a wider range of disorders (depression, bipolar disorder, chronic illnesses in general) and is more thoroughly non-directive in that it refrains from the compulsion of attitude change itself. Furthermore, Conservative Psychotherapy is in a complementary relationship with the philosophical and phenomenological foundations of Morita Therapy in that it has a neurobiological basis called the MAD+SB theory.
Note 3: Differences and Similarities with Supportive Psychotherapy
Regarding the relationship with Supportive Psychotherapy (Rockland, 1992; Gabbard, 2004): Supportive Psychotherapy aims for active “strengthening,” such as “strengthening the patient’s defenses and supporting ego functions.” Conservative Psychotherapy aims for “preservation,” such as “not violating the patient’s existing defenses, lifestyle, and the shape they have survived through.” Strengthening and preservation are different: strengthening is “making things better,” preservation is “not destroying the current state.” If Supportive Psychotherapy is “propulsion in an upward direction,” Conservative Psychotherapy is an “active choice of maintaining the status quo.”
Note 4: Critical Dialogue with the Recovery Model
The framework of “reconstructing life by an autonomous subject” emphasized by the “Recovery Model” (Anthony, 1993; Slade, 2009) has given hope and direction to many patients. Conservative Psychotherapy does not deny this model. However, it points out the fact that specific practices like “making them speak,” “making them narrativize,” and “making them have goals” can be harmful to some patients (especially those with acute depression, chronic cases, and patients hurt by speaking). The two have different ranges of application in terms of “applicable patients, period, and state,” and it is not a relationship where one is right and the other is wrong.
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