MAD Theory · Conservative Psychotherapy: Integrated Edition (Q&A) 2026.03.08
Conservative Psychotherapy ── MAD Theory Integrated Edition (Q&A) ── 30 Questions Answering the Doubts of Readers (Psychiatrists) Kon Tadashi, Shinagawa Psychosomatic Clinic
About This Q&A
This Q&A organizes, into 30 questions across 7 categories, the doubts that psychiatrists and psychotherapists are likely to hold regarding the integrated treatise on MAD Theory, SB Theory, and Conservative Psychotherapy. In formulating each answer, care was taken to clearly distinguish between “what is honestly acknowledged” and “what can be answered from within the theory.” This document describes not only the strengths of the theory, but also its limitations and unresolved points, with candor.
Part I: Questions About the Theoretical Foundation
Q1: What, in the end, do the “M-unit” and “D-unit” correspond to in the brain? Do they have neurobiological entities?
This is the most important question, and one that must be answered honestly.
The current answer is: “Functional correspondences can be indicated, but one-to-one neurobiological entities have not yet been definitively identified.”
MAD Theory is a model that does not first define neurobiological entities, but rather describes clinically observed phenomena as “functional clusters.”
As provisional correspondences: the M-unit has strong affinity with the integrated functional complex of the dopamine reward system (mesolimbic system), the noradrenaline arousal system (locus coeruleus), and the orexin arousal-maintenance system. The “sleep component” is thought to correspond to the sleep substance production process involving adenosine and prostaglandin D2. The D-unit can be provisionally understood as a composite of CRH–cortisol system hyperactivity (HPA axis), the action of inflammatory cytokines (IL-1β, IL-6, TNF-α), and reduced serotonin function.
However, these are “hypothetical correspondences” and not definitive identifications such as “M-unit = a specific nucleus.” The value of this theory lies not in the definitive identification of entities, but in the coherence of the explanatory model that describes clinical phenomena with consistent logic. The identification of entities is a task for future neurobiological research.
Q2: What does the “Primacy of Mania” mean? Are you claiming that manic hyperactivity precedes every case of depression?
The “Primacy of Mania” is the proposition that “before every depressive state, there exists some form of M-unit hyperactivity (a state of emergency).” The “manic hyperactivity” referred to here is not limited to clinical manic episodes (those meeting DSM-5 criteria).
Interpreted broadly: the rapid activation of the immune system due to viral infection; excessive tension, effort, and exertion in responding to psychological conflict or major stress; endogenous periods of elation and high energy—all of these correspond to a “full-mobilization emergency-response state” of the M-unit.
Therefore, the “Primacy of Mania” does not mean “a clinical manic episode necessarily precedes depression.” Rather, it refers to a broader developmental sequence—”hyperactivity → injury → freeze”—meaning that “before reaching a depressive state, some form of M-unit hyperactivity (overloaded state) must invariably have existed beforehand.” This is consistent with the clinical experience that “people who have always given everything they have are the ones who become depressed.”
Q3: Isn’t it contradictory that the M-unit is both “the source of activity” and simultaneously “the source of sleep”?
This appears contradictory, but is not. This dual functionality is one of the core propositions of MAD Theory.
As an analogy: the sympathetic nervous system in the autonomic nervous system governs “activity mode,” yet a healthy transition into sleep is made possible by the “appropriate calming” of sympathetic nervous activity. That is, activity and rest are not simple opposites but rather “two modes of the same system.”
A more precise explanation within MAD Theory is: the M-unit has two aspects—”the component that generates activity (manic component)” and “the component that induces sleep in the brain (sleep-induction component).” Under normal conditions, these two components maintain a balance. In manic states, the “manic component” overwhelms the “sleep-induction component,” resulting in hyperactive insomnia. In depression, both components disappear simultaneously, making neither activity nor deep sleep possible.
Insomnia in mania and insomnia in depression are qualitatively different.
As a neurobiological correspondence, reference can be made to the circuit in which the accumulation of orexin/hypocretin activity during wakefulness serves as an indirect driver of sleep pressure (adenosine) production. This is consistent with the empirical fact that “a brain that has been sufficiently active can sleep deeply.”
Q4: Is there a neurobiological basis for the mechanism by which “M-units are processed and destroyed during sleep”?
The most directly relevant is Tononi & Cirelli’s (2006) “Synaptic Homeostasis Hypothesis (SHY),” which proposes a mechanism whereby “synaptic connections strengthened during wakefulness are globally downscaled (weakened) during non-REM sleep.” This downscaling corresponds neurobiologically to the “M-unit organization and disposal program.”
In healthy individuals, downscaling functions adaptively as “capacity maintenance.” In depressed patients, the interpretation holds that this downscaling is “pathologically enhanced,” or alternatively that “upscaling (synaptic re-strengthening) to counteract downscaling is not functioning,” resulting in an excessive reduction of synaptic strength and neural activity toward morning.
Research by Ly et al. (2018) and others showing that pre-sleep administration of ketamine antagonizes this downscaling, induces synaptogenesis, and produces improvement in the following morning’s state supports this interpretation. However, the SHY hypothesis itself is still under investigation, and the correspondence with this theory’s proposition of “the toxicity of sleep” should honestly be treated as “a consistent hypothetical connection.”
Q5: Do SB (Sickness Behavior) theory and MAD Theory really connect? SB theory assumes a causal chain of “inflammation → depression,” while MAD Theory assumes an entirely different pathway of “M-unit injury → depression.”
The key to integration is the recognition that “the two theories explain different levels.”
SB theory answers the evolutionary and functional question: “Why have organisms evolutionarily maintained the behavioral pattern of the depressive state?” MAD Theory answers the question specific to the pathology: “Why does human depression present with features (insomnia, early-morning awakening, guilt, suicidal ideation, episode autonomization) that differ from SB?”
The connection lies in “the logic of pathogenesis by elimination.” Both SB and MAD Theory share the structure that “when the higher-order activity that should have existed drops out, the lower-order defensive state is exposed in raw form” (Jacksonianism).
Furthermore, the “shutdown of the activity system by inflammatory cytokines” described by SB theory can be subsumed as “one pathway of M-unit injury” in MAD Theory. The chain of viral infection → immune activation → cytokines → M-unit functional suppression constitutes the neural mechanism of SB, and this can be coherently understood as “one pathway by which inflammation brings down M-units.”
Part II: Questions About Clinical Theory
Q6: What is the difference between “Conservative Psychotherapy” and “Supportive Psychotherapy” (Rockland 1992, Gabbard 2004)? Aren’t they the same?
There is overlap, but the center of gravity differs. This distinction is important.
The goal of Supportive Psychotherapy is to “strengthen the patient’s defenses and support ego functioning.” It is a therapy that “promotes upward movement toward a better state.”
The goal of Conservative Psychotherapy is to “not disturb (preserve) the form, defensive structure, and lifestyle through which the patient has survived until now.” This is a protective therapy that means “not destroying the current state.”
Specific differences: Supportive Psychotherapy includes active “efforts toward improvement,” such as “teaching more adaptive coping” or “raising self-esteem.” Conservative Psychotherapy carefully refrains from any “intervention that attempts to improve existing defenses.” “Support up” and “preserve as is” point in different directions.
By analogy: Supportive Psychotherapy is “giving fertilizer to a plant to help it grow”; Conservative Psychotherapy is “when a plant is injured, not putting soil on the wound and protecting it from storms.”
Q7: Doesn’t a stance of “doing nothing” make the patient feel “abandoned”? Where does the therapist’s raison d’être lie?
This is one of the most important practical issues.
Conservative Psychotherapy is not “doing nothing”—it is “actively choosing not to disturb.” How this difference is communicated to the patient becomes the core of practice.
The therapist’s raison d’être is summarized in three functions:
Function 1: M-unit substitute stabilizer. The ongoing maintenance of the therapeutic relationship functions as a substitute for M-units, providing “a minimum supply of optimism” and “a foundation of safety.” The continuously supplied fact that “I am here for you even if you don’t change” serves as a counterargument to the D-unit’s assessment that “I am a cost to the group.”
Function 2: External supply of the stop signal. While M-units are absent, the therapist’s repeated provision of the recognition that “the desire to die is a temporary program that will disappear when M recovers” serves as an external stop signal against suicidal ideation.
Function 3: Advocacy for temporal injustice. In the face of pressure from the workplace, family, and institutions asking “why aren’t you better yet?”, the therapist serves as an advocate and buffer by stating “there is biologically necessary time.” This is an active form of social intervention.
The feeling of “being abandoned” arises when the therapist silently “does nothing.” In Conservative Psychotherapy, it is required to continuously demonstrate through words and actions that “my being here is the substance of treatment.”
Q8: Without “correcting cognition,” how do you address the patient’s “distorted cognition”?
The starting point is to question the very expression “distorted cognition.”
From the perspective of MAD Theory, the “pessimistic thinking, guilt, and worthlessness” in depression are not understood as cognition being “distorted,” but rather as “a state in which the D-unit is exclusively processing cognition in the absence of the M-unit.” The problem, in other words, is not “cognitive distortion” but “cognitive processing bias (the disappearance of M as a balancer).”
Based on this understanding, the direction of intervention shifts from “correcting the distortion” to “understanding that when the M-unit regenerates, cognitive balance will naturally recover (psychoeducation).”
Concretely: explaining to the patient that “the reason you feel this way now is not because your thinking is wrong, but because the balancer of your thinking is temporarily absent” allows the cognitive bias to be explained without reinforcing the patient’s self-reproach.
The CBT exercise of “searching for counterevidence” risks, in the absence of M-units, creating the contradictory situation of “asking the D-unit itself to process counterevidence against the D-unit.” Cognitive restructuring is work to be undertaken in the stable phase after M-units have regenerated.
Q9: Doesn’t “permitting chronicity” mean that the therapist causes the patient to become dependent over a long period? Doesn’t it create therapeutic dependency?
This is an important concern, and it must be honestly confronted as one of the ethical limitations of Conservative Psychotherapy.
First, a distinction must be made between “dependency” and “sustained support relationship.” Dependency is fixation in a state where the patient cannot function without the therapist; sustained support is “a state in which the patient’s daily functioning is maintained, while presupposing the existence of the therapist.”
The latter is what Conservative Psychotherapy aims for. The goal is not “deepening dependence on the therapeutic relationship,” but “enabling the patient to maintain daily life at minimal cost with the therapeutic relationship as a secure base.”
The problem of dependency tends to arise when the therapist begins to substitute for the patient’s functioning (taking over decision-making, fully absorbing the patient’s daily emotional processing). In Conservative Psychotherapy, the crucial boundary is: “the therapist is there,” but not “the therapist functions in the patient’s place.” Managing this boundary is ensured through supervision and regular review of the treatment structure.
There are also clear conditions for permitting chronicity: that the therapeutic relationship is maintained; that the worst outcomes are prevented; and that the patient’s daily functioning is maintained above a certain level. If these conditions are compromised, a strategic review becomes necessary.
Q10: You say “recovery in 2–4 months,” but what about patients who do not recover for years? Isn’t this a contradiction in the model?
This is an incisive question, and it also indicates the limits of the model.
“2–4 months” is the “basic biological time” required for M-units to regenerate after a single injury. If this period is prolonged, several explanatory pathways exist:
Pathway 1: Ongoing re-injury. If environmental triggers have not been removed (structural workplace problems, ongoing family relationship stress, co-morbid chronic illness), a cycle occurs in which M-units are re-injured before they can regenerate. This is a state of “repairing the engine while continuing to drive on the same harsh road,” and 2–4 months will not be sufficient for recovery.
Pathway 2: Kindling (sensitization) phenomenon. Repeated depressive episodes cause cumulative damage to M-units to accumulate, extending the time required for recovery. This corresponds to the clinical experience of “3 months the first time, 6 months the second, 1 year the third.”
Pathway 3: Inflammatory chronification (connection to the SB model). When chronic inflammation and persistent immune system activation continue, cytokine-mediated M-unit functional suppression persists. In this case, intervention targeting “the regenerative environment of M-units itself (the inflammatory burden)” becomes necessary.
Accordingly, cases of prolonged course are not “contradictions of the model,” but can be understood as “complex cases involving the additional pathologies of ongoing re-injury, kindling, and chronic inflammation.”
Q11: You speak of “threshold management of external stimuli,” but how is the “appropriate amount of stimulation” to be clinically determined? Are there specific indicators?
This is the technically most demanding aspect of Conservative Psychotherapy, and at present there are no “precise quantitative indicators.” However, the following can be presented as clinical guides for judgment.
Recovery-promoting stimuli (recommended range): Brief exposure to natural light (15–30 minutes); meals (sitting down at regular times even without appetite); brief conversation with family (not making the patient speak unilaterally, but serving as a listener); gentle walks of about 10–15 minutes. Common to all of these is that they are “passive receiving that does not require the patient to act actively.”
Clinical indicators as signs of excessive stimulation: (1) deterioration from the following day onward (the morning after stimulation is clearly worse than the previous day); (2) increased agitation and anxiety (compulsive tension of “I must do something”); (3) further deterioration of sleep (inability to sleep after stimulation); (4) direct reports from the patient that it “was exhausting.”
Thresholds vary greatly by individual and also change by stage of recovery. In the early stage (the acute phase when mornings are at their worst), it is practically effective to begin with minimal stimulation and gradually increase as diurnal variation ameliorates—a “staged stimulation management” approach.
The role of the psychiatrist becomes that of an “environmental tuner”: continuously fine-adjusting the type, quantity, and timing of stimulation while observing the patient’s response is the technical core of this therapy.
Part III: Questions About Ethical Issues
Q12: You speak of “the expertise of non-action,” but isn’t this a form of paternalism? When a patient says “I want to get better; I want to return to work quickly,” but the therapist says “wait”—doesn’t that violate the patient’s autonomy?
This is one of the most important ethical questions, and it requires a response on two levels.
Level 1: Temporal understanding of autonomy. From the perspective of MAD Theory, when M-units are non-functional, the patient’s decision-making capacity is temporarily impaired. The desire to “want to recover” and “want to return to work soon” is an authentic intention based on the future outlook supplied by M-units; however, the means chosen (“return to full force right now”) may be excessively driven by the cognitive bias of D-unit dominance (“if things stay this way, I will be a burden to everyone”). True respect for autonomy includes not only “following the patient’s currently expressed will,” but also a temporal perspective: “how will the patient evaluate this decision after the M-unit has regenerated?”
Level 2: Conditions for paternalism. In medical ethics, paternalism is ethically permissible when “the patient’s decision-making capacity is temporarily impaired, the intervention is consistent with the patient’s long-term interests, and it can be reasonably presumed that the patient, when autonomy is restored, will support the intervention” (Feinberg 1971). The acute phase of depression is likely to satisfy these conditions.
However, this is only “a temporary supplement to decision-making capacity during the acute and intermediate phases,” and as a matter of principle, decision-making authority over treatment policy should be returned to the patient upon entering the recovery phase. Furthermore, the harm of paternalism can be minimized by carefully designing the intensity, explanation, and consent process for the instruction to “wait.”
Q13: If you ethically justify “permitting chronicity,” doesn’t it become an indulgence that excuses the therapist from making an effort? There is a risk of justifying therapeutic laziness.
This criticism is valid and is one of the greatest dangers of Conservative Psychotherapy. Let me respond clearly.
In Conservative Psychotherapy, “permitting chronicity” is an active choice made on the premise that all three of the following conditions are simultaneously met:
Condition 1: Active maintenance of the therapeutic relationship. Permitting chronicity is not “abandonment of the relationship,” but presupposes “long-term maintenance of the relationship.” Regular consultations, continuous monitoring of the patient’s condition, preparation for crisis intervention, appropriate management of pharmacotherapy—”not rushing” proceeds on the foundation of all these being continued. Not “you don’t need to come,” but “please keep coming, even if slowly” is the conservative stance.
Condition 2: Active prevention of the worst outcomes. Active intervention to prevent the worst outcomes (suicide, social collapse, irreversible functional loss) is indispensable even in Conservative Psychotherapy. “Permitting chronicity” does not mean “permitting deterioration.”
Condition 3: Periodic strategic review. The therapist has an obligation to periodically ask “whether the current conservative stance is optimal.” Self-examination through supervision, case discussions, and consultation is necessary.
“Permitting chronicity” that lacks these three conditions is not Conservative Psychotherapy—it is mere neglect. Maintaining this distinction clearly is the therapist’s ethical responsibility.
Q14: Doesn’t the explanation that “suicidal ideation is a D-unit program” trivialize the patient’s subjectivity and existential suffering? Isn’t there an ethical problem with treating the desire to die as a “bug”?
This is a profound question, and the honest response is to hold the tension without resolving it.
First, the term “bug” is a clinical metaphor to simplify explanation to patients, and it does not deny the existential weight of suicidal ideation. The suffering of a patient who feels “I want to die” is genuine, and it is ethically unacceptable to trivialize that experience as “a mere malfunction.”
The intent of the “D-unit’s self-elimination program” explanation in Conservative Psychotherapy is to enable the patient to understand that: “your suffering is real, but the ‘conclusion pointing toward death’ that arises from within that suffering is a temporary judgment deviation under the special condition of current M-unit absence.” This is not a denial of suffering, but an attempt to separate suffering from the “conclusion toward death.”
However, in some patients, suicidal ideation functions not simply as M-unit absence, but as a legitimate response to deep existential despair, an unreasonable situation, or chronic suffering. In such cases, the “program bug” explanation may cause harm to the patient, and a more careful existential dialogue is required.
A model is a tool, and the duty to carefully evaluate the patient’s context before applying the tool to a patient precedes all psychotherapy.
Q15: “Temporal Justice” is a new concept—how does it align with existing frameworks in medical ethics?
“Temporal Justice” is not explicitly stated in the existing four principles of medical ethics (Beauchamp & Childress), but it can be interpreted as an extension of the “Justice” principle.
The ordinary Justice principle primarily refers to “fair distribution of medical resources,” but Temporal Justice argues for fairness in the temporal dimension: “the fairness of society guaranteeing the time necessary for biological recovery.”
As philosophical background, the logic of Rawls’s (1971) “original position (veil of ignorance)” can be invoked. The question “if you did not know that you would contract depression, what temporal guarantees would you seek in designing a social institution regarding recovery time from depression?” leads to support for temporal justice.
It can also be connected to the discussion of “protection of temporal resilience” discussed in the fields of disability studies and chronic illness ethics, and to the concept of “right to recover” in psychiatric care.
This concept is at the stage of proposition, and there remains room for refinement, critique, and revision through future medical-ethical examination. The honest position is to present this not as “a concept that fits within an established framework,” but as “a question that psychiatry newly poses to medical ethics.”
Part IV: Questions About Relationships with Existing Treatments
Q16: CBT (Cognitive Behavioral Therapy) currently has the strongest evidence base among psychotherapies. Does Conservative Psychotherapy conflict with CBT?
The relationship is not one of opposition, but rather that “the applicable period, pathology, and patient differ.”
CBT is most effective in “the stable phase when M-units have recovered, mild to moderate cases, and patients who have the capacity to perform cognitive work.” The basic techniques of CBT (thought records, behavioral experiments, cognitive restructuring) presuppose a certain level of M-unit functioning (cognitive processing capacity, capacity for self-reflection, ability to carry out tasks).
Conservative Psychotherapy is most appropriate in “the acute phase when M-units are frozen, severe depression, and chronic cases.” Forcing CBT in this condition is like “demanding construction when there are no materials and no tools.”
Therefore, as a principle for clinical differentiation: it is rational to use Conservative Psychotherapy as a foundation in the acute phase and gradually introduce CBT techniques in parallel with M-unit recovery. The temporal succession of “conservative → CBT” is the most appropriate integration model. Furthermore, using CBT as “preventive maintenance therapy” for relapse prevention is entirely consistent with Conservative Psychotherapy.
Q17: How do you think about the role of antidepressants? Does this mean it is acceptable to simply “wait” without using medication?
Quite the opposite. Pharmacotherapy occupies an important position in Conservative Psychotherapy.
Within the framework of MAD Theory, antidepressants are understood not as “directly causing” M-unit regeneration, but as playing the role of “preparing the regenerative environment.” Specifically: increased BDNF production providing neurotrophic support; alleviation of HPA axis hyperactivity (reduction of cortisol toxicity); suppression of inflammatory cytokine production (the anti-inflammatory action of SSRIs); improvement of sleep structure (especially correction of REM sleep excess)—these function to “remove the obstacles to M-unit regeneration.”
As a principle of pharmacotherapy within Conservative Psychotherapy: “refraining from rapid polypharmacy and excessive medication” is consistent with the conservative spirit. This is because an excessive pharmacological burden itself may adversely affect the regenerative environment. “Continuing appropriate monotherapy for a sufficient period” is the basis of conservative pharmacotherapy.
Mood stabilizers (lithium, lamotrigine) also play an important role as a pharmacological foundation of Conservative Psychotherapy in bipolar disorder, functioning to prevent manic switching—that is, “preventing the runaway ignition of M-units in the midst of regeneration.”
Q18: ECT and ketamine are effective as “active reset therapies”—why does Conservative Psychotherapy position these “passively”?
To state the position precisely: rather than “denying” ECT and ketamine, the stance is “carefully evaluating their indications from the position of conservatism.”
In MAD Theory, ECT and ketamine function as “reset therapies that forcibly restart (re-ignite) frozen M-units.” This is certainly effective. In cases involving life-threatening suicidal ideation, catatonia, and severe treatment-resistant cases in particular, these rapid interventions are justified and recommended.
The reason Conservative Psychotherapy positions these “passively” is based on the clinical reality that “in many cases, the environment has not changed.” Even if M-units are forcibly restarted, if the triggers that caused the injury (excessive workplace demands, unresolved family relationships, continuing chronic stress) remain, there is a high likelihood that the same overload will cause re-injury after restart.
This is not to say “ECT is ineffective.” It is a matter of prognosis: “even if M-units are temporarily restarted by ECT, the recurrence rate will be high if environmental correction and psychosocial support do not accompany it.” Conservative Psychotherapy should be used in combination with ECT and ketamine, taking charge of “organizing the regenerative environment after reset”—that is, environmental adjustment, external stimulation management, and maintenance of the therapeutic relationship.
Q19: What is the difference from Morita Therapy? Isn’t Morita Therapy sufficient?
Morita Therapy and Conservative Psychotherapy share the root of “ethics of non-manipulation,” but differ in their target, goals, and theoretical basis.
Morita Therapy’s indication is primarily neurosis (obsessive-compulsive disorder, social phobia, anxiety disorders), and its treatment goal is attitudinal change toward “things as they are.” The approach of “accepting symptoms and then acting toward purpose” presupposes a certain level of M-unit functioning (motivation toward action, capacity for self-reflection).
Conservative Psychotherapy primarily targets depression, bipolar disorder, and chronic mental illness in which M-units are frozen. The starting point is the recognition that “even inducing attitudinal change itself is an overload for the current patient,” and in refraining even from guiding toward the active attitudinal change of “things as they are,” it has a more fundamental non-directiveness.
Furthermore, Morita Therapy takes behavioral change (employment, activity) as its final goal, but “activity” in Conservative Psychotherapy remains positioned only as “provision of passive stimulation that serves as fertilizer for M-unit regeneration,” and does not become “activity as a goal in itself.”
The two have a complementary relationship, differing in the “pathological condition and recovery stage to which they are applied.” Morita Therapy may be appropriate for application as a “successor” to Conservative Psychotherapy, at the stage when M-units have recovered.
Part V: Questions About Institutional, Social, and Cultural Issues
Q20: Doesn’t a model dependent on the Japanese medical system (long-term outpatient visits, low financial burden) make application abroad and international dissemination difficult?
This is a valid point, and the institutional context-dependence of Conservative Psychotherapy is honestly acknowledged in this paper.
However, “institutional conditions” and the “core principles” of therapeutic attitude can be distinguished. Institutional conditions (whether long-term outpatient visits are possible) are the “infrastructure” of conservative therapy, but the core principles of “ethics of non-manipulation,” “biological logic of protecting the scab,” and “therapeutic relationship as M-unit substitute stabilizer” have universal content that does not depend on institutions.
In practice in international contexts, flexible implementation adapted to institutional infrastructure constraints is necessary while maintaining the “attitude” of Conservative Psychotherapy (non-invasive, watchful, accompanying). For example, even with a limited number of consultations, a “conservative attitude” can be expressed. The use of alternative infrastructure such as telemedicine and group support to supplement institutional constraints can also be considered.
Furthermore, the fact that the Japanese medical system has partially institutionalized “temporal justice” has value that can be internationally disseminated as a suggestion for other medical system designs. The internationalization of “Japanese psychotherapy” is perhaps not “exporting the Japanese system,” but “internationally advocating for the values that the Japanese system has protected (the guarantee of temporal margin).”
Q21: Doesn’t saying “it’s okay not to get better” cause the patient to give up on employment, social reintegration, and improvement in quality of life?
The proposition “it’s okay to remain as is” is not “give up on recovery”—it is a declaration of existential affirmation that “in this moment, the fact that you exist already has meaning.” These two are fundamentally different.
Conservative Psychotherapy does not deprive the patient of “hope for recovery.” Rather, it stands in the position of preventing “the possibility of recovery that might otherwise have been, from being damaged by overexertion and deterioration now.” The true meaning of “it’s okay not to get better” is to alleviate short-term urgency about recovery in order to protect long-term recovery potential.
Employment, social reintegration, and improvement in QOL are important goals at the stage after M-units have regenerated. Conservative Psychotherapy does not deny these. However, in opposition to the evaluative criterion that “if you don’t return to work immediately you have no value” or “not getting better is failure,” it provides the counter-recognition that “M-unit regeneration takes time; that is not failure, but biological reality.”
“Slowly recovering” produces a higher quality of final functional recovery than “rushing to break down.” Explaining the value of this choice to patients, families, and society is part of the active therapeutic work in Conservative Psychotherapy.
Q22: From the perspective of EBM (Evidence-Based Medicine), “Conservative Psychotherapy” has no RCT-based evidence. Isn’t calling it a “therapy” an overstatement?
This criticism is addressed with two responses: a discussion of the EBM evidence hierarchy, and the evidence strategy of Conservative Psychotherapy.
Discussion of EBM hierarchy. The EBM hierarchy that positions RCT and meta-analysis as “highest-level evidence” is most effective when the intervention can be made visible, quantified, and controlled. An intervention with the characteristics of Conservative Psychotherapy—”what is not done is the core of treatment,” “individualized, long-term, relationship-dependent”—is structurally difficult to verify by RCT (establishing a control group is nearly impossible). This difficulty does not mean “there is no evidence.” Qualitative research, observational research, long-term cohorts, and patient-reported outcomes are among the evidence-generation methods other than RCT that are appropriate.
Evidence base of Conservative Psychotherapy: (1) research showing that long-term maintenance of the therapeutic relationship contributes to improved prognosis (Norcross & Lambert 2019 meta-analysis); (2) evidence of the antidepressant effects of light therapy and aerobic exercise (biological basis for “daytime external stimulation”); (3) research showing that psychoeducation reduces suicidal ideation and hospitalization rates; (4) observational research showing that not demanding rapid return to work improves long-term prognosis—these function as evidence for the “constituent elements” of Conservative Psychotherapy.
At the stage where there is no RCT of Conservative Psychotherapy as a whole, the honest position is to use the name “therapy” with the explicit statement that it is “a propositional framework still under verification.”
Part VI: Questions Unique to MAD Theory
Q23: The explanation that “manic switching is the runaway ignition of M-units in the course of regeneration” is understandable, but why do some patients not switch to mania and follow a unipolar depressive course?
As a current response within MAD Theory: whether manic switching occurs is thought to depend on the “stability of the M-unit regeneration process.”
In unipolar depression patients, M-unit regeneration proceeds gradually “without runaway ignition.” This may mean the stability of the M-unit regeneration circuit, or alternatively that “the critical stimulation necessary for runaway ignition is not reached.”
In bipolar disorder patients, there exists some “instability (likely mitochondrial functional vulnerability, circadian rhythm gene polymorphisms, calcium signaling abnormalities)” in the M-unit regeneration circuit, giving rise to the hypothesis that the regeneration process tends toward “all-or-nothing” runaway re-ignition.
This also represents a connection with Kato’s (2000) mitochondrial dysfunction model. mtDNA deletion mutations and intracellular pH abnormalities in bipolar disorder can be interpreted as the neurobiological basis of “instability in the control mechanism of M-unit regeneration.”
However, the complete explanation of this distinction remains an unresolved issue in MAD Theory at present, and the identification of “factors that differentiate unipolar depression from bipolar disorder” is a task for future research.
Q24: The explanation that “suicide is less likely at the peak of depression and more likely during the lightening phase” doesn’t this contradict the “waiting” stance of Conservative Psychotherapy? If “the stage when M begins to recover” is the most dangerous, doesn’t waiting conservatively increase the danger?
This is one of the most important points of clinical tension, and must be honestly confronted.
The explanation in MAD Theory is: in the stage where the D-unit (source of suicidal ideation) is still active during recovery, a temporary “mixed manic-depressive state” occurs when M-units (source of action energy) partially recover. At this point “the desire to die” and “the energy to execute it” coexist, making the risk of suicide attempt highest.
Does this contradict the “waiting” stance? It does not. Because: Conservative Psychotherapy is not “merely waiting.” This very “period of the dangerous mixed state during recovery” is the period requiring the therapist’s most active intervention. Specifically: when signs of recovery begin to appear, clearly communicating to both patient and family that “this is a sign of improvement, but also simultaneously the period requiring the most caution”; increasing consultation frequency; lowering the threshold for hospitalization as needed; strengthening the supply of stop signals to M-units.
“Waiting” in Conservative Psychotherapy means “waiting while maintaining appropriate monitoring and protection corresponding to each stage of the recovery process”—not “waiting passively.” The mixed state during recovery is the phase where “the quality of how one waits” is most tested.
Q25: The role of the A-unit (Anankastic cell) is somewhat unclear. How should the A-unit be understood and managed in clinical depression practice?
The A-unit is the most thinly described part of MAD Theory, and this must be honestly acknowledged.
Current understanding: the A-unit is responsible for “steady-state maintenance and compulsive continuation” of the system. Clinically, it is observed as the behavioral pattern of “compulsive fulfillment of duty, perfectionism, inability to stop even when tired.”
In relation to the depression onset process: even when M-units are injured and damaged, the A-unit “forcibly continues the system,” delaying the manifestation of depression. The pre-onset pattern of “continuing to work until unable to work anymore” can be understood as this “final breakdown” of the A-unit.
In the acute phase of depression: with M having disappeared, the A-unit becomes relatively prominent, sometimes observed as compulsive rumination, agitation of “I must do something,” and idle spinning. In Conservative Psychotherapy, calming this A-unit “idle spinning” and assuring the patient that “now is the time to rest according to the D-unit (the scab)” becomes a practical task.
In relation to manic switching: when regenerating M-units ignite explosively, the A-unit may amplify the runaway as “maintenance/continuation.”
Detailed functional description of the A-unit is a future task for this theory.
Q26: If based on the “Primacy of Mania,” shouldn’t the top priority in depression treatment be elimination of the cause—”why the M-unit was injured”? Shouldn’t that be the core of environmental adjustment and psychotherapy?
Absolutely correct, and this is not in contradiction with Conservative Psychotherapy—it is in fact complementary. Those who advocate the Primacy of Mania say that the manic state is a fire, and the depressive state is the burnt residue. To prevent the next depressive state, the manic state that precedes it must be prevented. For this purpose, medication is used, the environment is adjusted, and patient education is conducted. Conservative Psychotherapy thinks through this process in finer subdivisions.
The overall picture of treatment in MAD Theory can be understood in “three stages”:
Stage 1: Acute phase (conservation phase). While M-units are injured and frozen, preventing interference with the regeneration process is the top priority. Active work to remove the cause at this stage risks “rubbing skin that has not yet formed.”
Stage 2: Intermediate phase (preparation phase). When the first signs of M-unit recovery begin to appear, carefully initiate intervention targeting the environmental and psychological factors behind “why the injury occurred.” Workplace environment adjustment, intervention in family relationships, reduction of chronic stress. These are undertaken as “infrastructure work to prevent re-injury.”
Stage 3: Recovery phase (prevention phase). After M-units have sufficiently regenerated, work on “pattern change to prevent the next injury.” Psychotherapy (CBT, psychoanalytic therapy, schema therapy) is most effective at this stage.
Conservative Psychotherapy primarily covers Stages 1 and 2, and “cause elimination” is a task for Stages 2–3. The answer to the question “why were M-units injured?” is a question to be explored together with the patient once the patient is sufficiently stable.
Part VII: Questions About Practice, Training, and Dissemination
Q27: What training is required to master Conservative Psychotherapy? Is it possible to “learn to do nothing”?
“Learning to do nothing” sounds paradoxical, but in reality requires very sophisticated training. The following can be considered as training necessary for mastering Conservative Psychotherapy:
Knowledge: Understanding of the neurobiological basis of MAD Theory and SB Theory. Knowledge of “harm assessment of non-action”—that is, the ability to precisely assess “which intervention would be an overload for the current patient.” Detailed understanding of depression recovery dynamics (diurnal variation, mixed states, risk of manic switching).
Technique: The ability to notice the therapist’s impulse to “want to do something” and to hold that impulse in abeyance (mindful self-observation). Dialogue technique for converting the patient’s “pressure to rush recovery” into the assurance that “now is the time to rest.” The technique of sustained co-presence—”enduring unchanged time together with the patient.”
Training methods: Verbalization, in individual supervision, of “the reasons why an intervention was not chosen.” “Practice in silence” in role play. Accumulation of clinical experience continuously managing patients over long periods. Habituation of case discussions reviewing “consultations in which nothing was done.”
“Doing nothing” is indeed a technique. To be able to choose it consciously, the prerequisite is knowing sufficiently “what can be done.” Only on the foundation of accumulated knowledge and technique does the choice to “deliberately not act” arise.
Q28: Conservative Psychotherapy is described as “Japanese,” but aren’t many Japanese psychiatrists also not practicing this? Is there a basis for the claim that this practice “exists in Japan”?
To be honest, the claim is not that “all Japanese psychiatrists practice Conservative Psychotherapy.” What this paper claims is that “in the cultural foundation of Japanese psychiatric clinical practice, the seeds of this attitude exist.”
The grounds that can be cited are: the fact that Morita Therapy, a Japanese-originated psychotherapy, has been systematized with “ethics of non-manipulation” as its core. The fact that long-term supportive psychotherapy has been widely practiced in Japanese outpatient psychiatric care (the structure of reimbursement scores for outpatient psychotherapy under the Ministry of Health, Labour and Welfare is also designed on the premise of long-term outpatient treatment). The fact that the “culture of not rushing,” symbolized by words like “Well, let’s just take it easy,” has been shared in clinical settings.
However, whether this “implicit culture” has become “conscious, theoretically systematized practice” is a separate question. One of the attempts of this paper is to make this “implicit culture” something that can be consciously practiced, by theorizing, articulating, and ethically justifying it.
Furthermore, the description “Japanese” does not intend geographic limitation. It is used in the historical sense of “developed by Japanese clinical culture,” and similar attitudes can exist in different forms in other cultural and institutional contexts.
Q29: You say “the therapist takes on time,” but doesn’t this increase the risk of burnout for the therapist themselves?
This is an extremely important question, related to the sustainability of Conservative Psychotherapy.
“Enduring unchanged time together with the patient” imposes a considerable psychological burden on therapists. Continuing to observe the same state over a long period without visible results, without gratitude, consumes therapists who have a strong drive to cure—the stronger the drive, the more exhausting. Understanding this, countermeasures are necessary.
As proposals by Conservative Psychotherapy for managing the therapist’s burnout risk:
Theoretical support. Resetting the evaluative criterion that “the fact that the current state is being maintained is itself a success of treatment” is important. A cognitive framework that prevents reading “no change” as “no results” protects the therapist.
Institutional support. Regular supervision, case discussions, peer support. The existence of colleagues with whom the difficulties of Conservative Psychotherapy can be shared is indispensable. The importance of team medicine that does not have one person carrying long-term refractory cases alone.
Personal support. Ensuring lifestyle habits that allow the therapist themselves to maintain their M-unit state (vacation, hobbies, physical activity, sufficient sleep). Under the recognition that “therapists are not immune to M-unit injury,” positioning investment in one’s own well-being as “part of professional ethics.”
Conservative Psychotherapy must be discussed in conjunction with consideration for the therapist’s sustainability.
Q30: Finally, what are the “most difficult patients to explain” in Conservative Psychotherapy? Please honestly tell us the limits of this theory.
This response to this question serves as the honest conclusion of this theory.
Limit 1: Cases with co-morbid personality disorders. When personality pathology such as borderline personality disorder or narcissistic personality disorder overlaps, the conservative attitude of “protecting the scab” may deprive the patient of opportunities for “correction through relationship (corrective emotional experience).” In these cases, more active interventions such as Dialectical Behavior Therapy (DBT) or Transference-Focused Psychotherapy (TFP) may be required.
Limit 2: Cases with trauma/PTSD as the primary pathology. In complex PTSD, the conservative attitude of “not making the patient speak, not delving deeper” may bring about “re-traumatization through silence.” Trauma processing requires staged exposure, and there are cases where cure is difficult with conservation alone.
Limit 3: Psychotic disorders (schizophrenia). MAD Theory is presented as a model of depression and bipolar disorder, and its application to schizophrenia requires separate theoretical examination.
Limit 4: Cases where serious social collapse is in progress. In cases where housing, financial stability, and family relationships have already collapsed, “waiting” may mean permitting irreversible deterioration of the situation. There are situations where urgent social intervention precedes Conservative Psychotherapy.
Having clearly recognized these limitations, Conservative Psychotherapy should be used as “a selective strategy whose application is determined according to the patient’s condition, pathology, timing, and context.”
— End —
