Sometimes, Healing Means Letting Go of the Way

I am a Japanese psychiatrist who has worked in psychiatry for more than 30 years. In this series, I share some of what I have learned about medicine, mental health, life, and people through my experiences in Japan and the United States. 

Sometimes, Healing Means Letting Go of the Way You Think

Taking One Step Further

When someone is suffering emotionally, we often tell them to change the way they think.

"Try to think more positively."

"Don't worry so much."

"Look at things from a different perspective."

These words may sound reasonable.

And sometimes, they are helpful.

Cognitive behavioral therapy, for example, teaches us to look at the way we think about events and to examine whether our thoughts are actually helping us.

I have used this kind of approach myself as a psychiatrist.

But over the years, I have also begun to wonder about something.

What if trying too hard to change the way we think becomes another source of suffering?

A person who is anxious may think,

"I shouldn't be anxious."

Someone who is depressed may think,

"I have to think more positively."

Someone who is worried may think,

"I need to stop worrying."

But then another problem appears.

They are not only suffering from anxiety.

They are also suffering because they believe they should not be anxious.

They are not only feeling depressed.

They are also blaming themselves for being depressed.

They are not only worried.

They are worried about the fact that they are worried.

It can become a kind of vicious circle.

The more we try to get rid of a feeling, the more strongly we may become aware of it.

This is one of the things I have come to think about through my experience as a psychiatrist.

Perhaps we do not always have to change the way we think.

Perhaps sometimes we need to step back from our thoughts.

There is a difference between saying,

"I must change this thought."

and saying,

"This is the thought I am having right now."

The second way of looking at it creates a little distance.

You do not have to fight the thought.

You do not have to believe it completely, either.

You can simply notice it.

"I am feeling anxious."

"I am thinking that something bad might happen."

"I am afraid that I will fail."

These are experiences happening inside us.

They are not necessarily facts.

This does not mean that we should simply accept everything and give up trying to improve our lives.

Quite the opposite.

Sometimes we need to take action.

If something in our life is causing us serious problems, we may need to change it.

If our work is making us sick, we may need to reconsider our work.

If a relationship is hurting us, we may need to create some distance.

If we have developed a habit that is damaging our health, we may need to change that habit.

But there are also things we cannot immediately change.

We cannot change the past.

We cannot control what other people think about us.

We cannot completely eliminate uncertainty from our lives.

And we cannot always control our own emotions.

Perhaps mental health does not mean being able to control all of these things.

Perhaps it means learning how to live with some of them.

This is where I find the ideas of Morita therapy interesting.

Morita therapy, which developed in Japan, has a somewhat different approach from simply trying to eliminate uncomfortable feelings.

Anxiety may still be there.

Fear may still be there.

But we do not necessarily have to wait until those feelings disappear before we begin living our lives.

We can feel anxious and still do what needs to be done.

We can be afraid and still take one step forward.

We can feel uncertain and still make a decision.

This may sound simple.

But for someone who has been struggling with their emotions, it can be a very important shift.

Instead of asking,

"How can I get rid of this feeling?"

we might ask,

"Even with this feeling, what can I do today?"

That is a small change in the question.

But sometimes a small change in the question can change the direction of our lives.

I think there is something similar in cognitive behavioral therapy.

We do not have to accept every thought as the truth.

We can examine it.

We can ask,

"Is this really true?"

"Is there another way of looking at it?"

But perhaps we should also be careful not to turn this into another rule:

"I must always think correctly."

There is no such person.

Human beings sometimes think irrationally.

We become angry.

We become jealous.

We become afraid.

We misunderstand things.

We worry about things that never happen.

That is part of being human.

We do not have to become perfectly rational before we can live a good life.

Sometimes, healing may mean letting go of the idea that we have to think in the "right" way.

We can notice our thoughts.

We can question them when necessary.

We can change what we can change.

And we can leave some things alone.

Perhaps that is what it means to take one step further.

Not simply changing our thoughts,

but changing our relationship with our thoughts.

Not trying to control every emotion,

but learning that we can live even when uncomfortable emotions are present.

And not waiting until we become a completely different person,

but beginning with the person we are today.

As a psychiatrist, I have come to think that this may be one of the quieter forms of healing.

Sometimes we do not need to push ourselves harder.

Sometimes we need to stop fighting so hard.

And then, perhaps, we can finally take one small step forward.

Knowing Is Not the Same as Changing

I am a Japanese psychiatrist who has worked in psychiatry for more than 30 years. In this series, I share some of what I have learned about medicine, mental health, life, and people through my experiences in Japan and the United States. 

What I Learned from Addiction Research in Minnesota

When I went to the University of Minnesota, I worked in Professor Hatsukami's laboratory.

The research there focused on nicotine dependence.

People were recruited through newspapers and other advertisements to participate in research.

Some were given nicotine intravenously, while others took it orally.

The researchers then observed what happened and collected the data.

The results were eventually presented at conferences and published in academic papers.

It was a serious research laboratory.

The professor was highly regarded in the field and was known as one of the leading experts on nicotine dependence.

But as I continued working there, I gradually began to wonder about something.

We were giving nicotine to people and observing their reactions.

We could say,

"This is what happens when nicotine is given to the human body."

That was certainly meaningful.

But I began to wonder:

Does that really tell us everything about nicotine dependence?

Nicotine dependence is not simply a reaction to nicotine.

There is a person's life behind it.

There are habits.

There are relationships.

There is work.

There is stress.

There is a history of how that person came to need nicotine.

And there is the reality that even when someone wants to quit, they may not be able to.

The more I thought about it, the more I felt that studying the effects of nicotine in a laboratory could only tell us one part of the story.

To be honest, I began to lose some of my enthusiasm for the research.

Of course, research has to be focused.

Scientists change one condition and observe what happens.

By doing this repeatedly, we gradually learn more about the human body and mind.

That is how science works.

I understood that.

But real human beings do not live inside a laboratory.

Each person has a different life.

Even when two people are dependent on nicotine, the reasons behind their dependence may be completely different.

So I began to feel that there was a difference between understanding one fact through research and understanding an entire human being.

More than ten years later, I returned to Minnesota.

It was a nostalgic place for me.

The city had changed since the days when I had lived there.

There were new railway lines and new stations.

I got off the train in Minneapolis and thought,

"Since I am back after all these years, perhaps I should visit the place where I used to buy the lunch boxes I liked."

But something unexpected happened.

As soon as I left the station, I was surrounded by cigarette smoke.

People were smoking everywhere outside the building.

It was not just one person.

Or two.

There were so many smokers that I was genuinely surprised.

I found myself escaping back inside the building.

I had imagined that I would walk around Minneapolis and remember the city as I knew it.

Instead, I was thinking,

"Is this really Minnesota?"

This was the place where I had studied.

It was also the home of a professor who was internationally recognized for her research on nicotine dependence.

In a sense, this was her own backyard.

I had expected that this would be a place where people were particularly well informed about nicotine dependence and smoking.

But what I saw in front of me was very different.

Many people were smoking.

And I could do little more than retreat indoors.

Then a question I had had during my time at the university came back to me.

What is research really for?

In the laboratory, we studied what happened when nicotine was given to people.

We wrote papers.

We presented our findings at conferences.

The researcher was highly respected as an expert in nicotine dependence.

And yet, more than ten years later, I was standing in that same city and seeing so many people smoking.

What, then, was research really accomplishing?

I do not mean that research is useless.

Of course not.

Research has taught us an enormous amount.

But I began to think that knowing something through research and actually changing society are two different things.

In science, "knowing" is extremely important.

We discover a cause.

We learn how something works.

We identify a risk.

We determine whether a treatment is effective.

But human life does not necessarily change simply because we know these things.

People know that smoking is bad for their health, and they still smoke.

They know that nicotine is addictive, and they still cannot quit.

They may be told,

"You should stop smoking."

But if cigarettes have become deeply embedded in their daily lives, knowing that they should stop is not enough.

This made me wonder, as a psychiatrist:

Can knowledge really change people?

Perhaps this was one of the questions that stayed with me throughout my career.

Human Beings Cannot Be Understood by Data Alone

Many years have passed since my time in Minnesota.

Looking back, I think that experience was very important to me.

In a research laboratory, we collect data from human subjects.

We analyze it.

We write papers.

We present the results at conferences.

All of that is necessary for science.

But the moment we step outside the laboratory, we encounter people who are living completely different lives.

And those people do not necessarily change because of research findings.

This is why I have come to think that psychiatry cannot end with simple formulas such as:

"This illness requires this medication."

Or:

"This symptom requires this treatment."

We also need to look at the person's actual life.

Can they get out of bed tomorrow morning?

Can they eat?

Can they talk to other people?

Can they go to work?

Can they sleep?

And perhaps most importantly:

Can they make their life even a little better tomorrow than it is today?

I have come to believe that these questions matter.

Research can reveal one part of a human being.

But to understand one person, we have to look at the whole of that person's life.

When I returned to Minnesota that day, I felt this once again.

And now, looking back, I think that the feeling I had when I "lost some of my enthusiasm" for the research was not really disappointment with research itself.

Perhaps it was the moment when I realized something much simpler:

Human beings do not change simply because we have discovered the answer.

Knowing is important.

But knowing is not the same as changing.

And perhaps that is one of the most important things I have learned as a psychiatrist.

How One Psychiatrist Changed the Course of Life

I am a Japanese psychiatrist who has worked in psychiatry for more than 30 years. In this series, I share some of what I have learned about medicine, mental health, life, and people through my experiences in Japan and the United States.  How One Psychiatrist Changed the Course of My Life

How One Psychiatrist Changed the Course of MyLife

An Unexpected Encounter in America 

Sometimes, a chance encounter can change the course of your life.

You may not realize it at the time.

You may simply say hello to someone, have a short conversation, and then go on with your life.

But years later, when you look back, you may realize that meeting that person changed everything.

Something like that happened to me during my time in the United States.

At the time, I was studying and doing research in Minneapolis.

One day, I attended a psychiatric conference in Cleveland.

There, I met a psychiatrist named Dr. Shaw.

He was from Taiwan and was working as a psychiatrist in the United States.

He had come to the conference with his wife.

At first, I thought his wife was Japanese, so I was the one who approached them and started talking.

It was a very ordinary encounter.

I had no idea that this brief conversation would change the direction of my life.

As we talked, Dr. Shaw asked me,

"Would you like to come to Cincinnati and train at the Veterans Hospital?"

I was surprised.

I had not been planning to move to Cincinnati.

But somehow, things moved very quickly after that.

Before I knew it, I had decided to leave Minneapolis and go to Cincinnati.

I drove there by myself.

It took me three days and two nights to make the journey.

When I arrived in Cincinnati, I contacted Dr. Shaw.

To my surprise, he had already spoken with someone in the hospital's personnel department.

They had prepared an identification card for me.

They had even arranged a training schedule.

It was almost as if they had been expecting me to arrive.

I was alone in a city I did not know.

So this kindness meant a great deal to me.

Looking back, I think that was one of the moments when I realized how mysterious human connections can be.

I had simply spoken to someone at a conference.

That was all.

And yet, that one conversation led to a new place, a new hospital, and new experiences that I could never have planned for myself.

At the Veterans Hospital in Cincinnati, I was able to see the treatment of people with addiction.

This was very different from what I had seen in the laboratory at the University of Minnesota.

In Minnesota, I had been looking at addiction as a subject of research.

In Cincinnati, I was seeing people who were actually living with addiction.

Sometimes I received telephone calls from patients who were dependent on heroin.

On another occasion, a former patient with a history of alcoholism, who was working as a cleaner at the hospital, suddenly had a seizure near an elevator.

These were things that I could never have fully understood by studying addiction only in a laboratory.

Addiction was not simply a research topic.

It was part of someone's actual life.

I could see the consequences in front of me.

But my time in America was not only about psychiatry and research.

There were many small experiences that have stayed in my memory.

On Thanksgiving, for example, the hospital gave out free hot dogs.

It was not a particularly important event.

But when you are living in another country, even small everyday experiences can become memorable.

I also noticed differences between Minneapolis and Cincinnati.

Minneapolis was a state capital.

Cincinnati was a very different kind of city.

The differences appeared even in ordinary things.

The central post office in Minneapolis was enormous and was open 24 hours a day.

The post office in Cincinnati felt much more like a typical post office in Japan.

It closed at four in the afternoon.

It made me realize that even within the same country, cities can be very different.

You do not necessarily understand these differences by reading about them.

You have to live there.

There was also a university next to the Veterans Hospital.

One day, some chemicals leaked in a laboratory.

Several fire trucks arrived.

Firefighters wearing protective suits came to the building and put up barriers around the area.

The building was closed off until everything was confirmed to be safe.

At the time, it seemed almost excessive to me.

But perhaps that was the point.

Instead of thinking, "It is probably safe enough," they treated even a possibility of danger seriously.

That attitude toward safety also left an impression on me.

Another thing I noticed was the way forensic medicine was regarded.

I had studied forensic medicine in graduate school.

In Japan, forensic medicine can sometimes seem like a somewhat hidden field of medicine.

But in the United States, I saw it presented much more openly as an established medical field.

It made me think about how the same field can be viewed differently depending on the country and its culture.

Even language can reveal cultural differences.

In America, doctors often referred to their consulting room as an "office."

A small private practice could be an office.

A large medical facility could also have offices.

In Japan, "examination room" and "office" feel like quite different concepts.

But in America, the word "office" seemed to emphasize the place where a doctor works.

These small differences in language made me think about how culture is reflected in everyday words.

There is another person I remember from my time in Minneapolis.

His name was Jejeong.

I had met him at an English school, and we would sometimes meet after classes.

When I was leaving Minneapolis for Cincinnati, I had some furniture and household items left in my apartment.

I could not take them back to Japan.

So I decided to give them to him rather than throw them away.

His wife apparently felt uncomfortable accepting them for free.

She told him,

"You should give him some money."

So Jejeong offered me twenty dollars.

I told him,

"Just keep it. I cannot take these things back to Japan anyway."

Then he said,

"Then let me take you for a drive."

So we went for a drive together.

During that drive, I learned about his life in Korea for the first time.

He had been a high school mathematics teacher.

He once went to school with a hangover and was scolded by the principal.

He did not get along well with some of the other teachers, and they often argued.

Eventually, he and his wife decided to study at the University of Minnesota together.

They graduated from the university.

But finding work was not easy.

They were Asian, and English was not their first language.

He eventually found a research position at the university, but that job also came to an end.

Until that conversation, I had not realized how much difficulty he had experienced.

He had always seemed cheerful when we talked.

Yet behind that cheerful personality was someone struggling to find his place in a foreign country.

He also told me about an idea he had.

He thought the water in Korea was not very clean.

He wanted to ship the clean water from Minnesota to Korea and sell it there.

I did not know whether he was serious or simply dreaming about the future.

But what stayed with me was the fact that, even while struggling in a foreign country and uncertain about his career, he was still thinking about what he might do next.

Eventually, the drive ended.

We said goodbye in front of my apartment.

After I returned to Japan, we continued to exchange emails from time to time.

Then, after he sent me a Christmas program, I suddenly lost contact with him.

I have no idea what happened to him after that.

Even now, I sometimes think about him.

I hope he is doing well.

During my time in America, I met many people.

Researchers.

Doctors.

Nurses.

Patients.

University students.

People I met at an English school.

And even strangers who were kind to me.

Some of those people became important parts of my life.

Others disappeared from my life, and I never saw them again.

When I think about what I gained from studying abroad, I realize that it was not only knowledge or research experience.

The people I met were also a great gift.

And perhaps this is one of the strange things about life.

Sometimes, we move forward not because we carefully planned our next step, but because we happened to meet someone.

A person says something to us.

We say yes.

And suddenly, we are on a different road.

We do not know where that road will lead.

Only later, when we look back, do we realize,

"If I had not met that person, I would not be where I am today."

My encounter with Dr. Shaw was one of those moments in my life.

So was my final drive with Jejeong.

I do not know what became of him.

But I still remember him.

Perhaps that is another thing that living abroad taught me.

We may travel to another country for knowledge, research, or training.

But sometimes, the most important things we bring home are the memories of the people we happened to meet along the way.

The Contradictions I Saw in American Psychiatry

I am a Japanese psychiatrist who has worked in psychiatry for more than 30 years. In this series, I share some of what I have learned about medicine, mental health, life, and people through my experiences in Japan and the United States. 

When I was training in psychiatry in the United States, I often found myself thinking about the way addiction was treated.

Patients who were dependent on drugs were sometimes given medications with longer half-lives, which were easier for medical professionals to manage.

Every day, the patients would come to a designated place.

A nurse would give them their medication and watch them take it.

After confirming that they had taken it, the nurse would even collect the container.

In other words, the addictive drug was not simply eliminated.

Instead, it was replaced with something that could be more easily controlled and managed by the medical staff.

At the same time, I saw a very different approach being used for benzodiazepines, such as certain sleeping pills and anti-anxiety medications, which can also lead to dependence.

In those cases, the medication was gradually reduced.

"Let's reduce your usual dose to two-thirds."

Then it would be reduced again.

Eventually, the goal was to stop the medication altogether.

I found myself feeling a certain contradiction.

Of course, I understood that there were medical reasons for using different approaches for different substances.

But as a psychiatrist, I could not help wondering:

Is it really enough to simply adjust the amount of medication?

What is the real purpose of psychiatric treatment?

Perhaps treatment should not be limited to reducing one medication or replacing one drug with another.

A person's way of thinking matters.

So do their daily habits, their relationships with other people, and the way they interpret what happens to them.

Perhaps psychiatric treatment should also help people gradually change these things.

Ideally, the goal would be for a person to eventually live without having to depend on medication.

That was how I thought about psychiatric treatment at the time.

But when I actually faced people with addiction, I realized that things were not nearly that simple.

You cannot simply tell someone,

"Stop taking the drug."

and expect them to stop.

You cannot simply say,

"Change the way you think."

and expect their thinking to change.

When a habit or dependence has become deeply rooted in someone's life over many years, it can be extremely difficult to change through willpower alone.

That is why medical professionals sometimes need to manage medications very carefully.

And this is where I began to see the large gap between ideals and reality.

The psychiatry I saw in America was highly rational in many ways.

At the same time, it contained contradictions.

To treat addiction, another medication may be used.

For another kind of dependence, medication may instead be gradually reduced.

And yet, perhaps what ultimately needs to change is not the medication itself, but the person's life, habits, and way of thinking.

This made me think about something beyond the American system.

Perhaps this is not simply a problem with American psychiatry.

Perhaps it is one of the fundamental difficulties of psychiatry itself.

How should we balance three things?

Using medication to control symptoms.

Gradually reducing medication when possible.

And helping patients change their own lives.

These three things are not always easy to bring together.

There is no simple answer.

Even after many years as a psychiatrist, I do not think I have found one.

Perhaps that is one of the things I learned most strongly during my time in America:

In psychiatry, what seems contradictory at first may actually reflect the difficulty of dealing with human beings.

We want medicine to be rational.

We want treatment to have clear answers.

But human beings are not always rational.

And recovery does not always follow a straight line.

That may be why psychiatry remains both difficult and fascinating.

What I Learned from Psychiatry in America

A Japanese Psychiatrist's Perspective

When I was training in psychiatry in the United States, I saw many things that were quite different from what I had known in Japan.

One of the things that left the strongest impression on me was the way patients with addiction were treated.

Every day, patients who were registered at a designated facility would come in.

A nurse would give them a long-acting medication in front of her.

She would watch them take it.

Afterward, the container was collected.

The same thing was done every day.

It was not a system in which the medication was simply handed to the patient and the patient was left to manage it on their own.

The medical staff watched the patient take the medication.

They even collected the container afterward.

I could feel how carefully addiction was being handled by the medical professionals.

At the same time, I saw another approach with benzodiazepine sleeping pills and anti-anxiety medications, which can also be addictive.

The medication was gradually reduced.

It was not stopped all at once.

Instead, the dose was lowered little by little.

But as I watched this, I began to have a question.

Was this, in some way, similar to telling a person who smokes,

"From today, try to smoke one cigarette less at a time, and gradually quit."

For someone who is dependent on something, even the act of "gradually reducing it" may not be easy.

A person may understand intellectually that they should stop.

But knowing that and actually being able to stop are two different things.

That experience made me realize once again how difficult the treatment of addiction can be.

There is another scene from that time that I still remember clearly.

After one patient's appointment was over, the doctor who had treated the patient remained alert until the patient had completely left the hospital.

I am a Japanese psychiatrist who has worked in psychiatry for more than 30 years. In this series, I share some of what I have learned about medicine, mental health, life, and people through my experiences in Japan and the United States. 

The patient had become angry and had argued with the doctor before leaving.

The doctor continued to watch carefully until the patient was outside the hospital.

I was somewhat surprised by this.

It felt very different from what I had been accustomed to seeing in Japan.

Until then, when I thought about psychiatric treatment, I probably thought mainly about listening to the patient and deciding what medication might be appropriate.

But treating a person with an addiction is not only about listening and prescribing medication.

The United States is a country where firearms are much more common than in Japan.

That means that, in some situations, a psychiatrist has to think about several kinds of safety at the same time:

the safety of the patient,

the safety of the people around the patient,

and the safety of the medical staff.

All of these things may have to be considered at once.

During my training in America, I learned something that cannot be found simply by reading a textbook about psychiatry.

I saw, with my own eyes, how difficult it can be to actually face a person struggling with addiction.

That experience has stayed with me throughout my career as a psychiatrist in Japan.

Addiction is not simply a matter of having a weak will.

A person may genuinely want to stop.

And yet, stopping can still be extremely difficult.

That is why I believe that medical professionals need a certain kind of caution when treating addiction.

It is not enough simply to prescribe medication.

We have to understand how difficult it can be for a person to change something that has become deeply rooted in their life.

That is what I learned from the scenes I witnessed in American psychiatry.

And even after all these years, I still remember them.

歩くのおすすめ

愛宕山を登ります。

能古島では、渡船場から能古パークまで歩きます。

急な坂を上っているとき。

あるいは、ただ黙々と歩いているとき。

不思議なことに、だんだん考えがまとまってくることがあります。

言ってみれば、神様から通知が来るような感じです。

スマートフォンが「ピコン」と鳴るわけではありません。

もちろん、画面に「神様からのお知らせ」と表示されるわけでもありません。

でも、歩いていると、突然、

「あ、こんなことをしたらいいんじゃないか」

「こういうふうにすれば、うまくまとまるかもしれない」

「これからは、こんな感じでやっていけばいいんじゃないか」

そんなことが、ふと頭に浮かんできます。

それまで、あれこれ考えてもまとまらなかったことが、急にまとまり始める。

今まで迷っていたことや悩んでいたことに対して、自分なりの答えが見えてくるのです。

まるで神様が、

「まだ気づいていないようなので、そろそろ通知しておきます」

と、メッセージを送ってくれているような感じです。

人は、じっとしていると、あまりいいことを考えないように思います。

昔の失敗を思い出したり。

「あのとき、あんなことを言わなければよかった」と後悔したり。

これから先のことを考えて、不安になったり。

考えれば考えるほど、悪い方向へ考えが進んでいくこともあります。

そんなときは、考えるのをやめようと思っても、なかなかやめられません。

だから、私は歩きます。

黙々と歩いていると、不思議なことに頭の中が少しずつ整理されてきます。

そして、しばらくすると、

「あ、これでいいんじゃないか」

という、神様からの通知が届くことがあります。

もちろん、いつも届くわけではありません。

電波の状態が悪いのか、神様が忙しいのか。

それでも、歩いていると、じっと家の中で考えているよりは、ずっと通知が届きやすいような気がします。

だから、暇があれば歩きに出ます。

愛宕山を登る。

能古島を歩く。

ただ、それだけです。

でも、体を動かしていると、頭の中まで少しずつ動き出すような気がします。

悩んでいることがある方。

考えがまとまらない方。

神様からの通知がなかなか届かない方。

一度、歩いてみるのもおすすめです。

『精神科医おどおど日記』を読んで――診断書を書くということ

『精神科医おどおど日記』を読んでいると、自分の日常診療と重なる場面が出てくることがある。

その中に、私自身も何度か経験したことのある場面が書かれていた。

初診で来院され、診察の早い段階で、

「休職の診断書を書いてほしい」

と言われる場面である。

著者は、休職の診断書を出す前に、もう少し症状を見極めたいと考えていた。

ストレスの原因がはっきりしている場合には、適応障害と診断することが多い。

適応障害とは、環境の変化やストレスによって一時的に心身の不調が生じる状態であり、原因となっている環境やストレスが改善されれば、症状も改善することがある。

その説明は、まさにその通りだと思った。

著者はもともと外科医で、その後、精神科に転科された方らしい。

本を読んでいても、診療に対する考え方がしっかりしていると感じる。

患者さんに、

「適応障害の可能性があると思います」

と伝えると、

「診断書は出ますか」

と聞かれたそうである。

著者は、いきなり休職の診断書を書くのではなく、

「病名を記載した診断書をお出ししますので、まず会社に受診したことを伝えてみてはどうでしょう」

と提案された。

そして、

「病気休暇がどのくらい利用できるのかも、会社に確認しておいたほうがよいと思います」

と説明された。

私は、この考え方は素晴らしいと思った。

診断書には、必ずしも「何か月休職を要する」と書かなければならないわけではない。

今後どうするのか。

休職するのか。

勤務を続けるのか。

配置を変えるのか。

仕事の内容を調整するのか。

そうしたことまで、初診の一回だけで決めることには慎重であるべきだと思う。

診断書に現在の診断名や状態だけを書き、今後のことについては、まず会社と相談してもらう。

これは、非常に合理的な考え方だと思った。

ところが、著者がそのように提案すると、患者さんの表情は曇り、腕を組んで考え込まれたそうである。

そして結局、休職の診断書を求める気持ちは変わらず、その病院を後にされた。

その後、その方は別の精神科を受診したという。

著者は、

「死にたい」

と言われたときも、精神科医はうそ発見器ではないと書いている。

患者さんの言葉をすべて疑うということではない。

しかし、初診の一回だけで、その人の状態のすべてを理解できるわけではない。

初診で安易に休職を勧めることは避けたい。

精神科診療では、経過を見るという視点が欠かせない。

受診したその日に、病名を確定できないことも珍しくない。

私も、その通りだと思う。

ところが世の中には、

「即日、休職診断書を出せます」

というようなことを、あたかも売り文句のように掲げている医療機関もあるらしい。

著者は、それを消費者金融のようだと表現していた。

もちろん、患者さんが本当に切羽詰まっている場合もある。

今日、どうしても会社に行けない。

もう限界である。

そのような状態の人に対して、形式論だけを述べて、

「もう少し経過を見ましょう」

と言えばよいというものでもない。

そこは難しいところである。

ただ、初診で来院されて、診察が始まって間もない段階で、

「休職の診断書を書いてください」

と言われたとき、私はいつも少し考える。

その人は、本当に休職が必要な状態なのか。

それとも、今の職場で何か問題が起きており、そこから逃れるために、まず休職という方法を考えているのか。

もちろん、逃げることが悪いわけではない。

本当に危険な職場から離れることが必要な場合もある。

しかし、精神科医が初診のその日に、

「この人は何か月間、仕事を休む必要がある」

と決めてしまってよいのだろうか。

『精神科医おどおど日記』の著者が提案した、

「まず診断名だけを書いた診断書を出す」

という方法は、とても参考になると思った。

ただ、その一方で、患者さんの立場から考えると、そこには一つ問題もある。

患者さんが最初から休職を希望している場合、

「診断名だけではなく、休職が必要だと書いてほしい」

と考えるかもしれない。

実際、著者が経験されたように、

「だったら、もう少し経過も書いてください」

「休職できるような診断書を書いてください」

と、さらに求められることもあるだろう。

なぜなら、その人が診断書を求めている目的は、診断名を知ることではなく、休職するためだからである。

そこで、私は別の方法もあるのではないかと思った。

例えば、初診で来院された方に、こう説明する。

「今日、お話を伺って、気力が落ちていることや、気分が沈んでいることは分かりました」

「会社で、折り合いの合わないことや、強いストレスを感じる状況があるのですね」

「ただ、今日一日のお話だけで、すぐに何か月休職が必要だと決めることは、私にはまだ難しいところがあります」

そして、

「このような場合、まずは会社の上司や担当の方に、現在の就労状況について相談することも一つの方法です」

「仕事の内容や勤務時間を調整できる可能性があるのか」

「病気休暇や休職の制度がどのようになっているのか」

「会社と相談したうえで、今後の処遇を考えていくこともできます」

と説明する。

そのうえで、

「現在の状態を示す診断書をお出しすることはできます」

と提案する。

例えば、

「現在、気力の減退や抑うつ気分などの症状が認められ、うつ状態にある」

というように、現在の状態を記載する。

それを会社に提出し、

「現在、このような状態で精神科を受診している」

ということを会社に知ってもらう。

その後、会社側と本人が話し合い、

仕事を続けるのか。

仕事を調整するのか。

休職するのか。

その選択肢を考えていく。

そして、その経過を見ながら、必要であれば改めて休職の診断書を検討する。

この方法はどうだろうか。

精神科医が初診のその日に、すべてを決める必要はない。

しかし一方で、

「まだ診断が確定できません」

「もう少し経過を見ましょう」

と言うだけでは、患者さんは会社に何を伝えればよいのか分からない。

だからこそ、

「今、どのような状態にあるのか」

を示す診断書には意味があるのではないかと思う。

診断書を書くということは、単に患者さんの希望する文章を書くことではない。

また、医師が一方的に、

「こうしてください」

と決めることでもない。

患者さんの現在の状態を医学的に判断し、その状態を社会や職場に伝える。

そして、その後どうするのかは、患者さん自身と会社、そして必要に応じて医師も一緒になって考えていく。

私は、診断書とは、そのための一つの道具なのではないかと思っている。

初診で休職の診断書を求められたとき、

「出す」

か、

「出さない」

か。

その二つだけではない。

まず、現在の状態を伝える。

そして、会社にも相談してもらう。

その間に、もう少し患者さんの状態を見ていく。

精神科診療には、時間をかけなければ分からないことがある。

その「時間」を確保しながら、患者さんを会社から突き放すこともない。

そのための診断書のあり方を、これからも考えていきたいと思った。

不採用になったからといって、その人の価値が否定されたわけではない

先日、就職の面接に行ったという方の話を聞いた。

求人アプリへの登録は、ご家族に手伝ってもらったそうだ。

自分で求人を探し、応募し、そしてようやく面接までこぎつけた。

決められた時間に会社へ行き、面接室に入り、担当の方としばらく話をしたという。

その方は、これまで長い間、一つの職場で働いてこられた。

しかし、勤務地の移動をきっかけに退職された。

その後、別の会社で働くことになったが、細かい作業が自分には難しいと感じ、自分から退職を申し出られた。

会社の方は、その方の人間性を評価してくださっていたのだろう。

「辞めなくてもいい」と、引き留められたそうである。

それでも本人は、「自分には仕事が十分にこなせない」と考え、退職することを選ばれた。

私は、その話を聞いて、この方はずいぶん真面目な方なのだと思った。

できないことをできるふりをして、会社にしがみつくこともできたのかもしれない。

しかし、自分が十分に仕事ができていないと思った。

だから、自分から辞めることを申し出た。

会社が引き留めてくれたということは、少なくとも、この人が何の価値もない人間だったわけではない。

むしろ、一緒に働いてきた人たちは、この方の人柄を認めていたのではないかと思う。

今回の面接は、特別なものではなかったようだ。

よくある質問をされ、これまでの仕事のことなどを話した。

そして最後に、

「結果は来週の月曜日にメールでご連絡します。ただし、連絡がなければ不採用と思ってください」

と言われたそうである。

私は、この話を聞いたとき、少し引っかかるものを感じた。

採用なら連絡をする。

しかし、不採用なら何の連絡もしない。

もちろん、企業にも事情があるのだろう。

応募者が多ければ、一人ひとりに連絡することは大変なのかもしれない。

最初から雇う気がなかった、と決めつけることはできない。

多くの人に会ってみて、その中で条件の合う人がいれば採用する。

そういうことなのかもしれない。

しかし、面接を受ける側からすれば、その一回の面接に、かなりの思いを込めていることがある。

特に、なかなか仕事が決まらず、不採用が続いている人であればなおさらである。

面接に行く。

人と会う。

自分のこれまでのことを話す。

そして、結果を待つ。

それは、その人にとっては決して小さな出来事ではない。

だからこそ、

「連絡がなければ、不採用と思ってください」

という言葉を聞くと、私は少し寂しい気持ちになった。

本人は、不採用が続いていることもあり、少し気を落としておられた。

何度も不採用になると、人は次第に、

「自分には能力がないのではないか」

「自分には価値がないのではないか」

と思うようになる。

けれども、私はそうではないと思う。

就職は、その人の能力だけで決まるものではない。

会社が今、どのような人を必要としているのか。

どのような仕事をしてもらいたいと思っているのか。

勤務時間や条件が合うのか。

その時に応募してきた人の中で、たまたま誰が選ばれるのか。

そこには、本人の努力や能力だけではどうにもならないことがたくさんある。

就職というのは、ある意味では「縁」なのだと思う。

百社に応募しても採用されない人が、百一社目で、

「ぜひ来てください」

と言われることがある。

それまでの百回の不採用によって、その人の価値が百回否定されたわけではない。

ただ、その会社とは縁がなかった。

それだけなのかもしれない。

私は、その方に、

「不採用が続いているからといって、あなたに能力や価値がないということではありません」

とお話しした。

そして、

「今の就職活動は、面接を受けたからといって、最初からその人を採用するつもりで行われているわけではありません。たくさんの人の中から、会社の都合や条件に合う人を探しているのです」

とお伝えした。

「あなたを必要としてくれる会社は、どこかにあると思います。今回はまだ、その会社と出会っていないだけかもしれません。どうか、めげずに、もう一度挑戦してみてください」

ともお話しした。

長い間、一つの職場で働き続けた人がいる。

次の職場では、自分には仕事が難しいと思い、引き留められても自分から退職を申し出た。

私は、そこにこの方の真面目さを感じる。

だからこそ、不採用が続いたことで、

「自分には価値がない」

と思ってほしくない。

人には、それぞれ向いている場所がある。

そして、自分に合う場所は、すぐに見つかるとは限らない。

何度も扉を叩いて、ようやく開く扉がある。

その扉が開くまでは、

「自分は駄目なのではないか」

と思ってしまうこともあるだろう。

けれども、開かなかった扉の数だけ、その人の価値が減っていくわけではない。

今回の扉が開かなかったとしても、それはその人自身が否定されたということではない。

ただ、その場所との縁がなかっただけなのだと思う。

だから、もう一度。

次の扉を叩いてみてほしい。

どこかに、その人を必要としている場所があるかもしれない。

そして、そこで初めて、

「今までの不採用は、ここにたどり着くまでの途中だったのか」

と思える日が来るかもしれない。

なぜ依存症は繰り返されるのか

田代まさしさんや清水健太郎さんなど、有名人の覚せい剤使用や再犯が繰り返し報道されたことで、「覚せい剤は怖いものだ」という印象が広く持たれるようになりました。

それ以外にも、有名人による覚せい剤や大麻などの違法薬物の問題が、たびたびニュースになります。

そのたびに、「なぜ繰り返すのか」「なぜやめられないのか」「依存症は治らないのか」といった問題が提起されます。

そして、いつの間にか、薬物そのものが「悪いもの」「依存性の強いもの」として、攻撃の対象になっていきます。

もちろん、違法薬物の使用には大きな問題があります。薬物による身体的・精神的な影響も無視することはできません。

しかし、依存症を考えるときに、薬物を使ったという「目に見える現象」だけを問題にしてしまうと、その人がなぜ薬物を使うようになったのかという、もっと大切な部分を見落としてしまうことがあります。

薬物を使用する人の中には、薬物によって苦痛や不安、孤独、緊張などから一時的に逃れようとしている人がいます。

そう考えると、薬物使用は、本人にとっては「何とか今の苦しさをしのぐための方法」になっていることがあります。

いわば、薬物が本人にとっての「自己治療」のような役割を果たしている場合があるのです。

もちろん、それは健康的な方法ではありません。しかし、そこまでして薬物を必要とするほど、その人が苦しい状態にあったということでもあります。

ところが、薬物を使うという末端の現象だけをなくそうとすると、「使わないようにすること」ばかりが治療の目標になってしまいます。

それだけでは、なかなか本質的な解決にはつながらないのではないでしょうか。

大切なのは、

「なぜ、この人は薬物を必要とするようになったのか」

というところまで目を向けることです。

薬物を使わなくても、その人が何とか苦しさに耐えられるようになる。

不安や孤独、緊張、抑うつなどを、薬物以外の方法でも少しずつ受け止められるようになる。

そして、「薬物がなくても生きていける」と思えるところまで、その人自身の力を少しずつ取り戻していく。

そこに依存症治療の本質があるのではないかと思います。

もちろん、これは時間のかかる作業です。

しかし、現在の依存症治療では、ときに「早く薬物をやめさせる」「早く結果を出す」ということが求められすぎてはいないでしょうか。

そこには、医療の報酬や経済的な問題、社会的な損失をできるだけ早く減らしたいという事情もあるでしょう。

けれども、人間の心は、短期間で都合よく変わるものではありません。

人を外から変えることはできません。

だからこそ、本人が自分自身で変わっていくための「ヒント」を与え、少しずつ変わることを支えていくことが大切なのだと思います。

たとえば、アルコール依存症の治療では、飲酒に伴う身体反応を利用して飲酒を抑制する薬が使われることがあります。これは飲酒という行動を直接抑えるという意味では、一つの治療方法です。

しかし、それだけで、その人が「なぜ飲まざるを得なかったのか」という問題まで解決することはできません。

飲酒という現象を抑えることと同時に、

「なぜ、この人は飲まなければならないほど苦しいのか」

というところにも目を向ける必要があります。

飲酒や薬物使用という行動を、ただ取り除こうとするのではなく、その行動の背後にある苦しさを理解する。

そして、その苦しさをほんの少しでも軽くできるように、その人が自分自身で変わっていくための道筋を一緒に探していく。

依存症の治療には、そうした時間と関わりが必要なのではないでしょうか。

回復のために、自分自身ができること

依存症に限らず、うつ状態などでつらい時期を過ごしていると、「何とかこの状態から抜け出したい」「誰かに自分を変えてほしい」と思うことがあります。

苦しさが強ければ強いほど、「この人なら何とかしてくれるのではないか」「この治療を受ければ楽になれるのではないか」と、外に答えを求めたくなるのは、決して不思議なことではありません。

実際、医療機関を訪れるときには、「できるだけ早く楽になりたい」「何とかしてほしい」という気持ちを抱えて来られる方も少なくありません。

その気持ちは、私たち医療者も理解しておく必要があります。

ただ、治療を続ける中で大切になってくるのは、**「自分の回復に、自分自身も参加していく」**ということです。

医師や家族、周囲の人は、回復のための方法を一緒に考えたり、必要な治療を提供したり、悩んだときに支えたりすることはできます。

しかし、本人に代わって、その人の人生を変えることはできません。

最終的に、自分の人生を少しずつ変えていくことができるのは、自分自身です。

これは、「自分ですべて何とかしなければならない」という意味ではありません。

つらいときには、人の力を借りていい。医療の力を借りてもいい。家族や周囲の人に支えてもらってもいい。

そのうえで、自分自身も回復に向けて一歩を踏み出していくことが大切なのだと思います。

治療者の役割も、「その人を変えてあげること」ではありません。

その人が自分自身の力を取り戻していくために、必要なことを一緒に考え、時には耳の痛いこともお伝えしながら、回復への方向を示していくことだと思います。

そのため、治療の中では、患者さんにとって必ずしも心地よいことばかりをお話しするわけではありません。

「それは周囲の人を変えることでは解決できないかもしれません」
「ここは、ご自身で少しずつ変えていく必要があります」
「今までとは違うやり方を試してみませんか」

そうした言葉が、そのときの心の状態によっては、厳しく感じられることもあるでしょう。

もちろん、医師の伝え方が適切でなかったり、患者さんの気持ちを十分にくみ取れていなかったりすることもあります。私自身も、診療を振り返りながら、もっとよい伝え方がなかったかと考えることがあります。

しかし一方で、医療者が患者さんにとって都合のよいことだけを言っていては、本当の意味で回復を支えることができない場合もあります。

そして、もう一つ、現在の医療には難しい問題があります。

それが、インターネット上の口コミや評価です。

一人の患者さんが診療の一場面をどのように受け止めたのかということと、その医療機関が実際にどのような診療を行っているのかということは、必ずしも同じではありません。

それでも、インターネット上では、一つの否定的な投稿が、診療を受けたことのない人の目にも触れ、その医療機関に対する印象や受診するかどうかの判断に影響することがあります。

医療機関にとって、これは決して小さな問題ではありません。

特に、事実関係や診療の背景を確認することができないまま、一方的な評価だけがインターネット上に残ってしまうと、それによって新たに受診しようとする方が不安を感じたり、受診をためらったりすることがあります。

医療機関にとっては、こうした投稿が診療そのものとは別のところで、経営や患者さんとの出会いにまで影響することがあります。場合によっては、単なる「感想」の範囲を超え、営業上の損害につながることもあります。

一方で、患者さんが治療について感じたことを表現すること自体を否定したいわけではありません。

医療には、患者さんと医療者との相性もあります。同じ言葉を聞いても、安心する人もいれば、厳しく感じる人もいます。

だからこそ、インターネット上の評価を見るときには、そこに書かれている内容だけでなく、**「その人はどのような状況で、どのような経緯で、その言葉を書いたのだろうか」**という視点も必要なのではないでしょうか。

医療者も患者さんも、お互いに完全な人間ではありません。

大切なのは、相手を変えようとすることではなく、自分自身ができることを少しずつ考えていくこと。

そして医療者にできるのは、その人が自分自身の力を取り戻していくための道筋を示し、必要なときに支えることです。

「あなたを変えてあげます」ではなく、
「あなた自身が回復していくことを、私たちはお手伝いします」。

私は、医療とはそのようなものだと考えています。