[in Japanese]

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The holistic medical care based upon the principles of psychosomatic medicine is a fundamental basis for clinical medicine, the practice of which all physicians should bear in mind. It is therefore of profound importance to have medical students realize the significance and necessity of psychosomatic medicine in various stages of the whole medical education process. In order to convince young students of psychosomatic medicine, we must present solid scientific data rather than abstract theories. It is most persuasive to show actual examples of incorporating up-to-day research findings produced by ourselves into the clinical practice of psychosomatic medicine. I must point out several problems in the conventional way of medical education. For example, practically no guidelines and lectures on thanatology or death education are included in the curriculum of medical education, despite the fact that we educate students to become doctors who must frequently face human death. The teaching of terminal care, which is just the practice of the holistic medical care itself, is still far from satisfactory. I have made it a rule to discuss in my own office these problems frankly and thoroughly with a small group of medical students who are on the assignment to our department during the undergraduate clinical training period. By pursuing discussions. I have been making an effort to develop students to be doctors with warm humanity who can perceive the inside of patients' feelings. My ideal doctor should possess l) the considerate and humble mind, 2) the ability to perceive what is unseen and 3) the sentiment to feel compassion. When these doctors practice psychosomatic medicine for the sake of patients' benefit, much more desirable way of medical care will come into being. Therefore, medical education plays a very important role.

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Recently, the range of activities of the clinical psychologist is expanding to varied clinical fields. In the hospital setting, cooperation between the physician and the clinical psychologist poses a challenging problem, because it often influences the therapeutic relationship with the patient. This paper reports the activities of the clinical psychologist working for the Department of Psychosomatic Medicine at Toho University Hospital. A perspective on the future role of the clinical psychologist in a general hospital is presented in terms of consultation-liaison functions in order to determine how physicians and clinical psychologists can cooperate with each other. At the Department of Psychosomatic Medicine at Toho University Hospital, the "A-T split" role-sharing formula is used when a patient is treated jointly by a clinical psychologist and a physician. The physician and the clinical psychologist have been successfully coordinating the treatment through exchanging daily information/opinion, written reports on the treatment course, and joint case conferences. However, the range of activities of the clinical psychologist is not confined to psychosomatic medicine in our institution, which functions as a general hospital : other clinical departments seek the therapist's help as well. We have come to believe that it is necessary to offer a consultation-liaison service. In this practice, good cooperation between the clinical psychologist and physicians from individual departments also raises key issues related to the successful attainment of these goals. Our experience at the Department of Psychosomatic Medicine supports our position that for this type of task assignment to be effective, both the clinical psychologist and the physician must become aware of and respect each other's roles and responsibilities as well as their own. Also essential for better therapeutic regimen coordination is regular exchange of well-prepared information and pertinent opinions between those in charge of the patient's treatment.

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Psychosomatic medicine (PSM) is a peculiar medical unit in which clinical psychologists (CPs) are expected to participate along with the classical physician-nurse team. The growing importance of CPs' role has been recognized. Nonetheless, its definition does not seem to have been established yet. In the present study, we have tried to clarify the role in the light of our hospital practice. There are two distinct jobs for CPs : (1) clinical multidimension interview, and ( 2 ) psychotherapy in collaboration with nurses and psychotherapists. The entire framework of the practice will be laid by the practising physicians, and CPs cannot trespass that confinement but they may work freely because they have their language and principles of their own. They can translate physicians' intention into psychological and psychotherapeutic programs. This type of relationship may resemble the hardware and software in a computer system with CPs representing the latter. In order to have this system work to the benefit of the patients, information has to flow quickly back to the attending physicians and a clinical conference of the entire team should be held from time to time. The importance of this cooperative system cannot be overemphasized in the practice of psychosomatic medicine.

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Recently more and more people have come to use private counseling centers in Japan. One rea. son is that there are people who want to get professional counseling services for their psycological problems which are diffcult to solve only with advises given by their friends, families, and/or colleagues. This is especially prevalent in large cities where the individual is more isolated. Although they realize the needs of counseling, they tend to hesitate receiving "psychiatric" treatment. Another reason is that there are needs counseling among those suffering from psychosomatic diseases and/or depressive state concurrently along with and/or after medical treatment. In accordance with such a tendency, more unconventional patients are making use of private counseling centers outside of hospitals. Terefore with increased responsibilities of clinical psychologists, mutual understanding and cooperative relationships among institutions and doctors are becoming more important. In this article, the roles of clinical psychologists in a private counseling center are discussed by analyzing clients who visited our center. Our center has seen 194 clients (56 males and 138 females) since its foundation in October, 1988 to the present(April, 1992). All of the clients were classified according to DSM-III-R. The roles of the private counseling center and its interaction with other medical institutions were also discussed. The clients were classified as follows : 1) Patients with no severe mental and physical problems which do not require continuous medical treatment. 2) Severe psychiatric disorders (schizophrenia and borderline personality disorders). 3) Affective disorders, anxiety disorders_, psychosomatic diseases, somatoform disorders and eating disorders. 4) School refusal and avoidant personality disorders. Most clients of types 1) and 2) found our center through mass-media and visited with their own will. For the clients of type 2), our center has played a referral role to offer hospitals. Our center has supported patients of types 1) and 2) for receiving proper psychiatric treatment by offering primary psycological care as the first step. Psychological treatment has been offered to the clients of type 3) concurrently with medical care. Clients of type 4) have not been treated in hospitals since they had not shown depressive state, impulse and/or physical problems. Most of them needed long-term psychological support and guidance. In summary, the roles of the private counseling center include : 1. to provide clients with primary psychological care before receiving proper psychiatric treatment. 2. to cooperate with a physician by providing the client with psychological service. 3. to provid unique psychological service as a professional counseling center.

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1. In Japan, confusion is evident as to the role and position of the Clinical Psychologist (CP) and the Ps.ychiatric Social Worker (PSW) as their qualifications are not prescribed by the current Japanese laws governing medical services. The government-managed medical insurance system do not cover fees for the team treatment. These institutional inadequacies have caused various problems and difficulties for the content and the practice of psychodynamic treatment. The paper reviews the current situation and recommends solutions from the perspective of a psychiatrist. 2. It is often that the doctor in psychiatry or psychosomatics and the CP provide similar or overlapping services. Models of relationship between the two, both successful and conflicting, are described with suggestions for better understanding on the part of the doctor. 3. The doctor functions in several roles and positions as administrator of the clinic/hospital, planner of the medical examination and treatment. team leader, psychotherapist and others. He/she needs to establish a system to differentiate and integrate these multiple roles. Further development of the system will positively affect the treatment as it allows more effective introduction of transferences, counter-transferences, splittings and acting-outs into the therapeutic process. The paper discusses requirements for management by the doctor to facilitate team work with the CP.

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When a clinical psychologist (CP) plays a positive role in therapy as a member of co-medical staff in psychosomatic medicine, quiet often various conflicts arise among the three-person relationship, especially when it consists of patient, doctor and CP. So far, the two-person psychodynamic relationship model has been applied to solve such conflicts. However, the author feels that this model gives no satisfying outcome. Through his experience with system family therapy, the author has become confident that the pathological three-person system model learned from system family therapy, is much more effective. Based on this model, the author proposes that the CP should play the main role of focusing on the improvement of the patient-doctor relationship. This role is called "Psychological Liaison Function of a Clinical Psychologist". This proposition seems to be similar to the role played by the liaison psychiatrist in liaison psychiatry. However, these two roles are different in their therapeutic structure and function and, furthermore, in their methodologies. In the psychological liaison function, first of all, the implicit rules that always arise from the three-person relationship should be made clear. The aim of this intervension is to prevent the pathological 2 to 1 structure from becoming the therapeutic relationship. The CP is required to maintain a double position, that is, to participate positively in the three-person system, and simultaneously to observe the three-person system which includes himself.

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Clinical psychologists have engaged themselves in the field of psychosomatic medicine in Japan since 1963 when the Faculty of Psychosomatic Medicine was established in Kyushu University. The purpose of this paper is to discuss the role and speciality of clinical psychologists in regard to psychosomatic medicine. The role of psychologists for the therapies of PSD are ; l) to take part in making a diagnosis of patient's psychological problems, 2) to participate in the psychotherapeutic approach to psychosomatic patients. In addition to these roles, it is also important for psychologists in university hospitals to educate medical students and to engage in psychological studies of PSDs in cooperation with physicians. However, since psychologists are not given such an official license as is given to other medical staff members, their position is still weak today. It is felt necessary to establish the official license system for psychologists in order to improve thier present position.

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Recently it has become common, among clinicians and researchers in psychosomatic medicine, to understand psychosomatic disease from a biopsychosocial standpoint. In other words, psychosomatic diseases result from various factors and involve various characteristic pathologies. In addition, conflict or collapse experiences usually precede the onset of psychosomatic disease, which results from attempting' to solve them, forming a closed, vicious circle. Many kinds of psychotherapy have been developed to cure such pathologies. Although clinical psychologists have made many contributions to the development of psychotherapy, perhaps they have lost their own fundamental standpoint. The purpose of this study is to clarify what fundamental skills are necessary to the clinical psychologist in their clinical practice in psychosomatic medicine by investigating the psychotherapeutic processes of patients with psychosomatic disease. Returning to the fundamentals of clinical practice, I examined the psychotherapeutic process in two cases using a patientcentered, problem-oriented method and attempted to clarify the fundamental skills of the clinical psychologist. Obtained results have been summarized in the following three points. l) The ability to put himself in his patient's place to enhance understanding and to establish a mutual relationship between therapist and patient to solve the problems. 2) Knowledge of the characteristic pathologies observed in psychosomatic diseases. 8) The ability to adequately evaluate and bring out the positive side of the patient, along with conducting therapy from one stage to the next after having solved the urgent problem.

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