The necessity for understanding diseases from a psychosomatic standpoint is exemplified with reference to bronchial asthma which is often considered a representative of psychosomatic disorders. In certain cases of childhood asthma, the important factors affecting the illness are found in sibling rivalry for parental love. ln these cases, relying on psychosomatic therapy to focus the child's awareness on the love that the child received from his parents is highly effective in resolving the crises. Other cases of adult asthma become intractable in spite of pharmacological and allergologicaI therapy necessitating the use of steroids, despite the adverse side effects associated with them. In such cases of bronchial asthma, psychosomatic therapy can alleviate symptom and withdraw from steroids, because the illness has psychosomatic mechanism. However, in order to practice psychosomatic therapy, the physician must understand the illness from a psychosomatic perspective. The failure to do so results in the failure to provide appropriate treatment, causing a worsening of symptoms due to the progress of the illness, or due to steroid related side effects; which can be considered iatrogenic. It is proposed that medical disorders resulting from the failure to provide appropriate therapy be classified as a "disorder due to negative iatrogenic factor" or "iatrogenic disorder by omission."

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In this paper, we investigated the relationship between changes in the family system and our health from the standpoint of family therapy for chronic pain which we often conducted in our hospital. Chronic pain has in particular the characteristics as a way of communication between patients and their families or circumstances. Thus it can be a good model by which to investigate not only the psychosomatic correlation but also the relation between upper and lower systems. In the Department of Psychosomatic Medicine, Kyushu University, a chronic pain patient is defined on the basis of our clinical experiences and reviews of associated literature as "a patient whose pain complaint or occupational impairment is in excess of what would be expected from the underlying organic pathology." Treatment of chronic pain patients has made remarkable progress by means of our psychosomatic approach in addition to medication such as anti-depressant, nerve block and rehabilitation, etc. However, even now there are many patients who are difficult to treat. We have tried to treat such cases by understanding their symptoms in relation to uppr systems. In the systems approach, symptoms are the result and cause of the distortion of human relationships among family members. The system theory cannot suppose the ideal healthy family relationship. The index of our health is the nexibility by which we adapt to the changes of family development such as marriage and birth, growth and independence of sons and daughters, aging and death of family members. Therefore, the family system becomes rigid when family members cannot adjust to the current social system in the course of familial life cycle. Psychosomatic symptoms can be one of the driving forces to regain the flexibility of the system. In recent years, the reduction of family size and privatization are progressing due to the development of industry and the decrease in birth rate. In Japan the father-oriented family system supported by the traditional social standard has been transformed into the mother-oriented family system that has been covered by it. ln this paper, we presented case reports of a young patient and an old one with chronic pain. In both cases, the role of the hospital seems to provide a buffer for the families to adjust to the new social system. In the current of familial transformation. the function of the hospital which supports the nuclear family and family members can be very important. We have to take such social back ground into consideration to treat psychosomatic patients.

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Through a study of 7 clinical cases of Eating Disorders with the feature of Borderline Personality Disorder, we could find 4 types of intrafamily relationships, namely 1) borderless family. 2) broken family, 3) double-bind family and 4) traditional family. According to Stierlin's Model, these 7 cases could not fulfill the task of "delegation" and stay inside the relational modes between "binding" and "exclusion." Moreover, the needs of these cases for love and dependency were so strong that the distorted family relationships such as borderless sticking. exclusion, spiritual control and overexpectation by parents seemed to strengthen the Primitive defense mechanisms. The distortion of family relationships were found to be under the infiuence of recent changes in the family structure from the extended family system to the nuclear family system. The therapeutic approach to the improvement of this distorted family relationships seemed to be a turning point in the treatment of this disorder.

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In recent years, the advancement of women in various workplace has resulted in more than 50% of all females over the age of 15. The number of working women is thereby approaching twenty million. According to the mass media, women are becoming more self sufficient and displaying greater sovereignty, leading to social and political reform. "Woman Power" is receiving high marks from these sources. This study, however, is focused on the negative ramifications of the advancement of woman and examines the effects from a sociopathological perspective. This institution has isolated munerous cases of illnesses resulting from the advance of women in the work force and broken them down into five major categories. The results of this analysis are as follows : Category I Illnesses of the Working Woman. Herself which include : "Superwoman Syndrome, " ''Perfect Woman, " "Happy Ending Complex : ' "Irritable Bowel Syndrome : ' "Disautonomy : "'Depressive State, " etc. Category II Illnesses in ike Children of Working Women, Based on their Upbringing, Which Surface During Adolescence including : "Eating Disorders, " "Personality Disorders, " etc. Category III Effects on the Spouses of Working Women which include : "Depressive State, " Impotence, " "Infidelity." Category IV The Psychological Effects on Now- Working Women which include : "Depressive State : " etc. Category V Miscellaneous which include : "Sexless Married Couples, " "Permanently Single, " "Separated. Yet Living Together." "Divorce, " etc. In recent years, major changes in both the structure and function of the family have appeared. The increased number of women in the work force is one aspect of society which has changed and this study investigates the negative effects of this phenomenon. Laws insuring equal working conditions for women have encouraged able women to enter the workplace and the stress that these women incur and the resultant diseases have become apparent. Young people have become increasingly independent and seek personal time and space wanting to extend their single years. There is also a tendency toward having fewer children. Even more importantly, the manner in which working mothers care for their children may lead to various disorders which onset at puberty.

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Of all patients who made an international marriage and who visited the psychiatric outpatient clinic of Jikei University Hospital between 1982 and 1993,15 patients who had particularly strong somatic symptoms in addition to mental symptoms were analyzed from the viewpoint of psychiatry and psychosomatic medicine to consider psychosomatic problems involved in international marriage. 1) International marriage for economic reasons is increasing in Japan. The number of Japanese men who get married to women from other Asian countries has recently increased in urban areas as well as in rural areas. 2) In such cases, conflicts concerning the position of the non-Japanese wife in the Japanese family and the relationship between the wife and the mother-in-law are problematic, rather than affectional conflicts between the wife and the husband themselves. 3) Poor marital relationship. such as divorce or separation, is underlying the illness. Although many of the non-Japanese wives or husbands intend to live permanently in Japan, regardless of the marital status, they are usually in an economically diffcult situation, only having a weak basis of livelihood. 4) Problems related to aging of persons who made an international marriage has gradually come to the surface. In these cases, children have grown up to blend in with the Japanese society, leaving their parents alone. 5) Somatic symptoms. including those regarded as climacteric disorders and aging phenomena. of patients who made an international marriage often involve the aspect of psychosomatic medicine. 6) Activities in the community and a positive relationship with volunteers who help non-Japanese residents are particularly important for patients who are apt to be isolated.

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The first aim of this paper is to introduce "Palliative care round" in Chiba University Hospital inpatient units, and the second aim is to discuss the importance of family intervention in palliative care, presenting two case reports including family interventions. Palliative care round has been done since 1990. In this round, some psychiatrists, anesthesiologists and nurses have attended and made a "palliative care team". This team visits the wards around the hospital once a week where patients are in the terminal phase suffering from cancer pain. The purpose of this round is to maintain patients' QOL as much as possible. Interventions for 1) removing pain, 2) reducing physical suffering like sleep disturbance, nausea, dyspnea, 3) easing anxiety and depression, are main practical strategies to carry out the purpose. An 4) giving support to patient's family through family intervention is another important strategy. In fact the family has a lot of burdens in the situation of palliative care. For example, family members are obliged to take a part of nursing at the bedside of the patient. Also they are bound to be in a dilemma whether or not they should tell "the truth" to the patient. because many patients are still not informed of the name of disease from the medical staff in our country. "Anticipatory grief" is another psychological burden for the family especially when it was banned to be expressed in the presence of the patient in the hospital. Therefore it is one of the important tasks in the palliative care which supports patient's family members to get rid of their physical, psychological and economical burdens. From the viewpoint of the system's theory it is also suggested that such an intervention as supporting family members is effective not only to improve their own QOL but to have a good influence on the patient. It would happen through the interpersonal relationships within the family. Two case reports are presented in this paper that show the effect of family interventions on the QOL of patient and his family. This paper concludes with a suggestion that some assement scales should be developed which make it possible to understand the situation and needs of the patient's family and which can help make effective interventions in the phase of palliative care. An assessment scale using for the same purpose in the field of mentally disabled is introduced for reference.

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