I solve the clinical ethics case of site. I resolve with medical staff in the field. Shows the clinical ethics education to achieve these. Awareness of clinical ethics problem, what is a good ethical judgment, using case study sheet, doing case study group. etc.

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In psychosomatic illnesses relatedness of the ego-consciousness to the body and feelings are blocked or highly limited. A conscious awareness and understanding of the relationship between the psyche and the body is an important focus in treatment of psychosomatic patients, which could also be regarded as restoring a proper relatedness between the psyche and the body. Jung thought that consciousness and the uconscious are compensatory and he maintained the importance of dialogue between them. He also emphasized the importance of the symbol producing function of the unconscious. Symbols are expressed in dreams, paintings and stories as well as symptoms. Although a standard analysis is not indicated with psychosomatic patients due to weakness of their ego strength, a spontaneous self-expression, without any interpretation or analysis, has a therapeutic effect in itself. Further, the symbolic materials expressed by the patients can be of great help to a therapist in understanding their inner world. An attitude of over-adaptation with psychosomatic patients usually hides problems of low self-esteem and lack of healthy narcissism behind. They need to experience the archetypal positive mother in the therapeutic process to restore genuine spontaneity, which would become the core of the sense of self to bring self-acceptance. The therapist needs to be open to his/her own inner creative impulses in order to help the patients experience their genuine spontaneity. Fragmented life history of a patient is woven into a unique story in therapy giving the sense of meaning to life, which is a creative process of healing as becoming a whole, and it is called the individuation process in Jung's psychology. It is rather a "healing" (to become whole) than a "cure" that Jungian psychotherapy aims at.

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Diabetes is a non-curable chronic disease, and self-care activities by patients themselves play an important role. Thus traditional acute care model does not work well in diabetes. Therefore, a philosophy of empowerment was introduced to patient education in diabetes by Dr. Robert M. Anderson and his colleagues of Michigan Diabetes Research and Training Center in 1990s. They found that every patient has a right and an ability to solve one's own problems in one's own diabetes. Patient empowerment has 3 essential elements : 1) the patient is located in center and make a final informed decision of daily self-care activities ; 2) healthcare professionals support them ; 3) patient and healthcare professionals collaborate each other. The healthcare professionals should try to build a good relationship between their patients first for the best use of empowerment. They also should learn how to make relevant questions which are focused on feelings and belief of their patients. To continue practicing empowerment and evaluate whether they really use empowerment well in the real-world setting, they should have a reflection time by themselves or with their colleagues in various way.

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The objectives of diabetes management are to reduce symptoms of diabetes, to prevent development or progression of diabetic complications and disease conditions associated with diabetes, and to enable affected individuals to maintain their quality of life (QOL) and life expectancy comparable to those seen in healthy individuals (excerpt from Evidence-based Practice Guideline for the Treatment for Diabetes in Japan 2013). Nurses often approach patients with diabetes to focus on the enhancement of their self-management ability to improve glycemic control. However, it often results in a refusal of intervention by nurses or no obvious effect of education in clinical practice. Here, I would like to discuss the effective way of approach to patients with diabetes from the viewpoint of nurse through my experience as a nurse specializing in diabetes.

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When we support the self-care of diabetes patients as a dietitian, we should perform nutritional assessment, nutritional care plan, implementation, monitoring and evaluation and quality control. Nutritional assessment includes health promotion and assess of the life environment in all except for dietary intake. When we assessment self-care consciousness of diabetes patients, the Theory of Health Promotion and Health Behavior is useful to have common understanding among the staff members. But the relationship between the staff and a patient is not always what can be expressed by the Theory of Health Promotion and Health Behavior. A case is presented to explain this point.

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Diabetes is incurable (Ishii, 1999) and progressive (UKPDS, 1996). People living with diabetes need self-medication (Anderson et al, 2000/2001). These traits of diabetes can raise their emotional burdens. In some cases, it can be difficult for people to live with diabetes and take care of it by themselves. Therefore, therapeutic relationship between healthcare providers and people living with diabetes and multi-disciplinary medicine teams are needed. In the medicine team of diabetes care, clinical psychologist has a role of motivating them to practice self-management for diabetes care and to cope with their stress (Nunoi,2003). Mrs A, a woman in her 60's living with diabetes, had type 2 diabetes. After recheck, she was diagnosed as slowly-progressive type 1 diabetes, and she started to accept her diabetes and willingly practiced self-management, including taking an insulin shot. A series of medical interviews of her was taken by a clinical psychologist with the intention of understanding the patient's self-management and self-actualization The interviews helped facilitate her to accept her diabetes and to care for her traumatic stress, depression and anxiety accompanied by acceptance of diabetes.

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Life-style and therapeutic behaviors, namely diet and exercise, are important factors in changing the conditions of patients with diabetes mellitus. In the past, to encourage appropriate therapeutic behavior by patients, therapists instructed them about the disease and the treatments. On the other hand, in recent years, supportive therapy with respect to the problem solving abilities of patients has been introduced. Many effects of such supportive therapy have been reported, but there are still some patients who cannot display their abilities. To support such patients effectively, it is necessary to understand them more comprehensively. In this paper, while showing the process of learning, the authors discuss the significance of understanding patients and the approach to more comprehensively understanding them. Though both the words encouraging patients to adopt better behavior and psychotherapy techniques have gained attention, the authors place emphasis on the importance of the approach in the preparatory stage.

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Objectives :In the glossary of the American Academy of Orofacial Pain, bruxism is defined as a "total parafunctional daily or nightly activity that includes grinding, gnashing, or clenching of the teeth. It takes place in the absence of subjective consciousness and it can be diagnosed by the presence of tooth wear facets which have not resulted from the chewing function". Although it is not a dysfunction, suitable treatment is needed because it has a destructive influence on a stomatognathic system, when the influence of the frequency and intensity of the action exceeds the tolerance of a living body. However, the cause is not clear, and the sprint treatment is mainly used as symptomatic therapy. The aim of this study is to clarify about the psychological factor relevant to bruxism. Subjects and Method : There were 327 participants (149 male, 178 female) with an average age (±standard deviation) of 50.5 (±17.3). They were divided into 110 non-bruxer, and 217 bruxer according to the diagnosis by dentists. A questionnaire (comprising an egogram and a stress self-evaluation check list) was completed concerning six factors; Critical Parent (CP) ; Nurturing Parent (NP) ; Adult (A) ; Free Child (FC) ; Adapted Child (AC) ; and stress. Multiple logistic regression analysis was performed to assess the association of the above factors with ego-states and stress as the independent variables and the existence of bruxism as the dependent variables. Results : On multiple logistic regression analysis significant relationships were noted for CP(OR=1.08, 95% CI; 1.01-1.16), NP(OR=0.93,95% CI; 0.87-0.99), AC(OR=1.10,95% CI: 1.03-1.19), stress (OR-2.69, 95% CI;1.33-5.42). Multiple logistic regression analysis revealed that CP, NP, AC and stress were significantly associated with the existence of bruxism. Conclusion : These results indicate that bruxism stems from psychological factors. Bruxer tends to have high score in stress, CP and AC. On the other hand, non-bruxer tend to have high score in NP.

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Background : Effective communication between cancer patients and their doctors is important in alleviating patients' physical and psychological burdens. Hence, there is a growing need to encourage an improvement in patientdoctor communication. Cancer outpatients often hesitate to speak with their doctors even when they have necessary information to provide or questions to ask. This study examines the relationships between patients' hesitation in speaking with their doctors and their communication behaviors. Subjects & Method : The participants were 51 individuals (21 male and 31 female, mean age 62.08±11.38 years) undergoing outpatient treatment with complementary and alternative medicine. They were asked to recall the most recent consultation with their primary doctor, and then completed questionnaires measuring the degree of their hesitation in that particular social exchange. The factors influencing patients' hesitation were analyzed using the maximum likelihood estimation. Subsequently, the relationship between patient characteristics and hesitation was examined using Mann-Whitney U and Kruskal-Wallis tests. Results : The results revealed that indecision regarding the topic of discussion, and the decision to forsake their doctors, are among the prime factors influencing patients' hesitance to engage in effective communication with their primary doctors. A marginally significant difference with respect to age, stage of disease, employment, and recurrence status was observed. In particular, patients with recurrence were more likely to exhibit hesitance in communication compared to patients without recurrence (p=0.05). In addition, patients under 50 years of age were more likely to be indecisive about the topics of discussion, compared to patients in their 60 s (p=0.08). Similarly, patients at stages I-III were more likely to be indecisive than were patients at stage IV (p=0.08). In addition, employed patients were more likely to forsake their doctors than were unemployed patients (p=0.08). However, hesitation did not significantly differ by sex, cancer type, treatment, ECOG performance status, presence or absence of metastasis, residential conditions, or disease duration. Conclusion : To encourage better patient-doctor communication, it is necessary to alleviate patients' hesitation to talk to their primary doctors. Communication skill training programs for patients targeting both the alleviation of patients' hesitation and the amelioration of patients' communication skills may be necessary.

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