趙 岳人

Sedentary behavior in patients with schizophrenia causes muscle weakness, is associated with a higher risk of metabolic syndrome, and contributes to mortality risk. This pilot case-control study aims to examine the associated factors for dynapenia/sarcopenia in patients with schizophrenia. The participants were 30 healthy individuals (healthy group) and 30 patients with schizophrenia (patient group), who were matched for age and sex. Descriptive statistics, Welch's t-test, cross-tabulations, adjusted residuals, Fisher's exact probability test (extended), and/or odds ratios (ORs) were calculated. In this study, dynapenia was significantly more prevalent in patients with schizophrenia than in healthy individuals. Regarding body water, Pearson's chi-square value was 4.41 (p = 0.04), and significantly more patients with dynapenia were below the normal range. In particular, body water and dynapenia showed a significant association, with an OR = 3.42 and 95% confidence interval [1.06, 11.09]. Notably, compared with participants of the healthy group, patients with schizophrenia were overweight, had less body water, and were at a higher risk for dynapenia. The impedance method and the digital grip dynamometer used in this study were simple and useful tools for evaluating muscle quality. To improve health conditions for patients with schizophrenia, additional attention should be paid to muscle weakness, nutritional status, and physical rehabilitation.

With the aging of the population in Japan, the number of bedridden patients who need long-term care is increasing. The Japanese government has been promoting the creation of an environment that enables everyone, including bedridden patients, to enjoy travel, based on the principle of normalization. However, it is difficult for bedridden patients to enjoy the scenery of distant places and to talk with the local people because they need support from helpers to travel to distant places using travel agencies. Therefore, to enhance their quality of life (QOL), we developed a remote-controlled drone system, which involves using only the eyes. We believe that bedridden patients are able to operate the system’s drone in a distant place, to easily view the scenery of the distant place with a camera installed on the drone, and to talk with the local people. However, we have never evaluated whether actual bedridden patients can operate the drone in a distant place, to see the scenery, and to talk with the local people. In this paper, we presented clinical experimental results to verify the effectiveness of this drone system. Findings showed that, not only subjects with relatively high levels of independence in activities of daily living, but also bedridden subjects, could operate the drone at a distant place with only their eyes and communicate with others.

This study aimed to conduct a systematic review to clarify patient understanding, understanding of caring concepts, understanding of technology, competency to express compassion, appropriate involvement in caring, and ethical and moral attitudes and responses toward patients. This systematic review was conducted through an electronic search across PubMed, Google Scholar, MEDLINE, and Science Direct. Authors independently appraised the methodological quality of the studies using the Mixed Method Appraisal Tool. A narrative synthesis approach was used to present these findings. Nine studies met the inclusion criteria and quality appraisal guidelines. Through thematic analysis, four major themes were identified:Technology and caring competency, Technology and patient-centered care, Empathetic skills, and Caring competency. This review has shown that patients choose physicians considering their emotions and communicate well with them, empowering them to take responsibility of their own or their loved ones' healthcare. In the age of technological advancement and availability of vast sources of information, it is expected of physicians to adapt to these character priorities while maintaining their sense of humanness, not only focusing on healing modalities, but also to guide, educate, and appropriately empower their patients toward achieving their healthcare goals. J. Med. Invest. 70 : 307-316, August, 2023.

Patients with schizophrenia may exhibit a flat affect and poor facial expressions. This study aimed to compare subjective facial emotion recognition (FER) and FER based on multi-task cascaded convolutional network (MTCNN) face detection in 31 patients with schizophrenia (patient group) and 40 healthy participants (healthy participant group). A Pepper Robot was used to converse with the 71 aforementioned participants; these conversations were recorded on video. Subjective FER (assigned by medical experts based on video recordings) and FER based on MTCNN face detection was used to understand facial expressions during conversations. This study confirmed the discriminant accuracy of the FER based on MTCNN face detection. The analysis of the smiles of healthy participants revealed that the kappa coefficients of subjective FER (by six examiners) and FER based on MTCNN face detection concurred (κ = 0.63). The perfect agreement rate between the subjective FER (by three medical experts) and FER based on MTCNN face detection in the patient, and healthy participant groups were analyzed using Fisher’s exact probability test where no significant difference was observed (p = 0.72). The validity and reliability were assessed by comparing the subjective FER and FER based on MTCNN face detection. The reliability coefficient of FER based on MTCNN face detection was low for both the patient and healthy participant groups.

Rapid progress in humanoid robot investigations offers possibilities for improving the competencies of people with social disorders, although this improvement of humanoid robots remains unexplored for schizophrenic people. Methods for creating future multimodal emotional data for robot interactions were studied in this case study of a 40-year-old male patient with disorganized schizophrenia without comorbidities. The qualitative data included heart rate variability (HRV), video-audio recordings, and field notes. HRV, Haar cascade classifier (HCC), and Empath API© were evaluated during conversations between the patient and robot. Two expert nurses and one psychiatrist evaluated facial expressions. The research hypothesis questioned whether HRV, HCC, and Empath API© are useful for creating future multimodal emotional data about robot-patient interactions. The HRV analysis showed persistent sympathetic dominance, matching the human-robot conversational situation. The result of HCC was in agreement with that of human observation, in the case of rough consensus. In the case of observed results disagreed upon by experts, the HCC result was also different. However, emotional assessments by experts using Empath API© were also found to be inconsistent. We believe that with further investigation, a clearer identification of methods for multimodal emotional data for robot interactions can be achieved for patients with schizophrenia.

The use of a remote-controlled drone system (RDS) by eye movements was studied to assist patients in psychiatric long-term care (PLTC) to allow them to view the environment outside the hospital, hoping that this will bring them some enjoyment. However, successfully applying this system requires human intermediaries in facilitating the interactions between patients and RDS operators. The aim of the study was to describe the role of nurses as intermediaries in the application of an RDS through eye movements of patients PLTC. This study employed the Intentional Observational Clinical Research Design. Data collection was performed in November 2021 at a psychiatric hospital with selected patients in PLTC. Seventeen patients took part in the indoor experiment, whereas 23 patients took part in the outdoor experiment. Fifteen of the 23 patients in the outdoor experiment were the same patients who took part in the indoor experiment. Most of the patients in the indoor and outdoor test arenas could successfully, delightfully, and safely fly the drone. This study demonstrated that RDS using just eye movements could increase the quality of life in older patients with psychiatric problems in PLTC. For the successful use of this drone system, nurse intermediaries assumed critically significant roles.

Background: Expressing enjoyment when conversing with healthcare robots is an opportunity to enhance the value of human robots with interactive capabilities. In clinical practice, it is common to find verbal dysfunctions in patients with schizophrenia. Thus, interactive communication characteristics may vary between Pepper robot, persons with schizophrenia, and healthy persons.Objective: Two case studies aimed to describe the characteristics of interactive communications, 1) between Pepper as a healthcare robot and two patients with schizophrenia, and 2) between Pepper as a healthcare robot and two healthy persons.Case Report: The “Intentional Observational Clinical Research Design” was used to collect data. Using audio-video technology, the conversational interactions between the four participants with the Pepper healthcare robot were recorded. Their interactions were observed, with significant events noted. After their interactions, the four participants were interviewed regarding their experience and impressions of interacting with the Pepper healthcare robot. Audio-video recordings were analyzed following the analysis and interpretation protocol, and the interview data were transcribed, analyzed, and interpreted.Discussion: There were similarities and differences in the interactive communication characteristics between the Pepper robot and the two participants with schizophrenia and between Pepper and the two healthy participants. The similarities were experiences of human enjoyment while interacting with the Pepper robot. This enjoyment was enhanced with the expectancy of the Pepper robot as able to entertain, and possessing interactive capabilities, indicating two-way conversational abilities. However, different communicating characteristics were found between the healthy participants’ impressions of the Pepper robot and the participants with schizophrenia. Healthy participants understood Pepper to be an automaton, with responses to questions often constrained and, on many occasions, displaying inaccurate gaze.Conclusion: Pepper robot showed capabilities for effective communication pertaining to expressing enjoyment. The accuracy and appropriateness of gaze remained a critical characteristic regardless of the situation or occasion with interactions between persons with schizophrenia, and between healthy persons. It is important to consider that in the future, for effective use of healthcare robots with multiple users, improvements in the areas of the appropriateness of gaze, response time during the conversation, and entertaining functions are critically observed.

Frequent exposure to patient deaths prompts nurses to experience grief. Unresolved grief leads to harmful consequences of nurses' mental health and quality of nursing care. A cross-sectional study using an online survey was conducted to determine the psychometric properties of the Grief traits and State Scale for Nurses. Exploratory factor analysis revealed two factors measuring the level of nurses' grief traits (Cronbach's alpha: 0.84) and two factors in grief state (Cronbach's alpha: 0.86). Nurses' feelings of unable to provide good care were associated with a higher risk of grief (odds ratio (OR): 4.30, 95% confidence interval (CI): 1.45-12.75), uncomfortable feeling toward deaths (OR: 11.29, 95%CI: 1.48-85.91), and emotional exhaustion (OR: 7.12, 95%CI: 1.63-30.99). Results indicated that the scale was reliable in determining the levels of their grief. Nurse managers can use the scale to identify their nurses' levels of grief, creating opportunities to influence the resolution of the grief experiences.

Although progress is being made in affective computing, issues remain in enabling the effective expression of compassionate communication by healthcare robots. Identifying, describing and reconciling these concerns are important in order to provide quality contemporary healthcare for older adults with dementia. The purpose of this case study was to explore the development issues of healthcare robots in expressing compassionate communication for older adults with dementia. An exploratory descriptive case study was conducted with the Pepper robot and older adults with dementia using high-tech digital cameras to document significant communication proceedings that occurred during the activities. Data were collected in December 2020. The application program for an intentional conversation using Pepper was jointly developed by Tanioka's team and the Xing Company, allowing Pepper's words and head movements to be remotely controlled. The analysis of the results revealed four development issues, namely, (1) accurate sensing behavior for "listening" to voices appropriately and accurately interacting with subjects; (2) inefficiency in "listening" and "gaze" activities; (3) fidelity of behavioral responses; and (4) deficiency in natural language processing AI development, i.e., the ability to respond actively to situations that were not pre-programmed by the developer. Conversational engagements between the Pepper robot and patients with dementia illustrated a practical usage of technologies with artificial intelligence and natural language processing. The development issues found in this study require reconciliation in order to enhance the potential for healthcare robot engagement in compassionate communication in the care of older adults with dementia.

In many countries, the rate of aging in their population is rapidly increasing. It is expected that this increasing trend influences the number of patients in bedridden states who have difficulty moving their extremities, such as those patients with amyotrophic lateral sclerosis (ALS). The patients are limited in many aspects of their daily lives; this includes not seeing what is outside of their rooms, affecting their quality of life (QOL). Thus, this study aims to evaluate the Remote-controlled Drone System using the Eye-tracking device through the Internet (RDSEI) to improve QOL for patients in bedridden conditions. The novel RDSEI is proposed and developed by the Kai laboratory. The RDSEI consists of a drone, a transmitter, a control screen, an eye-tracking device, a video capture device, a server computer, and a client computer. The subjects of this experimental evaluation of the RDSEI were five healthy male adults (average age: 20.6 years old). Experimental results indicated that all the subjects could control the drone easily by using this system, although there were delays, blurriness, and freezing of the video. Therefore, it was concluded that by using this system, the subjects could control the drone by only their eye movements, thereby enabling them to see the outside world through the drone's camera. In the future, the patients will be able to control the RDSEI from remote locations and converse with persons in remote locations. (C) 2019 Elsevier Espana, S.L.U. All rights reserved.

The aim of this study is to examine the proposed control method of the assist suit with a Velocity-Based Mechanical Safety Device (VBMSD) for patients with difficulty moving their lower legs by themselves. The proposed control method for the assist suit assists the patients as if the patients move their knee joint under zero gravity. A physical simulation model is used to examine whether the gravitational torque of the subject's lower leg and foot was canceled by the torque generated by the assist suit. Experimental results indicated that the gravitational torque of the subject's lower leg and foot is canceled by the torque generated by the assist suit. The control of the assist suit was not adversely influenced by the VBMSD. That is, the VBMSD did not prevent the control of the assist suit. The proposed control method makes the assist suit assist the patient in moving his/her knee joint in a zero gravity-like environment. However, a weight of 3 kg was used instead of an actual patient in the experiment. Experiments with actual patients should be conducted to verify the effectiveness of the proposed control method in clinical use. Furthermore, it will be necessary to take into consideration the patients' general conditions and symptoms. (C) 2019 Elsevier Espana, S.L.U. All rights reserved.

Humanoid robots are increasingly deployed in various health facilities to complement long-term care in Japan. Although this technology influx is still in its infancy, many health providers are optimistic about its capabilities. Thus, it is crucial to investigate its preliminary utilization and effects as precautionary measures in understanding the use of humanoid technology in healthcare. The study intends to describe the rehabilitation care experience for older patients with schizophrenia and/or dementia in the use of Pepper humanoid robot. A qualitative case study was conducted to explore the rehabilitation recreational activities of older patients with schizophrenia and/or dementia (n = 9) in geriatric health facilities. After securing ethical clearance, observational data were recorded and analyzed using a case-oriented understanding and framework of reaction, interaction, and benefaction. Reaction focuses on their attitudes and impressions toward Pepper. During the rehabilitation and recreational sessions, interaction deals with the relationship between older patients with schizophrenia and/or dementia, Pepper, and providers. Lastly, benefaction reflects the actual health outcome of the reaction and interaction with Pepper. As observed, humanoid robots can elicit simple and individual instructions for simple activities (e.g. exercise) and start the simple conversation (question-answer loop) with its subjects. However, deploying humanoid robots in long-term care requires numerous improvements in robotic technology to elicit an increase in communication and other physical activities, motivation, and a sense of calmness from its clients. (C) 2019 Elsevier Espana, S.L.U. All rights reserved.

Healthcare for the increasing senior population is a significant challenge. To address this problem, the use of healthcare robot is increasingly being recognized to have strong potential in addressing older adult and psychiatric patients' healthcare and welfare needs. The purpose of this preliminary study is to evaluate the changes in the autonomic nervous activity of an elderly patient with schizophrenia during upper limb range of motion (ROM) exercises led by Pepper (SoftBank Robotics) with the application program of Care Prevention Gymnastics Exercises (Pepper-CPGE) made by Xing Company in Japan. A Pepper-CPGE-led three-minute radio gymnastics program (Radio Exercises #1, consisted of three types of exercises) and instructions were developed. The normal aging 69-year old schizophrenic subject followed instructions from Pepper throughout the intervention. Electrocardiography (ECG) records, heart rate, acceleration score, and ROM exercises of upper limb were collected and analyzed using the GSM's Bonaly Light instrument and ImageJ analysis. (1) The high-frequency (HF) (indicative of parasympathetic nervous activity), and low-frequency (LF)/HF ratio (indicative of sympathetic nerve activity) were increased in reference from the baseline data before the exercise stretching the chest. (2) The momentum decreased as the ROM of shoulder joint flexion declined. Declines in both parasympathetic and sympathetic nervous activity were observed. Also, (3) when the exercise "bend the body forward" was performed, the HF and LF/HF also decreased. Evaluation of robot-based rehabilitation exercise program effectiveness by the ROM exercises image analysis and autonomic nervous activity is essential for the futurist programming of ROM exercise among patients with schizophrenia. (C) 2019 Elsevier Espana, S.L.U. All rights reserved.

<jats:p>Why would humanoid caring robots (HCRs) need consciousness? Because HCRs need to be gentle like human beings. In addition, HCRs need to be trusted by their patients, and have a shared understanding of patients' life experiences, their illnesses, and their treatments. HCRs need to express “competency as caring” to naturally convey their nursing as healing to patients and their families. HCRs should also have self-consciousness and express their emotions without needing inducement by persons' behaviors. Artificial “brains” and artificial consciousness are therefore necessary for HCRs. The purpose of this article was to explore humanoid consciousness and the possibilities of a technologically enhanced future with HCRs as participants in the care of human persons.</jats:p>

<jats:p>The purpose of this article is to frame the development of humanoid healthcare robots (HHRs) within Caring Science. Efforts to introduce robot technologies in nursing practice and to use them in elderly and high-tech healthcare environments have begun in developed countries. HHRs can be used to assist nurses with tasks or to perform care-related tasks independently. HHRs need to be programmed to demonstrate respectful, compassionate, and person-centered care. In this article we suggest Caring Science-informed approaches based on five philosophies/theories that can be used in programming the responses and communication patterns of HHRs.</jats:p>

This case study focuses on caring for a patient living with schizophrenia who has been isolated from the community caused by long-term hospitalization in Japan. Using the philosophical perspective of caring, which focuses on nurturing the wholeness and well-being of persons in caring relationship, the case study illuminates the caring, empathy, and courage among the interdisciplinary team. The purpose of this case study is to discuss the interdisciplinary caring process for patients living with schizophrenia using Carper's ways of knowing. Personal knowing is presented through the lens of patients and families and the stigma associated with mental illness. The expression of respect and caring for the patient and their families led by the interdisciplinary team aided in destigmatization of mental illness. Empirical and ethical knowing is demonstrated through the mental health care team's delivery of high quality and clinical excellence with competence, compassion and caring. Aesthetic knowing was offered by the interdisciplinary team focused on the patient's underlying hopes, dreams and aspirations. Through the support of the interdisciplinary team, patients are able to move toward their goals, hopes and dreams, externalizing tasks, as they grow together through mutual caring.

Healthcare for older adults is a significant problem in Japan and in other developed countries. To address this problem, healthcare robots, now realized, can assist and meet healthcare and welfare practice demands. The aim of this study was to clarify characteristics of Transactive Relationships (TR) in older adults, in care workers as intermediaries, and Pepper (Softbank Robotics Corporation) a robot equipped with the application program of Care Prevention Gymnastics Exercises for Pepper (Pepper-CPGE) made by Xing Company, Japan. Data were collected by observing TRs between Pepper and older patients in Kagawa Prefecture, Japan between from May 8 to August 1 2018. The Transactive Relationship Theory of Nursing (TRETON) was used to explain how Pepper-CPGE led the exercises with older adults as physical exercises. The role of Pepper-CPGE was to provide instructions for the older adults in performing gymnastic exercises. During the exercising activity, care workers were present to prevent falls of the older adults, and to operate and observe the video presentations by supporting and caring for the participants. In using Pepper-CPGE, it was possible to change the role of the healthcare providers, originally thought to contribute to increasing the quality of older adult care and their rehabilitation.

A female patient in her sixties with schizophrenia had secretly disposed of all her medication and was not cooperating with hospital staff for about four months. During one of our consultations she mentioned that she wanted to be out of hospital by a certain date. That date happened to be her grandchild's birthday. It was at this point that she shared her goals with us, and voluntarily started having treatment. She was able to return home three months later, just in time to celebrate her grandchild's birthday with her family. A male patient in his sixties was able to leave the seclusion room after 10 years. The first doctor in charge and other hospital staff had firmly believed that releasing him from the seclusion room wasn't a possibility. However the patient decided he wanted to be discharged and was interested in finding out how to go about it. The moment he realized it was possible, his outlook changed immensely. He gradually started to open up and communicate better with his new doctor in charge, and was able to work towards his newly found goals. Staff members were also surprised when he was able to leave the seclusion room. They realized this patient was another person like them who had dreams and goals, and stopped stereotyping patients who seemed to be 'difficult to handle'. I have always experienced the power of goal sharing at clinical scenes, and have noticed its importance for patients making a start on the road to recovery. In order to discuss goals and the way to go about achieving them, I use a simple drawing of a mountain. I call this mountain 'A Personal Goal Map'. I like to think of myself (the doctor) as the mountain guide, and my patient as the mountain climber. The three key philosophies are acknowledging individuality, diversity and freedom. These are important when we think about where we are now, where we are going, and where we want to be. Firstly at the start point, we need to define the patient's problem and discuss ideas and goals, which help us along the Trust Path. The more patients and staff trust and understand each other the easier it is to climb up the Initial Treatment Path. We need to build up trustful relations so we can share personal goals and make a proper assessment and diagnosis, and talk about the safety, efficacy, cost and suitability of the initial treatment. Secondly, we need to take a rest and make more plans for the Recovery Path. It is on this path that we decide on comprehensive treatment together. We may be able to improve the patient's cognitive functions by using atypical anti-psychotic agents. We can then give them information, instructions and warnings about medicine usage so the patient is able to understand their condition. It is only after the patient can understand these things fully and act positively that we can start to climb the final path, the Achievement Path. We should review the suitability and efficacy of the treatment again, and it is at this stage that the mountain guide steps back and watches the mountain climber take the final steps towards the mountain peak goal. Lastly, the patient will feel elation and a sense of fulfillment and self-pride, and no doubt will be ready to look for the next mountain peak to climb. In order for you to enjoy the benefits at the clinical scene, all you need is a piece of paper, a pen, and a limitless imagination for better personal goal sharing. At Meisei hospital we promote the 'Minotake Team Approach', which calls for flexible management so we hospital staff can help each other as professionals. We treat patients as individuals using words and expressions they understand (such as local dialect and nonmedical terms), and give them access to easy to understand resources such as leaflets delivered by universities or pharmaceutical companies. We ask our staff to act naturally with the patients, and to just do what they can do to help the patients work towards their personal goals.

当院(単科精神科病院)入院中のA氏が大腸がんを発症した。総合病院へ転院し放射線治療が開始されたが、精神状態が悪化したため、がん治療を中断し、当院へ再入院となった。その後、精神状態は安定したがA氏はがん治療を受け入れず、総合病院への転院を強く拒んだ。A氏・家族・主治医・看護スタッフとの話し合いの結果、がん治療を中止し、疼痛コントロールをしながら、当病棟で最期まで看ることを決めた。がんはすでにステージIVにあり、余命半年という状況で、腰椎への転移のため両下肢・腰部に激しい疼痛が生じていた。A氏はがん告知を受けても十分な病識はない。しかし、予後への漠然とした不安は強い。看護はどうかかわればよいのか?A氏がここで最期を迎えると決めたのだから、看護も一緒に歩もうと決めた。生きていてよかったとA氏に感じてもらえるよう、人間らしく尊厳ある最期を迎えてほしいと全力でかかわった。激しい癌性疼痛をデュロテップパッチ(麻薬)でコントロールしながら、本人の要望の実現・QOLの向上・不安の除去にチームの力を集中させた。時折穏やかな笑顔を見せながら、最後まで、自分の人生を生き抜いたA氏に、看護者として多くのことを学んだ。A氏とのかかわりのなかで効果的であったと考える要因を、客観的に分析・評価し精神科における終末期看護のあり方を考察する。(著者抄録)

BACKGROUND: Every psychiatrist must pay careful attention to avoid violating human rights when initiating coercive treatments such as seclusion and restraint. However, these interventions are indispensable in clinical psychiatry, and they are often used as strategies to treat agitated patients. In this study, we investigated young psychiatrists' attitudes toward psychiatric coercive measures. METHODS: A total of 183 young psychiatrists participated as subjects in our study. A questionnaire with a case vignette describing a patient with acute psychosis was sent to the study subjects via the Internet or by mail. This questionnaire included scoring the necessity for hospitalization, and the likelihood of prescribing seclusion and/or restraint, on a 9-point Likert scale (with 9 indicating strong agreement). RESULTS: There was general agreement among the study subjects that the case should be admitted to a hospital (8.91 +/- 0.3) and secluded (8.43 +/- 1.0). The estimated length of hospitalization was 13.53 +/- 6.4 weeks. Regarding the likelihood of prescribing restraint, results showed great diversity (5.14 +/- 2.5 on 9-point scale); psychiatrists working at general hospitals scored significantly higher (6.25 +/- 2.5) than those working at university hospitals (5.02 +/- 2.3) or psychiatric hospitals (4.15 +/- 2.6). A two-group comparison of the length of inpatient care revealed a significant difference between those psychiatrists who scored 1-3 (n = 55, 14.22 +/- 7.4 wks) and those who scored 7-9 (n = 62, 12.22 +/- 4.0) regarding the need to use restraint. CONCLUSION: Our results may reflect the current dilemma in Japanese psychiatry wherein psychiatrists must initiate coercive measures to shorten hospitalization stays. This study prompted its subject psychiatrists to consider coercive psychiatric treatments.

It is suggested that any clinician working on the Miyako islands, Okinawa, Japan, be a mediator or a negotiator between two worlds, namely the shamanistic and the modern psychiatric ones. On these islands, to subscribe to either is possible only by ignoring conflicting clinical realities. The main point is to summarize the complementary practices of these two medical systems on these islands. Psychiatric illness attributed to kamidaari is introduced. The initiatory illness for seeing a shaman is called kamidaari or kamburi. From the viewpoint of medical anthropology, aspects of the treatment of such patients in a shamanistic 'climate' (which is called fudo in Japanese), will be reported. In the shamanistic fudo, it must be recognized that, at a critical moment, shamanistic epistemology and psychiatric epistemology penetrate each other, and they exist together in a clinical 'mesh'. Two epistemologies must join in a coalition to access, and build continuity into, psychiatric and shamanistic medical care. It is demonstrated that these two worlds almost merge in dialogue but do not fuse, and that clinical relations occur on the boundary between these two epistemologies. 'Climatic' specific therapeutic stances are introduced and are clinically illustrated.