Friday, November 30, 2018

Unravelling the puzzle of point locations a little

For many years I was completely unaware of the fact that different branches of acupuncture used anatomical locations for some of their points which differed from the ones I had been taught.  The first five or more years of my practice were spent in a complete five element bubble, since at that time JR Worsley’s college at Leamington was the largest college, and many of us who trained there were completely unaware of the existence of other schools of acupuncture.  I know I certainly was, until rumours started to spread around the acupuncture community that acupuncturists who had visited China were bringing back with them another form of acupuncture which appeared not so much to complement what we had learned, but to cast doubt in the minds of some five element acupuncturists about the validity of what they were practising.  This was first brought home to me when standing in a lunch queue at an acupuncture event and being told by a fellow acupuncturist, with some disdain in her voice, “JR has a very odd way with moxibustion”, followed by, “You don’t still only do five element acupuncture, do you?”.

I always find it interesting when I observe how often people are only too happy to grab hold of anything which might seem to undermine some practice or concept which holds a dominant position, almost as though they cannot wait to mock what before they expressed admiration for, or indeed, as in the case of many five element acupuncturists, actually used for years in their practice.  This happens all too often, particularly where somebody has been pre-eminent in one discipline.  Perhaps it is then only natural that those sheltering in the shadow of such a person may start to feel increasingly disempowered, and look for ways of asserting their own independence of thought.  This happened most famously with Carl Jung’s abandonment of his admiration for his mentor, Sigmund Freud, and the same thing happened in this country when JR Worsley’s legacy to acupuncture started being mocked in the way I encountered.

In a very short space of time this was followed by a growing onslaught by the acupuncture world in general, led unfortunately by the British Acupuncture Council, on the right of five element acupuncture to be considered as a stand-alone discipline.  I have written a lot about the difficulties I, as a devoted five element acupuncturist, have encountered in defence of my practice over the years, but in this blog I want to look at how influences from China have apparently changed this country’s approach to the location of certain points, and how far this is still something five element acupuncture needs to take into account.

The subtle undermining of an accepted five element tradition extended also to the area of point location, where people started discussing whether the five element locations used, based on a long-established tradition going back through to JR Worsley’s teachers, Jacques Lavier and Wu Wei Ping, came up against the locations modern Chinese acupuncture was now deciding for us, and which have come to be replaced by many British acupuncture colleges.  I am certainly no historian of acupuncture, nor have I any way of knowing whether the point locations which have gradually superseded some of those used in five element acupuncture have clinical validity or not.  And this is the only factor in the debate about different point locations which I feel needs to be taken into account.  If I needle a point in my well-practised five element location will a point at a slightly different location used in modern Chinese acupuncture, and following hard on its heels, modern British acupuncture, have the same clinical effect?

We sometimes think that acupuncture does not lend itself to “evidence-based research” in quite the same way as scientifically-based therapies, because it does not seem possible in a holistic discipline such as ours, and similarly in any of the different forms of psychotherapy, to obtain sufficient objective evidence of the efficacy of any clinical procedure which cannot be measured by some physical instrument.  But I think my many years of practice have provided me with just as much evidence that the points I use in treatment have actually effected material changes in my patients, and ones which are perceptible to others, provided that their senses are sufficiently honed to perceive sensory and emotional changes.

When a patient says, as one of my patients did yesterday, that “the treatment you gave me a few days ago really made me feel I could face life again,” is that not evidence of the efficacy of the particular treatment, made possible by needling specific acupuncture points?  The problem is that a reader of this blog only has my word for this, and if I were to invite observers into my practice room during the treatment, might the presence of unfamiliar faces affect the patient’s response to the treatment, and perhaps nullify it?  I do, though, have what I like to call one objective proof of the location of one of the disputed locations of an acupuncture point as a result of a moving encounter I had when consulting JR Worsley about one of my patients.

This point is the one on the Kidney meridian which in the five element point numbering is IV (Ki) 7.  As any five element acupuncturist knows, this is one of the first points in the combination of six points, needled bilaterally, used to clear one of the most serious energy blocks recognized in five element acupuncture, that of a Husband/Wife imbalance.  IV 7 is a tonification point, drawing energy from Water’s mother element, Metal, and in the five element location is at 3 ACI (cun) from the prominence of the medial malleolus.  We were taught to needle all six points before taking the pulses to see whether we had cleared the block, in effect checking whether the patient’s Heart energy - (I (Ht) 7 is the last point in the procedure - was recovering sufficiently to combat the spiritual despair which is one of the main indicators of this block.

I had taken a patient to see JR Worsley, and he had diagnosed this block, leaving me to carry out the treatment.  As this was early on in my acupuncture career, it took me some time to mark up the points, particularly those on the Kidney meridian which require much careful measuring of the leg, so when JR returned I had only had time to needle the first two points, III (Bl) 67 and IV (Ki) 7.  Before I had told him that I had not completed the whole procedure, he took the pulses, nodded at me, and said, “That’s cleared.  Good.”  It was then that I realised that the re-establishment of a strong connection between the Metal and Water elements through the tonification points must have been sufficient to clear the block.  From then on I have always checked the pulses at this early stage in the procedure just to see if this often happens, which I find it does.  Each time, though, I go on to carry out the full procedure because I recognize that needling the remaining points strengthens the connection between the elements which a H/W imbalance shows has been weakened.

From this, and from my own later experiences, corroborated by my years of clearing many H/W blocks, I know that the tonification point on the Kidney meridian is definitely where we locate it in five element acupuncture, at 3 ACI from the level of the medial malleolus.  The Kidney source point, IV (Ki) 3, too, which also forms part of the H/W procedure, is at a different location from the more recently accepted location.  I therefore recommend any practitioner trying to clear a H/W block to adopt the five element anatomical location of these two points.  I like to think that I am stepping in the footsteps of an acupuncture master in using the points exactly where he told us they were, and feel that something of the energy I felt passing from him through to the patients I brought to him for consultation is transferring itself a little to me as I needle the points where he told us to find them.

Friday, November 23, 2018

In praise of youth

The older I get, and I am now surprisingly old I find, the more I seem to be drawn to the young, from the little babies in their prams looking so eagerly around themselves as they enjoy taking possession of a bright new world, to the young students from many different acupuncture colleges in this country and abroad, who crowded into our latest SOFEA clinical seminar last week.  I am no longer in the acupuncture loop which knows how many acupuncture colleges there still are around Britain, but to my knowledge quite a few have had to close, and their replacements seem to be more in the nature of small independent training establishments, even too small to be called colleges or schools, in which a few dedicated acupuncturists endeavour to pass on their knowledge to a few equally dedicated and enthusiastic students.  This is a faint modern imitation of countless years of individual master/pupil transmissions which was considered to be the only acceptable route of transmission in earlier days.

I am always so pleased to see the keenness with which these burgeoning acupuncturists learn to embrace five element acupuncture early on in their careers, because, for obvious reasons, the longer practitioners have to immerse themselves in the profound and, to me, magical world of the elements, the more easily they will find themselves at home within it.  One of the problems for all the many TCM practitioners who have attended what we used to call SOFEA’s five element conversion seminars has always been the need for practitioners new to five element acupuncture to summon up sufficient courage to move to a discipline which cannot be viewed merely as an add-on to what they have studied, but requires them to put aside their previous learning and embrace the new in its entirety.  To do this, when most practitioners are working on their own and haven’t the support network provided by studying at a five element college as I did, requires them to be absolutely convinced of the validity of five element acupuncture as a stand-alone discipline, and the stamina to confront all the inevitable ups and downs which embarking on a new direction to their practice demands of them.

I always admire the way that Mei Long, one of my co-tutors at our Chinese seminars, was so instantly convinced of the truth underlying five element acupuncture that she changed direction from TCM in a single leap of faith, and has never looked back, being now one of the most competent five element practitioners I have been privileged to work with.  She was certainly younger than I was when she encountered it for the first time, for I was all of 45 before I had even seen an acupuncture needle.  But I was fortunate that at that time in the UK five element acupuncture was a dominant influence in the few acupuncture colleges which then existed, and had not yet been undermined by the influx of modern Chinese acupuncture into this country.  I therefore welcome all those young student acupuncturists out there who seem to share so wholeheartedly in my love of the elements, and make running our seminars in this country so worthwhile for Guy and me. 

This is also a good time to tell you that we are running two further five element clinical seminars in London in 2019, the first on Friday 8 February 2019, and the second on Sunday 9 June 2019, both at Neal’s Yard Therapy Rooms in Covent Garden.  The February seminar is now almost fully booked and has a waiting list, but there are still places available in June.  Details of both seminars can be downloaded from our website www.sofea.co.uk 

Thursday, November 15, 2018

Emerging from another productive five element seminar

It always takes me a few days to come down from the high I finish on at the end of each of our five element seminars.  Having just finished our latest two-day event, I still wake with a smile on my face, one that has been there from the moment Guy and I opened the doors to our first arrivals on Monday 12 November, and stayed there for the whole two days of the seminar, until it was temporarily replaced by a few tears as we hugged each other and bid each other good and satisfying times in our practice until we meet again in February.

It is such a delight for me to have such welcome confirmation of five element acupuncture’s firm hold on the hearts of many of what I call the “original” JR-trained practitioners, as well as now, happily, the many acupuncture students finding their way to us to reinforce their five element understanding.  It is probably no coincidence that this upturn in the interest in this branch of acupuncture is occurring at the same time as, or I suspect as a direct result of, the enormous interest Chinese acupuncturists are showing in learning from both my writings and the seminars Mei, Guy and I run twice-yearly in Beijing.  I laugh as I look at the photo of us with our 275 Chinese students (posted on Facebook for all to see), and compare it to the photo of the initially small group of under 20 practitioners with which we started our adventures in China 8 years ago.  I have often been asked whether I will frame this latest photo, but answer by saying that our next seminar in April 2019 will expand to more than 300 practitioners, so I’ll need an even larger frame and a bigger wall space on which to hang the photos each time I go.

Guy and I have already planned our next London clinical seminar which will be on Friday 8 February 2019.  Details and a booking form can now be downloaded from our website www.sofea.co.uk.  Since we are holding this seminar at a smaller venue in Neal’s Yard, we are now already half-booked, so applications will have to be made promptly if you want to join us.

Friday, November 2, 2018

A plea for tolerance: how a knowledge of the qualities of the five elements can help all of us understand each other better

I was reminded of one of the most rewarding aspects of my five element practice during a conversation I had with a Chinese psychotherapist during our latest seminar in Beijing.  This illustrated very neatly something I have consistently emphasized over the years.  Very soon after I started my five element studies all those many years ago, I realised that my understanding of the elements was shaping my approach not only to health and ill-health, which was my original reason for embarking on these studies, but also, at the deepest level, to how I related to other people.  My study of the elements helped me to a greater acceptance of the incredible diversity of human reactions, and this was making me more tolerant of those who differed from me.

The Chinese psychotherapist I spoke to specializes in family therapy, and told me how coming to my five element seminars and reading my books was proving very helpful in his own practice.  He asked my permission to quote from my books in his teaching, permission I was only too happy to give him.  I am always glad that my descriptions of the elements are useful not only to acupuncturists but to people of other therapies, as a way of helping them understand human interactions better. 

I have often said that I love the old English saying, “All the world is odd, except thou and me, and even thou art a little odd,” because it so accurately and neatly describes a common human failing, which we are all guilty of.  We tend to judge other people from the standpoint of our own prejudices, our own likes and dislikes, rather than seeing them as having equally valid, though often very different and conflicting views to our own.  We all have a common human tendency to judge others as though inadequate in some way if they act or think differently from us.  A knowledge of the elements therefore teaches us greater humility, and leads to greater tolerance, something this increasingly intolerant world of ours so badly needs..

 

  

 

Wood: the element of future potential

I have a lovely quote by a Wood friend of mine which I would like to share.  She is planning to make many changes in her life at the moment, and as she left the coffee house where we were meeting, she called out from the door: “I’m always looking at possibilities.”

I can’t think of a neater description of one of the Wood element’s most important qualities, that of giving itself, and others, hope for the future.

Sunday, October 14, 2018

Thoughts on the 12 guardian officials in preparation for our coming seminar in Beijing

Guy Caplan, Mei Long (from the Netherlands) and I are off in a few days for our next seminar in Beijing (from 17 – 26 October).  I have lost count, but I think this will be the 14th seminar we have given there.  As usual, each time I go, I like to think of something new I would like to concentrate our teaching upon.  This time, it has been prompted by an email sent to me by Caroline, a dedicated five element acupuncturist and the lovely translator of my books.  She wondered whether I could talk more about the functions of the 12 officials, because the people she teaches at the five element introductory seminars held before we come seem only to think of them in terms of physical organs, and not as having the deeper meanings associated with their individual elements. 

That made me realise that I, too, concentrate much more upon the elements as a whole, rather than trying to distinguish which of the yin or yang officials holds a dominant position.  I have always thought that it was difficult enough homing in on the correct element, and that I would only confuse myself by trying too hard to see which of its two officials is the most important.  JR Worsley would diagnose somebody as being a “Metal CF”, and then write next to this “IX” or “X” in brackets, meaning that either the Lung or the Colon was the dominant aspect of the Metal element for this particular patient.  I have now rather cheekily coined the phrase “guardian official” to describe this official.  In all the time that I observed patients with him, I never heard him explain what it was in the patient which made him select one or other official, except in the case of the Small Intestine (II).  Here he would always specify, not that this patient’s CF was a I/II as we say in five element acupuncture, but simply a II CF.  I remember very clearly him saying one day as he watched a video of himself asking a patient a question, “Only a II CF would answer like that”.  This taught me a lot about the Small Intestine and the way it looks as it tries to find the correct answer to a question.

Thinking about this carefully in preparation for my Beijing seminar has also brought to my mind the question which has remained a slight puzzle for me throughout my acupuncture life.  In all the hundreds of patients JR diagnosed in front of me, I never once heard him say that a person was a “I CF” (in other words had the Heart as his/her guardian official).  Somebody told me that he had indeed diagnosed an acquaintance of mine as a “I CF”, but that was only hearsay, and never corroborated by JR himself.  And my doubts about the Heart official being the primary cause of an imbalance (that’s what “CF” means) always seemed to me something that a tutor of mine at Leamington put well into words for me.  He said that he himself felt that the Heart, the Supreme Controller of body, mind and spirit, would never allow itself to be so much weakened as to be the ultimate “causative factor of disease”.  Unfortunately I never thought to ask JR himself why I had never seen him diagnose a person as being a Heart CF, so this has always remained an unanswered question for me.  Somehow, though, I have always felt that what my tutor told us rings true. 

There has always been a slight niggle in my mind about this diagnosis, because I felt very strongly when I was with this person, that she was very like me, and that our two Small Intestines were engaged in a slight tussle for supremacy, as each tried to sort the other person out.  Surely the Heart, such a yin official, would just be residing quietly rather than battling with me, as my own yang Small Intestine quite likes to do when it is under some sort of stress.  The niggle was also strengthened by the fact that this person liked to feel that she was a rather rare person by reason of her guardian official being the most important official of the twelve.  I did wonder whether she had herself spread this rumour, rather than that JR had actually diagnosed her as such, but I will never know, whatever my slight suspicions.
 
So I am now thinking carefully about the different qualities of the officials so as to help the 300 or so practitioners gathering next week to hear us in Beijing.  They, of course, are brought up on rote learning of the Neijing Suwen, and I have told them to prepare for what we will be talking about by re-reading Suwen Chapter 8, which is all about the officials, and gives each of them their distinctive name.  Now I have to ask myself, “Do I really understand how the Liver differs from the Gall Bladder in a person with Wood as their guardian element, or the Stomach from the Spleen for Earth?”  These are all very important questions to which I am ashamed not to have paid sufficient attention over the years.  So, as usual, my visits to China and all the other seminars I have held over the years offer fresh stimulation to my thoughts.

 

 

Sunday, September 16, 2018

A draft introduction to another book

I am just drafting the introduction to some more of my writings about the elements, and am posting this below as a blog.

"I am drawing together in this book some of the writings about my practice as five element acupuncturist which I feel will be helpful for any of my colleagues, particularly now those in China, who want to benefit from what I have gradually learnt over the years.  I am especially keen to pass on the lessons from my own acupuncture master, JR Worsley, with whom I studied closely for several years as part of my postgraduate training.  One of the many things I remember him telling us was that we would always learn more from what we didn’t get right to start with, especially our diagnosis of guardian element, than when we got things right.  I know that the mistakes I made in my early practice were always valuable lessons for me, and I therefore hope that what I write here will give five element practitioners a little more confidence and enjoyment in their five element practice.
 
We can never be neutral observers of life.  As all scientists now acknowledge, the observer is always part of what is observed, so there is no such thing as being objective.  Our judgements are always subjective.  The important thing is to be aware of this and to try and understand ourselves as deeply as possible so that we can understand the nature of our involvement in any human interaction.  In five element acupuncture terms, this means understanding how our own guardian element colours how we perceive all the people we meet, and in particular how this fact colours our interactions with our patients, and our diagnosis of their particular element.
 
All I write about the elements is always therefore to some extent coloured by what I perceive through the filter of my own element, Fire, and in particular its inner core, the Small Intestine and the Heart deep within.  Anybody reading what I write must therefore take this into account, and accept my particular slant on the elements which a lifetime of being Fire gives to it.  Of course I have many, many years of observing how people of other elements interact with other people, and learning from these observations so that I hope I have  also much to say about the world as seen through the filters of elements which are not my own.  
 
The subjective nature of all our interactions with the world around us is undoubtedly why I notice that my writings about the elements which I present here are not evenly spread over the five, but tend to be focussed more on Wood and Fire, with Earth a slightly more distant third.  Throughout my writing life, I appear to have written far less about Metal and Water.  I rationalize this a little by thinking of the order in which the elements are placed around the great five element circle.  Fire’s relationship to its fellow elements is closest to its mother element, Wood, and its child element, Earth, whilst it has a more distant relationship to the following two yin elements, Metal and Water.  I wonder also whether this helps explain my yang Fire’s deeper understanding of totally yang Wood and half-yang Earth, than of the two more mysterious and more hidden yin elements.  Despite myself, then, this book is tilted slightly more towards the yang, the sunny side of the mountain and daylight, than towards the yin, the shady side of the mountain and the darkening light.
 
As I draw together the observations of all the elements and their interactions with each other which I present here, it is useful for those reading this to understand that, unique as each human being is, everybody will have their own individual take on the elements which will lead to their own often quite different perceptions, but ones which are as valid as mine are for me.  The important thing is that we should constantly test our understanding against what we learn from our interactions with one patient after another, so that we remain honest enough to modify our thoughts to take account of any new insights we gain."

 

 

Tuesday, August 28, 2018

It's never a good idea to try to persuade a patient to continue treatment

I never think it is right for me to answer questions from practitioners who ask me for help in trying to diagnose a patient’s element or what specific treatment to give.  I can only do this when I am actually there with the patient in the practice room.  On the other hand, there are general questions about five element practice which I find useful to answer, and which often stimulate me into writing a blog.  Into this category falls something which a practitioner, Caline Chew from Singapore, has just emailed me about.  I cannot help her with specific questions about the treatment of her patients, but she finished her email as follows:  “…..I don’t know how I can convince (my patient) to stay on the treatment.”

I always say that treatment can only be successful when both patient and practitioner are equally involved, 50% the patient and 50% the practitioner.  It is therefore good to remember that we can never help a patient who is reluctant to receive treatment.  As soon as we sense this, we need to stop what we are doing and address the issue.  Dealing with a patient who openly doubts the effectiveness of our treatment is always disturbing for any practitioner, nor can we do good work if we are not sure what is going on in the practice room.

One of the tips I learnt many years ago from JR Worsley, which I have followed successfully ever since in all cases where my relationship to my patient is under some strain, is always to be honest with the patient, and tell them as soon as I sense that there is a problem.  You need to be brave enough to ask them whether they, too, feel that this is so.  I always preface what I say with the words, “I feel that ….”  Saying this removes any risk of the patient feeling that we are blaming them for what is not right, and gives them the courage to be open with us.  I am then often surprised by my patients’ answers, which may be quite different from what I have imagined.  This frankness between us goes a long way to solve some of the tricky patient/practitioner issues which complicate our work.

So this is the advice I am going to give Caline, with the hope that it will help restore a good relationship with her patient.  I hope, too, that this will clear up some of her own doubts about what she is doing.

 

Saturday, August 25, 2018

More on what makes the Earth element angry

Here are two observations about what I wrote in my last blog by two of my Earth practitioner friends, one living in Beijing and the other in London.  Both comments have helped me to understand Earth a little better.

My Chinese friend wrote:  “Thank you for sending me your new blogs, I learned a lot about what makes Fire angry. And about what makes Earth angry, I agree with you when you say that “Earth can show its anger when it feels that somebody is not paying enough attention to what it wants to say, or interrupts it in mid-sentence.” But I think “angry” might be a little bit too strong here from my point of view, because I would only feel a bit unhappy about that, and if that’s something I really want to express, I will try to find another chance to tell the practitioner about it. But I will get angry if I tell the practitioner something that really makes me upset or sad or worried, and the practitioner shows no understanding but says something like ”that’s nothing, I don't know why you…”, I may even stop getting treatment from him or her. And in everyday life, I think Earth may get angry when it feels that somebody it really cares about is not paying enough attention to its devotion, or even worse, totally denying it.”

And when asked what would make her angry, my English friend told me: “It would take a lot to make me angry.”


After publishing this blog, this friend added the following to her comments: 
 
"Just to add to mine.... when I get angry about something I feel that I have to express myself over a period of time to different people until I have reached the point that I can let go of it. I guess this is my Earth processing.  And having space and time to mull it over. Also by talking about it over and over it is my way of being understood and heard."



 
 

Saturday, August 18, 2018

What do the different elements get angry about?

I always like looking at the ways the different elements express their emotions, and  my last blog (14 August) has made me think about how each element expresses its anger. 

When we express emotions other than the one our particular element imprints us with, these other emotions will always be coloured a little by the specific emotion which has our guardian element’s stamp upon it.  If I take the example of Metal, then Metal’s expression of anger will always be tinged with Metal’s own emotional needs, one of which is its demand for others to respect it.  What makes Metal most angry, therefore, are likely to be those things which impact negatively upon its sense of self-respect, or, by extension, upon the self-respect of others around it.  I have seen Metal people becoming extremely angry, and to me quite frighteningly so, when somebody has ridiculed them openly in front of other people.

Earth can show its anger when it feels that somebody is not paying enough attention to what it wants to say, or interrupts it in mid-sentence.  Its need is not so much a craving for sympathy, but a craving for understanding in its widest sense.  It wants to be given the space and time to express exactly how it feels, and becomes irritated if it is not allowed to do this.  This is something that I, as a rather over-hasty Fire person, have sometimes been guilty of doing, at my Earth patients’ cost. 

I have found Water’s expression of anger to be more hidden, but like Metal’s it can be quite frightening to witness.  It can appear out of the blue (what a Water-like phrase!), like a tornado erupting suddenly out of a clear sky.  Water needs to be constantly on the move, and its sudden expression of anger can be its response to feeling that something is blocking its path.  Behind this outburst of anger lies all the power which Water exerts on all it does.

There is then the Wood element’s own expression of anger.  This is an element most at ease within a given structure and with order in its life.  It is when structure and order are under threat that its dominant emotion of anger will show its stress.   It is easy for us to see an exaggerated example of this in the shouting and fighting to be observed in drunken people on the streets at night.  There is, however, the flipside to this, which is often forgotten, and which often leads us to misdiagnose the Wood element.  This is the suppressed expression of this emotion which we call lack of anger.  Here the voice can speak in an exaggerated whisper instead of a shout, and there may be a marked inability to express anger where anger would be a balanced reaction to some external event. 

Lastly, how do I think Fire tends to express its anger?  I should know, because I am, after all, Fire, but there is always the complication with Fire that, unlike any other element, it has two sides to it, which I have called Inner and Outer Fire.  I have always felt that in some ways this double-sided element could really be described as harbouring two elements, making a total of six in all.  I remember saying this to JR Worsley one day, and was rather delighted when he nodded.  Of course the two sides share Fire’s sensory signatures of colour, sound and smell, but their emotional approach to life is very different.  I can really only speak at first-hand for Inner Fire, although having observed Outer Fire for many years I have learnt to understand some of its qualities as I have those of the other elements.

I know what makes me angry, and that is any injustice meted out to other people, not so much injustice of which I am the object.  I like to fight my battles more on behalf of others than on behalf of myself, and feel deeply, and thus become very angry, when others are wronged.  In my experience Outer Fire’s anger is more directed at feeling that they have been the victim of some injustice.  Both sides of Fire, though, will not harbour grudges for long for they tend to feel that difficulties in any of their relationships with others may somehow be their fault.  Their anger is therefore likely to simmer down quite quickly, once they acknowledge their own role in whatever initially angered them. 

These are my thoughts on the different expressions of anger which each of the five elements may show.