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.

 

Some early mistakes in my practice

Looking back at the early years of my practice, I sometimes cringe with shame at some of the mistakes I made.  These were not, as some people might assume, to do with my very basic understanding of the elements, or my choice of treatments, although they, too, were with hindsight often rather naïve or even somewhat inappropriate.  Instead they were nearly all to do with my relationship to my patients.  Based on something which JR Worsley had impressed upon us, I somehow thought that I had to make myself available to my patients at all times, even interpreting what he said as meaning that a patient should be able to contact me at any time they wanted to.  Those were the days well before emails and mobile phones when patient-practitioner contact was nearly 100% by good old-fashioned landline.  Since I worked from home, I soon realised that I needed to install a dedicated practice line so as not to confuse my private with my professional phone calls.  This meant also having two answering machines, making quite an impressive array of phone equipment lining my kitchen shelf.

I still remember the excitement of coming back home and seeing the “message received” light blinking on my practice phone.  I would always hope that this meant that a new patient was making contact, for each new patient was then a highly exciting event.  There was, however, one definite advantage of patients having to get in touch with me by phone, and not, as usually happens nowadays, by email or text message.  This meant that when I answered them our first contact was always person-to-person, and not the much more impersonal contact of the written word through emails.  It is now often overlooked how important this initial contact can be, not only because it offers both patient and practitioner a bridge to that key aspect of five element treatment, which is the setting up of a good relationship with our patients, but it also gives us the luxury of trying to diagnose two key components of an element’s presence, the tone of voice and the emotion the patient is showing.  On the patient’s side, it helps get them past the often challenging situation of a first meeting in the practice room.  I felt that this first phone call shaped the nature of my future relationship to my patients.

But the flipside of these personal phone calls was that it gave my patients the impression that they could phone me whenever they wanted to, and this was where I started to make things difficult for myself.  I didn’t then have enough confidence to lay down careful guidelines as to when they could phone and what they could phone me about.  And I soon found this led to a further mistake.  Patients got used to phoning me at odd hours of the day, either early in the morning or, most often, rather late in the evening.  And I would find myself engaged in long conversations with them, all of which, I should have told them, were best suited to being continued at their next treatment.  It took me quite some time, and many interrupted evenings of phone calls, before I realised that what the patients and I were talking about belonged much more appropriately to the practice room, where it would help me determine the kind of treatment the patient needed.  As five element acupuncturists it is the treatment we offer our patient which helps solve their problems, and although five element acupuncture is partly a talking therapy, because of course our patients need to talk to us and we to them, it is good to remember that it is the needle, not our words, which eventually helps them.

This open-door, or rather open-telephone, policy of mine also opened the door to the thorny question of discussing the element I was treating them on.  I learnt to my cost that it is never a good idea to talk this through with a patient, because often one of the reasons for doing this can be our unconscious desire for reassurance from the patient that we are on the right track, and it is surely not their task to help us.  We are often hoping that they will confirm that we have made the right choice.  And I have come to realise that nobody, even the most experienced five element practitioner, is good at diagnosing their own element, though practitioners often like to feel that they are the best judge of this.  Unfortunately this is rarely the case, since we all tend to be rather blind to our own faults and like to think we have a special relationship to an element whose qualities we admire.  And if you mistakenly start to discuss a patient’s element with them, what do you do when you change your mind and change element, or change it several times?    Do you tell your patient this or leave them with the mistaken idea that they are of the Earth element when you have perhaps moved through Fire before finally landing on Wood?   We all know how often we find ourselves trawling through the elements before finally finding the correct one.  Thankfully, though, this happens less and less for me now.  So take heart all you novice five element acupuncturists out there.

So now I always advise practitioners to lay down firm guidelines for their patients on when and how to get in touch with them between treatments.   If we don’t do this, we are laying ourselves open to the possibility of patients controlling treatment.  For further discussion about this see my two blogs of 14 June 2018: Never let a patient take control in the practice room, and A lesson from JR Worsley: the importance of keeping control in the practice room.

Finally, it is not a good idea to tell patients what points you are using except very occasionally.  It is difficult enough for us to put into words why we are choosing a particular point or set of points, let alone explain this to a lay person.  If they ask, I have learnt to say, “I am not here to teach you to be an acupuncturist.  If you are interested in learning more, I suggest you read my Simple Guide to Five Element Acupuncture which explains my approach to treating you”.  The following are some of the few exceptions to this rule:  telling patients about horary and seasonal treatments (because we have to book our patients in at specific times for these), and correcting an Akabane imbalance, because patients are often fascinated to find that the readings change after treatment.  I have found that this is a very good way of convincing rather sceptical patients, particularly hard-headed businessmen, at the very start of treatment that there is something in what I do.

It is also useful to explain to patients that some of their symptoms may be the result of an entry/exit block, and obviously we need to explain in a little detail why we think a CV/GV (Ren Mai/Du Mai) block needs to be cleared.  In the case of this block I always first ask if the patient feels very exhausted all the time, a very good sign of a CV/GV block, and I tell them that this is because the main pathways of energy running up and down the body are blocked, draining them of energy.  Sometimes I add the fact that JR Worsley told us that if only these points were on the wrist we would do them on every patient!

On the other hand for obvious reasons I never tell a patient that I am about to clear a Husband/Wife block or do Possession treatment, because the last thing you want to do is worry the patient by giving them the idea that there is something seriously wrong with them.  With Possession, however, I tell the patient that I am doing some lovely connecting treatment, and that I need their help to make sure that they feel each of the seven points properly.  I have noticed that patients needing this treatment really understand what I mean when I say this, as though I am reassuring them that I know that they feel disconnected.  This is also a good way of describing Possession, which is in effect a level of disconnection of the spirit.

I am passing on some of my tips for what to tell patients because I wish I had been told much of what I learnt by hit and miss through my own practice.  It would have avoided some of the problems I created for myself.

A lesson from JR Worsley: The importance of keeping control in the practice room

A further lesson which I learnt early on from JR Worsley was a very important one that we often don’t confront in our attempts to make the practice room a welcoming place, and that is ensuring that a practitioner must never allow a patient to take control of what goes on in the practice room.  For once we have lost control, it is very difficult to regain it.  Control can relate to many areas of our practice.  It can cover whether we allow a patient to dictate to us which points they will allow us to needle, at what intervals treatments should be spaced, whether or not we need to answer their questions about the treatment we are giving, and whether they choose not to answer our questions.  If we allow the patient to decide how the treatment will proceed, each of these situations is potentially one where we are assuming that they are the ones who know what needs to be done.  This is of course never the case, and is particularly true in the always tricky case of treating a fellow practitioner or somebody with some knowledge of acupuncture.

The following are some examples of times when I have lost control of the practice room in some way, showing how I at first failed to deal with the situation satisfactorily before finally, after hearing JR’s voice, regaining the control I was in danger of losing.

One of these changed totally the way in which I learnt to deal with patients I found difficult.  Of course we should never call a patient simply “a difficult patient”.  Instead, we should always add the words, “a patient I find difficult”, because our perceptions of people always colour our relationships to them.  A patient whom one practitioner finds difficult may be easy for another practitioner to relate to.  So it is always important to chart for ourselves what kind of situation we find difficult to deal with because often, when looked at closely, this will usually tell us more about ourselves and our own prejudices and inadequacies than about the patients themselves who we feel are making things difficult for us.

Analysed in this way, I realised that what particularly irritated me in a patient’s behaviour was often something as apparently insignificant as arriving a little late for treatment or always phoning to check the time of their next appointment, even though I had seen them enter this into their diary.  In such cases JR taught us a very simple procedure.  “Tell the patient what you find difficult”, but we must always make sure to include the words “I find” in what we say: “I find it difficult when….”   This is acknowledging that our feelings are filtered through our own perceptions.  It is then up to the patient to correct these perceptions or to agree that they are true.  This ensures that you avoid pointing an accusatory finger at them, and are instead asking them whether what you feel tallies with what they feel.

At the same time JR’s advice also taught me how important it was to confront any problem you are having with your patient as soon as possible, rather than trying to ignore it, because it is these sorts of problems, however trivial you may feel they are (does it after all matter if a patient is a few minutes late for a treatment?) which can take on a surprising level of importance out of proportion to their actual significance.  They can then cast disturbing shadows over our time with our patient.  For example, before I adopted JR’s advice, I would often be thinking during the treatment itself about how I should be dealing with the situation of the patient arriving persistently late rather than concentrating on the treatment.  Instead I might be cross at myself for being a bit too cowardly to dare say anything, perhaps fearing that I might offend them or that I was endangering the good patient/practitioner relationship I was trying to set up.  In fact the reverse would be true.  I was risking harming this relationship by the very fact that I was delaying dealing with a troubling issue which was getting between me and my patient.  And this was taking up precious time in the practice room which should instead have been spent concentrating upon the treatment.

Another layer was added to the incident of the patient arriving late.   After I had told her that I found this difficult, I noticed a slight change in our relationship which I had not anticipated.  She apologized and promised to make sure that she arrived on time, but actually started to arrive much too early with a rather defiant look on her face, as though challenging me in some way, which I found both puzzling and disturbing.  Something in the situation had obviously unsettled her.  It took me some time to realise that, instead of just accepting the simple fact that she needed to arrive on time, she had interpreted what I said to her as a sign that somehow she had lost face with me, and saw my comment as a reprimand which she was annoyed by.  She was telling me this not in words but in the rather defiant and slightly triumphant look on her face as she persistently arrived much too early for the next few treatments, as though saying, “See, I’m being a good girl now and doing what you told me to do, but I’m not happy with your ticking me off in this way.”  In effect, I felt she was acting like a sulky little child, and showing me an unexpected side to her character.  She was a high-flying business woman, and I had no doubt she was the sort of person who would always make sure that she arrived well on time for any of her important business meetings.  So why not with me?  Did I represent somebody who evoked a relationship where the roles of who was in charge were blurred or difficult for her to deal with, the obvious person being, of course, her mother, since I am quite a bit older than she is?

I may seem to be making rather heavy weather of this slight, but clear change in our relationship, but it made me uneasy enough to view her name in the diary with some trepidation, as though I knew there was yet another issue here that I was not dealing with properly.  It really felt that there was a hidden struggle for control going on between us in the practice room.  We have talked this through now, and she agrees that the situation of me being her therapist and she the patient somehow made her feel as though I had taken on the superior role, and she has always found that difficult, in whatever therapeutic situation she had been in.  And it turned out that it did indeed remind her of resenting her rather controlling mother.  I think we have now talked this through sufficiently to move on, but it has left a slight feeling of discomfort in the air between us, which I hope will be dispelled in time.
Often it is just this feeling I have that something is not quite right between the patient and me which leads me to understanding my patient better.  Sometimes, of course, the opposite can happen.  If a patient feels that we are moving on to emotional ground which they find too uncomfortable to deal with and wish to avoid, these become the times when a patient may suddenly stop treatment rather than confront what is causing the unease.  And I, as practitioner, may not be adept enough to work out a way of helping me get round this particular obstacle to treatment.

Another issue which can often cause us problems is the extent to which we allow a patient to become involved in treatment situations.  This becomes a particularly difficult area in five element acupuncture if we start discussing with our patients which particular element we have decided to treat them on.  I know that different practitioners have different opinions about the wisdom of doing this.  Some do not mind at all going through with their patient the reasons why they have chosen a particular element.  I am not convinced, though, about some of the practitioners’ motives for doing this.  Hidden deep within this decision may be the practitioner’s often unconscious need to get some reassurance from the patient about the treatment we are offering them.  We may feel we are on the right track if the patient appears to agree with our choice, or our confidence in our diagnosis may be undermined if the patient shows disbelief at our choice.  In both cases, we are in effect allowing the patient to influence the diagnosis, a bad idea when we consider that they are not trained to recognize the elements as we have been, and also because they may have a predilection for one or other element from their rather superficial knowledge of them.  By letting our patients influence our choice of element may well be because we may unconsciously be revealing our lack of confidence in our own diagnosis by drawing the patient in to help us.

I remember clearly the day during my training at Leamington when a group of students went up to be diagnosed by JR, and arrived back depressed in the classroom, because he had diagnosed quite a few of them as Earth, when they were convinced they were Fire, Fire apparently having a better press for them than what they regarded as the neediness of Earth.

This brings me to the always tricky problem which rears its head once we approach treating a fellow five element acupuncturist.  Here there is not just the compulsion we all seem to feel to support our treatment choices by drawing an acupuncturist/patient into discussing what treatment is needed, but there is the additional problem that a practitioner often has their own fixed idea about their element, assuming that somehow their own personal understanding of themselves makes them better qualified to diagnose themselves than their practitioner.  The opposite is true.  We often like to flatter ourselves that we possess emotional qualities which we admire, whilst ignoring those aspects of ourselves which have a less attractive side.  So we are not good judges of which is our dominant element, or even of the elements of our nearest and dearest.  I remember very vividly completely misdiagnosing one of my children, choosing to interpret his behaviour in a selective way which fitted my somewhat erroneous perception of him, much coloured, and I realise therefore distorted, by my love for him. 

We have to accept that all of us have a tendency to regard one or other element in a more favourable light than the others, however hard we try not to, because events in our personal lives have shaped our approach to the elements.  All this has proved an excellent lesson for me not to treat those to whom we are too close, although this can sometimes not be avoided, particularly if there is no other five element practitioner geographically close enough.  The important thing is to be aware of the drawbacks, of which there are many.

 

 

 

Never let a patient take control in the practice room

It is interesting how often somebody asks me a question or tells me about something which has happened in their practice which illustrates something I have just written or am thinking about.

I just received the following email from Hongmei, a five element acupuncturist in Singapore:

“Last Thursday I had a small issue. One of my patients has been doing the 5 Element treatments for nearly 5 months. I strictly followed the procedure.  But last Thursday she urged me to squeeze her in (that day I was fully booked). I agreed to let her come to see me after my normal work hours. She was very bothered by her sleepless night, and asked me to do the CV GV for her. She had it first time in mid April , and then another time in mid May. Two weeks later I did some other treatment (clearing a different Entry/Exit block, CV14 and Earth source points). She said after this treatment she did not feel well, could not sleep and easily got upset. She asked why and wanted only the CV GV. I explained to her again how 5 Element acupuncture worked. I refused to do the CV GV for her again after I took her pulse , and suggested another treatment. She got very upset and refused to do what I suggested. I let her sleep in my clinic for a while. She then decided to do nothing. I let her go. But I felt awful. I was very tired. My energy was not good. I did not handle it beautifully. But it’s a good lesson. I am learning.”

In reply to this email, I just sent Hongmei the following extract of something I had just written, with the title “Never let a patient take control in the practice room”, a particularly appropriate piece to help Hongmei at the moment, I feel.

A further lesson which I learnt early on from JR Worsley was a very important one that we often don’t confront in our attempts to make the practice room a welcoming place, and that is ensuring that a practitioner must never allow a patient to take control of what goes on in the practice room.  For once we have lost control, it is very difficult to regain it.  Control can relate to many areas of our practice.  It can cover whether we allow a patient to dictate to us which points they will allow us to needle, at what intervals treatments should be spaced, whether or not we need to answer their questions about the treatment we are giving, and whether they choose not to answer our questions.  If we allow the patient to decide how the treatment will proceed, each of these situations is potentially one where we are assuming that they are the ones who know what needs to be done.  This is of course never the case, and is particularly true in the always tricky case of treating a fellow practitioner or somebody with some knowledge of acupuncture.”

Reading through what she has written carefully, I see that there are a few things that I would like to point out which might help in future, apart from the obvious fact that she seemed to allow her patient to interfere in the treatment more than is wise. 

1. We shouldn’t need to explain our selection of treatments to our patients, because this is to draw them into the practitioner role, something which it is always unwise for us to do. 

2. Then there is rarely, if ever, a need to clear a CV/GV (Ren Mai/Du Mai) block more than once, provided we are sure we got the points the first time.
3. There are many reasons why patient say that they don’t feel good after a treatment.  It’s unusual, because all the elements like being helped, but often it is a way of a patient trying to control the treatment, and should not be regarded as evidence that we have given the wrong treatment.  Patients have all sorts of different motives for not wanting to acknowledge the success of treatment.
4. “She refused to do what I suggested.”  As soon as a patient refuses to allow us to do the treatment we think is necessary, we must immediately stop treatment (after all they are in effect withdrawing their consent to any further treatment).  At this point, Hongmei should have told the patient she could not help her any further.  She should certainly not have let her “sleep in (her) clinic for a while”. Allowing the patient to sleep in the clinic sounds as if Hongmei was worried by her patient’s reaction, and was trying to placate her – never a good idea

What I admire about Hongmei’s account of this interaction with her patient is her honesty in seeing that she did not handle the situation well.  When she reads the remainder of my blog from which the extract above is taken (see my next blog), she will see that I give my own examples of how I, too, have often lost control in the practice room, and therefore failed to help my patients.  We all live and learn, as I do after all these years in practice.

Beware of becoming too comfortable in our work

All therapist can fall into bad habits over the years, risking becoming careless in what we do.  One such pitfall is that we may become a little bit too comfortable in our work, not challenging ourselves as much as should do.  We may start to forget that each time we see our patient we see a slightly different person who is altered by the passage of time.  The patient before us is not the same person we saw at the last treatment.  We have to understand the need to see them with fresh eyes, requiring possibly a different approach from us.

It is indeed very difficult to retain a freshness of approach to our patients if they have been coming to us for a long time.   Often we are only too pleased to welcome patients we think are doing well, because we feel they are unlikely to challenge us by presenting us with new problems.  These are patients whose treatment we assume to know in advance.  Here we can be at risk of falling into rather too well-worn a rut if we are not careful, thinking that our patients will be as they were before.  Perhaps unconsciously we ignore the possibility that they may have changed in some way, since changes require us to make more effort.  It is much easier, we may think, to continue doing what we have done so apparently satisfactorily before.

And then we may not see, or choose not to see, something in our patient which should be pointing us in a new direction.  A long- term patient of mine, whose treatment I regarded as being simple to plan ahead for, turned up for one appointment not as I expected her to be.  If I had not been alert, I could easily have overlooked the slight change I perceived in her.  She herself volunteered nothing until I probed a little more and discovered that quite a disturbing event had happened to her, which totally changed the direction of the treatment I was intending to give.  Looking back on this afterwards I realized that I had been in danger of assuming in advance that I would find her as I had done before, and might perhaps have ignored the pointer alerting me to a need to re-evaluate the treatment I was intending to give her, which was now no longer appropriate.  We must never assume that we know our patient’s needs of today, since yesterday may have changed them

 

 

Getting to know our patients

If you are going to be of any help at all to another human being, as we as acupuncturists surely hope to be, then we have to make every effort to get to know who the person is who is coming to us for help.  And getting to know somebody is certainly not as easy as it may sound.  For each of us can present different faces to the world, having learnt during our life to adapt ourselves to the different people we encounter.  The practice room represents an unknown world, and at first patients will be unsure both about the treatment being offered and the person offering this treatment.  Practitioners, too, meeting an unfamiliar person, will have their own concerns to face in adapting to what is to them also a new situation. 

All this represents different kinds of challenges.  Patients are being asked to reveal something of themselves to a stranger about whose capacity for empathy and ability to put them at their ease they are initially unsure of. They will be asking themselves whether the practitioner is a safe person to whom to show any vulnerabilities, those which all of us may wish to hide from others, but which reveal the true nature of why we are seeking help.  The practitioner, too, will be trying to adapt to the many different ways patients present themselves in the unfamiliar situation they find themselves in.

There is a great skill in helping a patient overcome their natural reticence at opening themselves up to another person.  We have to learn ways of convincing our patients that we are a safe repository for self-exposure of this kind.  We need to know what kind of a relationship with their practitioner our patients feels comfortable with, since for each person this differs.  Some, with a trust in human nature, will assume that anybody in the guise of practitioner will be worthy of this trust.  Others, at the other end of the spectrum, will take much longer and request much greater evidence from their practitioner that the practice room is a safe place before lowering their defences.

The initial encounters between patient and practitioner are therefore delicate affairs, requiring great sensitivity on the practitioner’s part to all the little signs we give out indicating where others must tread warily when they approach us.  If practitioners do not pick up such signals, we are very likely to act too clumsily and effectively silence our patient.  Here, as with all things, a knowledge of the elements comes to the practitioner’s aid.  For each element demands a different approach from us.  And as we get better and better at analyzing the complex nature of each approach, this will give us increased insight into what may well be our patient’s element.

 

 

An example of the insensitivity of modern medicine

I am often appalled by the insensitivity the medical profession can show towards its patients.  Hidden within the well-intentioned aim of ensuring that patients are not banished from any discussion about what the future course of an illness is thought likely to be, doctors have started to err on the side of telling patients too much about the possible implications of some slight symptom or some tiny deviation from the normal in the results of some medical test or other.  In so doing, they seem to forget that they are handing over the kind of information which is likely to frighten their patients.


I recently heard an example of this.  A friend of mine went for a general check-up to a newly-appointed doctor at her medical practice who conscientiously read through all her notes to familiarize himself with what was wrong with her.  She had had a slight stroke some years back and was on medication to stabilize her heart.  The doctor looked up from his notes, and said “You realise, don’t you, that it says here that you are likely to get Alzheimers at some point in the future.”  Apparently some research had shown a correlation between having a stroke and Alzheimers.


I asked my friend how hearing this had affected her.  She is a very balanced, practical person with a good deal of understanding of medical matters and a sensible approach to her own health, certainly not the sort of person who would indulge in worrying excessively about what the future held for her.  But she said that, despite her best efforts to ignore what she had been told, his words were still preying on her mind and had changed her approach to how she viewed her health.  And yet there was no indication whatsoever of her having the slightest symptom of Alzheimers, nor was there any medical or lifestyle advice which the doctor could have suggested to reduce the “likelihood” of it occurring in the future.  So what possible purpose, apart from making her fearful, had telling her this served? 


My father, who was a doctor, always said that he had seen so many miracles in his long medical practice that he learned never to predict the course of an illness, and to take away hope was in effect condemning a patient to an earlier death.  A little bit of hope was taken away from my friend yesterday by those few words, spoken no doubt with the best of intentions, but unfortunately with the worst of results.


We should never take away a patient’s hope.  We don’t have to pretend, even if it is obvious that a person is close to death, and we need to answer truthfully if asked, but if a patient wants to pretend that they have more time than we think they have that is their right.  And if hope allows them to feel a little better, however ill they are, they are likely to live a little longer, and perhaps die more peacefully.

 

The spacing of treatments: an art in itself

I have just spent a happy few days in Berlin with two very dedicated German five element acupuncturists, Christian and Thomas.  This was very stimulating, both culturally, because I saw more of Berlin on this, my second visit, and from an acupuncture point of view, as it always is. 


It was during a day spent looking at patients together that I was made aware once more of the importance of the question of the spacing of treatments as representing an essential, but often overlooked, aspect of how we help our patients.


I don’t think that we pay enough attention to this in the normal course of events.  At the start of a patient’s treatment I expect we all tend to give them a number of weekly treatments, normally something like six or so, and then we tend to space treatments more widely from once every 2-3 weeks to monthly and eventually to once a season and less.  It is what happens as we move further on in treatment that problems can arise.  I was made aware of this again by one of the questions I was asked.  How was the practitioner to deal with a patient who, he said, “insisted” on weekly treatments whilst also maintaining that treatment was not helping him in any way. 


We have various ways of assessing the effect of treatment.  There are our own observations as to whether we notice any changes or not, and then there are the patient’s own assessments of how treatment is going.  Usually these two sets of observations will coincide.  Problems only start when the two differ, as for example if the practitioner notices how much better the patient looks, or the changes he/she is making to their life, and yet the patient him/herself says that there has been no change at all.  We cannot try to persuade the patient by saying things like, “but you seem to be walking better” or, “you have not been talking about your family problems as much”, because that is denying the patient the right to make their own assessment of what they consider constitutes improvement.  On the other hand, we may be concerned that the patient is choosing not to acknowledge that there have been changes for other reasons.  These may include such things as a fear that we are “giving up” on them, or, more subtly, as part of some kind of a hidden power struggle between the patient and us.  Some people can be unconsciously reluctant to accept the help of others.


How do we as acupuncturists get over this difficulty?  If the relationship between our patient and us has been well-grounded from the start, there should be no problem, as the patient’s strengthened energies give them sufficient support gradually to do without our help.  But if something in this relationship has tilted it towards over-dependence on us or otherwise distorted it, it may become more difficult to hand control back to the patient.  We may, for example, allow our patients to contact us too often between treatments by phone or now increasingly by email, something I was guilty of in the early days of my practice, because I felt I always had to be there to help my patients whenever they needed me.   This can make it all too easy to blur the necessary lines of separation between patient and practitioner which make a healthy relationship possible.   


We must never forget that our aim must always be to reach a point where we step back and treatment is no longer needed, the point where patients are now able to maintain balance by themselves.  If we are having difficulties with working out how gradually to space out treatments for patients we can see require less treatment, we should examine our relationship with them to see if we have encouraged on over-reliance on us, and, if so, start gently to take steps to encourage the patient to greater independence.   Of course, as with everything relating to our patients, our approach to each one will be different, and must be adapted to their individual needs.  With one patient treatments may remain weekly for much longer than with another.  At each stage we have to assess whether our relationship to our patient is adapting flexibly to that patient’s needs, and not depend upon a fixed formula for the spacing of appointments.

 

The symbolism of symptoms

It is always important to consider where and when physical symptoms appear on the body, and the nature of these symptoms.  If we think of the body as housing our soul, as we should as acupuncturists for whom body and soul are one, then a symptom of the body must bear a close relationship to the soul encased within this body.  I was reminded of this recently when helping a fellow practitioner with one of her patients who had been suffering for six years from a debilitating condition which affected her throat.  Not only did this make speech difficult, but it gave her the constant feeling of being throttled.  She had had all kinds of treatment, but nothing had so far helped.

When questioned about whether anything had happened at the time this started six years ago, it turned out that this was when a very much loved father-in-law had suddenly died.  This man had been very loving and caring, all that her own father, dead many years ago, had not been.  The mention of her father-in-law made me wonder what her relationship to her own father was which had caused her husband’s father to play such a prominent role in her life.  I could see that any mention of her own father caused her a great deal of stress, so probing gently a little more I discovered that he had abused her sexually when she was a teenager, something she had told nobody until now.  Without distorting the facts and the timescale in any way, it was not too fanciful to interpret the loss of her beloved father-in-law as an event which re-awakened the trauma of her abuse by her father and therefore proved the catalyst for the appearance of her throat problems.  It is likely that her father threatened her if she told anybody about the abuse, consigning her to enforced silence, in effect a form of suffocation.  This could be regarded as a possible cause for the appearance of the physical symptom of a throttled voice.

Apart from work on her element (Earth), I suggested that we add a point which I like very much, CV (Ren Mai) 22, the Window of Conception Vessel.  I feel it allows light to shine upon this most important central pathway, and, in her case, was exactly located where she experienced the feelings of suffocation.  I will find out in the coming weeks whether this first admission of the abuse she suffered and the treatment we gave her have helped her fully regain her voice.  As she left, her practitioner told me that her voice already sounded stronger and more normal.

 

Two humbling experiences

I have been very humbled by two experiences I have had in the last month or so, one as I left China, and the other on my return.  Both are heart-warming reminders to me of how fortunate I am to do what I do. 

My Chinese experience came on the last day of my stay in Nanning.  My host, Liu Lihong, wanted to find out how each of the 60 students who had attended our two weeks of seminars had found them.  So we asked each one in turn to tell us.  What astounded me, and I hope pleased Liu Lihong, was the group’s unanimous expression of overwhelming delight in what they had learnt and how amazed they were at the compassion and understanding we showed the many patients whose treatments they observed.  This was a facet of practice apparently totally new to them, and opened a fresh window for them onto the importance of developing a warm patient/practitioner relationship.   

My other example, from the other side of the world here in London, illustrates just this important aspect of our practice.  It comes in an email from the practitioner who has been telling me of her experience in treating a terminally ill cancer patient over the last few months of his life, and how profound an effect this has had on her (see my two previous blogs on 27 Feb and 25 March).

Although she was sad to have to report her patient’s death, she sees her time with him in the most positive light.  With her permission, I give below her description of what the experience has meant to her:

“The past months since his diagnosis in January this year have been a real roller coaster for him, both physically and emotionally. Things took a dramatic turn for the worse last Wednesday and I feel so relieved that his suffering and strife were not prolonged further and that he is now truly at peace.

I feel very privileged to have been invited into this person's life. His very obvious Wood CF was very refreshing to me, though not without its challenges to his nearest and dearest.  His thirst for information about his treatments and acupuncture as a whole was a delight and not at all threatening to me - he was extremely open to the whole Chinese medicine ethos and it could be said that he was rather unorthodox in his beliefs and actions, and extremely proud of the fact he was too!

His openness, honesty and need for straight talking could have easily come across as slightly abrasive, but for me it made the whole subject of cancer and death very accessible. At a time when some would feel the need to avoid or skirt around what is a very difficult subject, I felt able to talk candidly to him without fear of overstepping the mark or holding back, in order to say what needed to be said.

You have often said, Nora, how you learn so much from your patients. My relationship with this patient has been a very emotional, memorable and powerful lesson - but most of all, very humbling indeed.”

As with my patient Martine, about whom I wrote in the last chapter of my Pattern of Things, experiences such as those this practitioner had to learn to deal with touch us at the deepest level.  They leave us much changed, and by this change open us up to greater understanding of the needs of our patients. 

Both these experiences, from different parts of the world, remind me once again of the common thread which runs through all of us.  Whatever tribe, race, country or continent we come from, the five great fingers of the elements hold each of us in their grasp, shaping the deepest aspects of ourselves and giving us a common humanity.

Thoughts on another difficult practice situation

Please note here that I do not say “how to deal with a difficult patient”.  It is not that patients are simply difficult in themselves, but that we as people find them difficult to deal with.  For practitioners, that is a crucial difference.  As Shakespeare might have said, “the fault lies not in our stars (or in this case our patients) but in ourselves…”

So here goes about this particular difficult situation.  The patient was one who came for treatment as part of a clinical day I spent helping another practitioner with his patients.  She is a woman of 35 and moves around in a wheelchair.  Her medical notes show that she was diagnosed as autistic and with attention deficit problems as a child.  She has a long list of other medical conditions, the main being a spinal accident which left her confined to bed for a year when she was 8 and meningitis when she was 10.

What interested me was noting that she appeared to be quite capable of moving without help from the wheelchair to the treatment couch, nor did she have any difficulty in turning over on the couch.  Her legs, too, did not have the look of ones where the muscles have atrophied from little use.  She was wearing very heavy short boots, much like men’s army boots, which looked incongruous on a wheelchair-bound person by reason of their sheer weight alone.  She brought with her a little doll, the kind a five-year old child might have, which she insisted on tucking next to her on the couch. I also noticed other disconcertingly odd things which made me question how far she was actually incapacitated. 

Having expected from the notes that contact with her might be difficult because of her autism, I was surprised to see how easily she seemed to relate to us, and in particular noticed that she was darting hidden glances at me when she thought I wasn’t watching.

The practitioner is also her medical practitioner, and had started his five element treatment by relying only on her medical diagnosis rather than on a much more extensive five element diagnosis which would not have concentrated so exclusively on her physical conditions.  The distinction between his role as her physician and as her acupuncturist had become understandably blurred.  Initally, I, too, made the mistake of going along with this.  

The practitioner and I therefore assumed all sorts of things about her condition, basing ourselves on very little information about her current medical condition.  Did she in fact need a wheelchair at all, and could she be described as still being “autistic”?   

As is obvious to any five element acupuncturist from what I have written, we decided to treat her with Internal Dragons.  We followed this with an Aggressive Energy drain and the source points of her element which I thought was Fire.  I had a question mark around Inner Fire (Small Intestine), something to do with the quickness of her understanding (even though she didn’t like to show that she did understand) and the sharpness of her glance! 

I felt surprisingly angry at the end of the treatment, as though she had got under my skin and had outmanoeuvred us.  And I went so far as to tell the practitioner that I wasn’t sure there was any point in continuing treating her with acupuncture because she appeared to be manipulating the situation in a way that made treatment impossible.

It was my anger which brought me to my senses, and I told the practitioner later that I did not think I had dealt properly with the situation.  I had failed to take the right steps to get her treatment back in the correct five element groove.  We should have done a proper Traditional Diagnosis after the treatment in whatever time we had available, to be continued at the next treatment.  She should be asked to demonstrate how far she can stand and walk by herself, and the practitioner should get some answers to more detailed questions about her life.  We were not even clear about her living situation.  Does she live alone or with her family?  Does she have friends?  What does she do with her time?    

But all is not lost.  I have suggested to the practitioner that he should now start as though from scratch, trying to forget the wheelchair and the label of autism. Nor must he allow himself to be manipulated back into the old relationship where she appeared to be dictating how she wanted him to treat her.  My mistake was to allow her to do the same to me.

This is the only way in which we can help this patient.  And we should try to do that, rather than walk away.  She is really crying out for help, and has probably been crying out for this help all her life in the only way she knows how.   

It may be helpful to read this blog in conjunction with my blogs of 13 September 2011 “Losing control in the practice room” and of 9 October 2011 “Regaining control in the practice room”, which complement this blog and deal with other problems in the practice room. 

And so my learning continues!

 

Why it is never wise to treat our friends

I have recently been asked to treat two friends, one very close and the other more a friend of a friend.   Both of them were reluctant to go to another acupuncturist, and both were in quite a lot of distress.

This has made me think carefully about what has always guided me in my decision to treat or not to treat a friend.  Ideally, as we all know, we should not be treating family and friends because their very closeness means that we are not detached enough to see them clearly and to cope with finding out exactly what is wrong with them.  We assume, usually very wrongly, that we really know all about them, and can therefore skip doing a proper diagnosis and move straight on to treatment.  But my experiences in the past have put a lie to this, for I have often assumed somebody I know is of one element and decided quite some time later that they reveal another side to themselves and I have had to change my mind.  This has happened with me with a very close relative and a very close friend, both of whom I had somehow put into an element box which, looking back, I suppose I felt was part of my comfort zone.   When I later discovered how wrong I had been, I realised that I had almost deliberately been overlooking aspects of these two people which made me feel uneasy.  Since learning these two difficult lessons, I have been very reluctant indeed to treat those close to me, unless there is absolutely no alternative (for example, if geographically there is no other practitioner near enough to treat them, or they are hospitalized and would simply go without treatment).

With family members, however unwise being their practitioner is, it is unlikely that my treating them is going to cause a change in our relationship.  With friends, I have found, things are quite different, and my relationship to the friends I have had to treat in the past has always changed, and never for the better.  Usually what has happened is that the friend now views me only as their therapist, and wishes me to continue in this role even when I am not treating (by talking over symptoms or the effects of treatment in a social context, for example).  In a more extreme case, the friendship itself became endangered by the fact that a somewhat competitive friend did not like to feel that I was somehow gaining the upper hand, and persisted in claiming that treatment was making her feel worse.  In the end, I lost her both as friend and patient, because we never rediscovered our easy relationship of before.

In the two examples that have come my way now, I have, with a sense of relief, passed both the friend and the friend of a friend on to a fellow practitioner, knowing that I was doing the right thing.  This was not done without a slight tussle, because my first impulse is to offer help to anybody asking me for help, and it requires some strength of character for me to move aside.

       

Regaining control in the practice room: how the elements cast their magic upon patient and practitioner

This is a follow-up to my blog of September 13th on losing control in the practice room.

I am delighted to be able to say that this patient’s next treatment not only restored my faith in my own ability to maintain control, but also, and, far more importantly, showed me once again how the elements cast their magic not only upon our patients as they start to heal them, but also upon us as practitioners, as they remind us of their ability to transform.

My patient appeared at the door of my practice room as, in my eyes, quite another person. He greeted me less nervously, and with a warm smile that had not been there last time. He was much less nervous of the needles, chatted about his week’s work very easily, and interestingly did not, as he had done last time, demand a time for his next appointment. Instead, he apologized that his work-schedule was making it difficult for me to fit him into the times I normally see patients. The relationship between us had relaxed markedly. I can only attribute this to the transformative effect, on my patient, of strengthening his Water element and thus reducing his fear, and, on me, of helping me understand that the somewhat threatening interplay between us at his first treatment was caused by his fear and by my not responding appropriately to this fear.

And so I continue to learn.

Showing different sides of ourselves to different people

On the whole, in our relationships with the people we choose as friends we tend to show only one side of ourselves, the one which fits comfortably with the other person. It is likely that we will have discarded early on any too uncomfortable fits, unless we enjoy punishing ourselves or unless, as I as a young girl found I did, I felt it was somehow my fault that I didn’t get on with somebody and persisted in maintaining the friendship long after it stopped adding something to my life. Things are much more difficult with family relationships, because on the whole they are there for a lifetime;  we therefore have to learn ways of avoiding those areas we find uncomfortable, and we do this more or less successfully.

With patients we enter quite a different level of relationship. We do not choose them as we do our friends. They ask to see us, and we agree to treat them unless there is any professional reason why we should not accept them as patients. We are expected to enter into a patient/practitioner relationship with them whatever our personal likes or dislikes, for our personal preferences should not play a part here. Whether a patient votes the same way as we do or has religious beliefs that we do not should not be a reason for our not treating them. There is also something reassuring in the fact that, unlike in the case of our family and friends, we do not need to extend our concern for our patients into that part of our life which lies beyond the practice room. It is one of the signs of a maturing approach to our practice that we learn not to let it overshadow the rest of our lives as often happens in the early days of our practice, when we may become too preoccupied with analysing every tiniest part of our interaction with our patients.

I have often quoted the words of Sogyal Rinpoche, “Do not get attached to your giving”, but I am happy to repeat them here for they have in many ways helped me maintain the necessary professional detachment without which we may allow our own feelings to cloud our perceptions, and in this way fail our patients.

Fears patients may have

If we are honest, we must acknowledge that we all feel some slight apprehension at meeting a person for the first time, particularly when we are about to embark on some form of therapy, where the therapist takes on the role of the person who knows, and we may feel we take on a somewhat subservient role, of the person to whom something will be done, about which we at first know very little. In the case of acupuncture, there is the additional fear of the needle itself, instilled within all of us from our earliest days of sitting on our mother’s knee and submitting to the pain of vaccinations through a similar instrument. However much we may try to hide or override this fear as adults, it is always to some extent there, however faintly. In some, the fear of the needle may be so strong that it stops them from entering our practice room in the first place. All these fears, faint or strong, may set up a barrier to our first contacts with our patient which we need to take into account.

As patients, we also have to deal with our natural fear of exposing ourselves to another person, as our practitioner tries to get to know us. The words “tries to” are here significant, because, either deliberately or involuntarily, we may resist revealing too much of ourselves in the early stages of treatment if we are uneasy about the kind of relationship with our practitioner this will expose us to. We may not actually tell lies, although that, too must not be ruled out, but we may, as the expression goes, be economical with the truth, saying just enough not actually to tell an untruth, but not enough to tell the truth about ourselves. This means that we will inevitably paint only a partial picture of what is going on within us, which can easily be misinterpreted by our practitioner. It takes a surprisingly long time for a patient to feel safe and confident enough in their practitioner’s compassion and discretion to open themselves up with honesty. In fact, I believe that each of us will always retain a part of ourselves which we reveal to nobody but ourselves, not even, or perhaps particularly not, to our nearest and dearest, for many different reasons, amongst them the need to retain our own sense of self-respect. As practitioners, we must always allow our patients the right to keep this private area within themselves hidden to the outside world rather than expecting them to open themselves up to us in total honesty, but we must not lose sight of the fact that it may be there.

This is where our perception of the elements guides us towards what is really going on within a patient, for the elements, unlike words, do not lie; they just learn to hide themselves a little to too intrusive an eye. This is also why we should never rely on words spoken to tell us the truth, but use sensory and emotional signatures clearly to spell out this truth in their own particular way. It is easy for our lips to lie in the words they utter, but not in the way they shape themselves as they are uttering this lie, or the way our eyes can reveal something at odds with the tone of our speech.