Each person is “a house with four rooms”

I have just bought the second volume of the autobiography of the lovely writer, Rumer Godden, who lived most of her life in India. It is called A House with Four Rooms. I quote her dedication at the front of the book:

”There is an Indian proverb or axiom that says that everyone is a house with four rooms, a physical, a mental, an emotional and a spiritual. Most of us tend to live in one room most of the time but, unless we go into every room every day, even if only to keep it aired, we are not a complete person.”

Mid-August Lunch (Pranzo di Ferragosto)

I have a friend, Susan, to thank for pointing me towards this lovely film about a middle-aged son, his aged mother and an unexpected houseful of similarly aged women over the weekend of this holiday. It is a tender and true film, which made me laugh, smile and cry a bit, but more importantly helped restore my faith in what a skilled writer and film director can do with the simplest material.

Like my little circular box (see previous blog), it continues to make me smile as I write about it. And this is all the more important, as I find that there have been very few other things in the wider world outside which make me smile at the moment.

The pleasure of beautiful things

Yesterday I bought a little circular box which I had seen in the window of a local charity shop and fallen in love with. I was told it was carved out of rhinoceros horn, but I don’t know whether that is true or whether it is merely imitation plastic. In any case, if it is made of horn, I hope that the rhinoceros from which it came died of natural causes and was not one of the poor animals now hunted by poachers for just such a piece of horn.

The box is about 3 ins in diameter and about 1½ ins high, and has a little hinged lid with a little carved knob on top. Its tiny brass hinges and the brass studs around its base point to its being quite old. I can’t see a modern trinket-maker spending the kind of time needed to work these into the side panels. And it is also carefully lined with slightly worn black velvet which could again indicate an object made at a time when craftsmanship was more readily available and cheaper than now. It is a kind of mottled brown in colour, shot through with cream, and the small panels of its base could indeed come from something circular, such as a horn. I will not know what it is really made of, and when it is likely to have been made, until I give it to a friend of mine who haunts the Victoria and Albert Museum and knows all about these kinds of things.

I have put it on a low table on which I gather precious things I take pleasure in looking at. Here it is joined by a tiny green malachite elephant, said to come from the Congo, and a small replica of the Degas dancer, stretching her hands behind her and pointing her toes. I smile whenever I look at my little box. At a penny a smile, it is surely worth the few pounds I paid for it.

“Don’t get attached to your giving”

Behind many of our fears as practitioners may lie the concern that a patient who is not perhaps getting what he/she wants from treatment, or whose treatment is not progressing as quickly as they had hoped, may decide that they do not want to continue treatment. We must not allow this fear to dictate the course of treatment. We should always let them to leave with as little feeling of disappointment or doubts about our own performance as possible, and learn to move on quickly.

It often happens that we never know why a patient stops coming to see us. Some few tell us why they are stopping, but many others, usually the majority, simply disappear, probably because they are too embarrassed to tell us why they are stopping. And this can happen after many months or even years of being our patients. The hardest to take are those long-standing patients of ours who either decide to move to another practitioner or stop having treatment of any kind without informing us. These we may never hear of again, and, human curiosity being what it is, we would dearly like to know what is going on in their lives, but may never do so, except by chance. As I heard a very wise Tibetan master, Sogyal Rinpoche, saying: “Don’t get attached to your giving”, one of the hardest lessons we have to learn.

Sometimes we hear news of our patient indirectly through somebody else. One such occasion, which I treasure for teaching me a lot about the effect of even a few treatments, occurred recently. A new patient of mine said that he had heard of me through a good friend of his who had had treatment from me, and who had told him that this treatment “had transformed her life”. I struggled to remember who the patient was, but looking back through my notes realised that she had come to see me for precisely three treatments many years ago, and then stopped coming. Without hearing what her friend told me, I would have qualified her treatment as a failure, as I did at the time. So we never really know what effect our treatments, and perhaps more importantly our presence and approach, can have. And this episode taught me not to underestimate the power of the interaction between the patient and me, nor of the power of those first few treatments in which the elements are addressed so directly and so vigorously for the first time, particularly through the initial cleansing treatment (AE drain) we give. Sometimes for some patients all that is needed is to point the elements in the right direction through these first simple, but pure, treatments, and leave the elements to continue on the path towards restored health through their own efforts as it were. Other patients may need our support for longer.

It is of course obvious that the nature of the relationship we enter into with our patients is crucial to the success of treatment. Of course a patient will have personal preferences which may have nothing to do with a practitioner’s competence, and we have to accept that. A patient must feel at ease with their practitioner, as one of the essential prerequisites for successful treatment. If this relationship is for some reason not right, patients will be reluctant to continue treatment, and the treatment itself will rest on very shaky foundations. The kind of uncertainties an uneasy relationship brings with it can lead the elements to hide or distort themselves, as though a screen has been thrown up between us, and the hesitancies which such unease can create in us as practitioners can confuse our perceptions of how to interpret what we see. We may ourselves be anxious and overlook anxiety in our patient, for example, or irritated and interpret through our own angry eyes our patient’s emotion as anger.

The lines of communication flowing between the patient and us and between us and the patient need to be as uncluttered as possible, so that the messages passing along these lines are interpreted according to their true meanings rather than being distorted by kinks somewhere along the way.

A practitioner’s intention

Each practitioner in their own way influences the course of treatment not merely by their selection of the treatment itself but by their very presence and the nature of this presence. This is the quality which should make the insertion of a needle into an acupuncture point so much more than that needed to obtain a blood sample from a hypodermic needle. For, enclosed as it were within the physical action of penetrating the skin with the needle, there should be some inner quality transmitted by the practitioner’s spirit into the heart of the action which transforms this action from a mere physical process into something akin to what is imparted by a caress.

And that is not too emotive a description of what we do, for at a deep level where the practitioner attempts to engage the patient’s spirit, he/she must do that with the kind of gentle warmth we impart to those we love. At the heart of all acupuncture treatment at the level of which I am talking lies love, the warmth of one human being for another, allied here to the desire to help another, which is a practitioner’s role. Though the needle is solid, unlike a hypodermic needle, in one way it should be regarded as hollow, offering a channel through which the practitioner passes something more elusive and intangible than a physical substance. Within this lie such ephemeral gifts as the practitioner’s experience. This will include the confidence he/she will impart born of this experience, which will include an understanding of the transformation the action residing within points can bring about in a patient.

It is therefore vital to understand that the actual insertion of the needle is only a very small part of the process by which the energy to which the point has access is stirred, in much the same way as the manner in which we touch a child can comfort or frighten it. If we are unaware of this, we become mechanical acupuncturists, going through standard rituals, and our needle is then little more than a more delicate hypodermic needle inserted at a physical level to carry out a specific physical action. But, as I argue strongly, what we do must always have within it something of the spirit, and thus the selection of an acupuncture point and its needling must also always be bathed in just such a spirit. So when I select a point I will already have endowed it with something from my spirit which breathes into it my own understanding of why I have chosen it for this particular patient and for this particular treatment, and when I lift the needle what I intend this point to do for my patient flows from me into the needle.

It is difficult to define the elusive nature of the quality we bring with us into the practice room, which is why one person using the same points for the same treatment as another practitioner may have a completely different effect. There is no doubt that the more focused the practitioner is, the more effective treatment becomes. Another acupuncturist once told me that he was surprised that he did not get the same results from treatment as I did, although he was trained in the same discipline and used the same points for the same reasons. This initially puzzled me, until I realised that, at heart, he had doubts about the efficacy of what he was doing, whereas I did not.

It is important that we do not think that this area of our practice, that in which a practitioner can summon to treatment some quality of understanding they have gained from their experience, is only accessible to the experienced practitioner and might make it difficult for a novice practitioner to carry out good treatment. This is far from the case. It is merely that it is important that a practitioner from the earliest days is made aware of this important facet of their practice, and is thus open to harnessing whatever experience they slowly acquire to guide their treatments in the right way. We can focus our intention to achieve whatever we hope to achieve from the first few hesitant steps we take in practice through to those more confident steps experience helps us to take. Merely being aware that a practitioner brings something all their own to the insertion of the needle which can endow that insertion with something much deeper is the first step in this direction.

Point names, and how far they help us in point selection

The individual site we know of as a point has been endowed since the earliest days with a (nearly) unique Chinese name about whose meaning there is much learned debate in those circles which boast a knowledge of ancient Chinese. It might be considered simple to use a point’s name as the basis for treatment, without reference either to the meridian on which it lies or to its anatomical position. This represents to me a crude form of point selection, if used as the main basis for selecting what treatment to offer, for it is to take a point out of the context of the body as an interconnecting globe of energy pathways.

Since I have started translating Elisabeth Rochat de la Vallée’s work on Chinese point names, I have become increasingly aware of the complex issues surrounding the meaning of point names discussed in the many classical texts she examines. This has helped me recognise that there are wide variations in meanings attributed in these texts to the same point names. They also show many differences not only as to where some points are located, but also on which meridian they are to be placed.

If there is so much debate in the classical texts, it is understandable how much all of this shades over into the even more complex area of the translation of names into other languages. Linguistic purists may complain that the English (or French or German or Japanese) words may eventually bear little or no relation to the original Chinese character upon which they are supposedly based, but such changes are inevitable, given the journey from culture to culture and from language to language that these names have made. This being so, I think, for my part, that a study of the original Chinese characters, fascinating and illuminating though this is, may well best be left to the historian and the linguist, if I, as a practising acupuncturist, am not to be overwhelmed. What I feel is the most important to me clinically is the rationale underlying my point selection, and how far some idea of the meaning of a point’s name helps me in this choice.

Every practitioner will have absorbed a number of points into their practice which they feel comfortable to use, and it is likely that this list will contain points with which we have grown familiar because of their use in the tradition we have inherited. The important thing here is that we develop an understanding of our own concept of the meridian network, with an internal logic we can justify to ourselves as we choose individual points. We must place our point selection in the widest context possible, and develop our own rationale for the points we select. Nor must we forget how many layers of learning seep into us from all the many different people we have learned from, who are trained in the discipline which shapes the branch of acupuncture we inherit. All these different pathways of learning, including what personal interpretation we make of a point's name, together go to form a kind of individual acupuncture heritage, and coalesce to form the understanding we have of what points to choose, making point selection always into a very personal journey of adventure.

The important thing here is to be prepared at any stage to widen both our repertoire of points and our perceptions as to when to use a point. I have often found that another practitioner will mention to me a point they use which may be one that I have never thought of using, or one that has somehow dropped off my radar. Adding this point to those I select from then reinvigorates me, refreshing my practice, much as if I am putting new flowers into my practice room. Our practice needs constant stimulation with new ideas of this kind if it is not to grow stale. This is one of the reasons why I like writing about acupuncture, because thinking about what I want to write makes me examine every aspect of my practice with a fresh eye, as though coming new to it.

Seasonal treatment

I have a reader of this blog, Sean, to thank for prompting me to write the following, in answer to his question about my treatment of a Wood patient: “I’d like to know why you choose AEPs of Wood, especially for an autumn seasonal treatment.”

The error here is in thinking that I was giving “autumn seasonal treatment” to this Wood patient. The only seasonal treatment I do is treating a patient’s guardian element in the season of that element, and with its own element points (for example, St 36 and Sp 3 (Earth points within the Earth officials) in late summer for an Earth patient). No other points, including therefore AEPs, have any connection with seasonal treatments, except of course that any treatment we do in an element's season will have that little extra effect because it is drawing on nature's contribution to that element.

I know some people give seasonal treatment for patients of other elements apart from the element whose season they are in. In other words, for a Fire patient they may give a Metal seasonal treatment, LI 1 and Lu 8. I do not do that, as I see it as unnecessarily moving away from the patient’s own element. An element in balance should be able to deal with any seasonal changes through strengthening treatment on its own points. But the guardian element is always under greater strain than any other element, and will feel this load particularly in its own season. This is why we try to help it by doubling up the support we are offering, in other words by adding more Metal to Metal in autumn, or more Wood to Wood in spring, which is what we are doing when we do seasonal treatments.

All this applies, of course, to horary treatments as well (treating a Water patient with Bl 66 and Ki 10 in Water time, between 3 and 7 pm). And to be able to do a seasonal treatment in horary time is said to be the best treatment of all (you are in effect trebling the amount of help you are giving an element). For logistical reasons, this is difficult to do for some elements (Wood and Metal in particular), since patients would have to come to our practices in the night. JR encouraged us to arrange for several patients to come together during these anti-social hours, which, as a good pupil, I started doing, until I realised that a few patients who had loyally turned up between 11 and 3 in the night for their Wood horary treatments turned out, with more treatment, not to be Wood after all! I have since, for obvious reasons, not least my own health, discontinued this practice.

The cumulative effect of points

It is good to understand the difficulty of assessing exactly what effect one point has rather than that of an accumulation of points added to the effect over time. A point might, in principle, I assume, prove its efficacy not immediately but after some time, as change can occur slowly. Since our patients on the whole continue their treatment with us from week to week, they will have further points needled which may have added to the effect of what we can call that original point, cancelled it or given it a completely different emphasis, so that it is no longer possible to assess exactly which point did what when. Certainly even if it were only the first point that has this future effect, we will never be able to isolate this for all the above reasons, so unless we are simply to needle one point once and await its effect, without adding any further points for a sufficiently long time to give us some certainty of whether it has had an effect or not, we can never know in absolute terms what the effect of that one point on that one patient at that one time is.

Does it matter? Well, yes, it does, but only if we are trying to assess the value of individual points in isolation and to test the accuracy of the information, all generally anecdotal and handed down, by word of mouth or hearsay, or from traditional sources which have grown up around that point and give it a weight and substance that we have no way at all of assessing. I am, however, emphasizing the cumulative importance of treatment rather than that of an individual point. The long-term effects of points used together, either in combination in the same treatment or in sequence as part of a pattern of treatment, will be observable over time and can thus be attributed, one can assume, to the cumulative effect of all the points that have been needled so far. We will never know whether it is indeed only one amongst many that has been effective, or whether it is the whole lot of them combined, or whether it is any combination of some of them, with some remaining ineffective, as another evidence of the dead wood I mentioned. But at least we can gain confirmation or not about the cumulative effect of the points we have so far needled.

Think element, not points

When we approach treatment, our mantra should always be: Think element, not points. We know that we treat by needling a series of points, but we must think of these points not as individual stitches in a garment, but as shaping the garment as a whole. It has always surprised me how much attention practitioners seem to pay to individual points, whilst placing very much in a subsidiary role the element upon whose meridians these points lie, of which they form only a small part.

I am convinced of the cumulative nature of working upon an element, rather than the need to rely upon the individual action of specific points. In my view it is therefore never just one individual point which does the trick, and turns the tide of treatment as it were. Rather, there is a gradual accumulation of effect, as the selection of different points on that meridian/element adds layer upon layer to the element’s effectiveness in redressing a patient’s imbalances. There may come a tipping-point as a result of one treatment, where ill-health turns at last to good health, but it is created, not by the points selected for that particular treatment, but as a result of having, with each preceding treatment, through the selection of one point or a series of points after another, placed weight upon weight on the side of the scales of health labelled balance.

The greater the over-emphasis on points to the detriment of the subtleties of the elemental and meridian networks to which they belong, the more practitioners are reluctant to engage with the elements at the deep level such a relationship calls for. This deep level of understanding helps remove the emphasis on individual points, replacing it instead with what I regard as a much simpler scenario. Here the power of each element and of its servants, its two yin and yang officials, remains always to the fore, with correspondingly less emphasis placed on deciding which of its points to select to harness its energy. All points belonging to an element enhance in different ways that element’s energy, each becoming one of the many doorways through which this energy can be directed. This is why it is possible for practitioners to choose quite different points on the same meridian and yet lead to a similar level of improvement in the patient.

If the effectiveness of treatment lies in the cumulative effect of selecting points on the same element rather than in selecting a succession of unrelated, individual points, it is then very much a matter for individual practitioners’ preferences which points relating to that element are selected at which stage of treatment. These selections are usually based on the protocols used in the particular branch of acupuncture in which they have been trained or by the individual teachers who have passed on their knowledge to them, and they will therefore vary from school to school and from practitioner to practitioner.

My calming routine

I have developed a kind of calming routine as soon as I experience the tension of not knowing which element to concentrate upon. If I am unable to home in on any particular dominant sensory or emotional signal coming from one element above all the others, I will experience that all-too familiar feeling of slight panic at not knowing what to do next, which all five element acupuncturists will, if they are honest, often feel. I then move into a routine which I have devised for myself in which I slow down what I am doing, and try to put myself back in the position I was in when I first met the patient. In other words I try to see the patient with completely fresh eyes once again. To do this I may concentrate on one of the sensory signals, voice, for example, and just engage in some conversation, not primarily to hear what the patient is saying, but how they are saying it. Or I may make a deliberate effort to smell, maybe by moving the blanket away to get closer to the body. I may also take this as an opportunity to look again at my notes. Doing this helps to insert a pause in what I am doing, since I have to page through the file and there has to be silence whilst I am reading. The patient, lying quietly there, is not aware of any hesitation in me, seeing only that I am absorbed in reading my notes and therefore is more likely than not to be pleased that I am taking so much time and care over them rather than, as I might worry, becoming impatient.

In fact the cultivation of periods of silence when nothing is happening except in the practitioner’s mind is a good practice to follow. It allows the patient to relax and the practitioner to think unhurriedly. One of the problems we may all have is in believing that we must always be doing something in the practice room, as though action is always a sign that we know what we are doing. If we don’t know what to do, because we are not reading the signals coming from the patient clearly enough to work out what treatment we need to do, we must give ourselves time to think, without feeling that our silence will be interpreted as incompetence by the patient.

I have always been quite happy, too, with admitting to a patient whose treatment appears not to be progressing that, as I have learnt to put it, “there is something here which I don’t understand”, and asking them whether they are happy to give me the time to work this out. No patient has ever been anything but delighted that I am prepared to give them so much of my time, and all have been happy to agree to coming more frequently for treatment if I think this is necessary, until I have worked out the direction I want treatment to take. For it is unprofessional if, knowing that we are unsure where treatment is going, we then agree not to see the patient for quite a long time, say a month ahead. This only delays the time we will take to get our treatment focused properly, and does nothing but increase the level of our uncertainty, since we have too much time to worry over our patient, with no feedback from seeing them to help us.

We should instead openly discuss our uncertainty to the patient, and ask them to give us the time to work out what we need to do. In such a situation it is essential that we see the patient as frequently as possible, because this gives us the opportunity of looking at them afresh and with these new eyes seeing the elements within them more clearly. Nor should we worry, as some of us do, about our patient’s finances here. We should leave it to them to say whether what may be an unexpected return to frequent treatments is making things financially difficult for them and, if so, perhaps we should consider reducing our fees for a short time. In the long run this saves patients both time and ultimately money since the frequency of treatment now will reduce the overall time the patient needs to come for treatment.