Abstract
This article deals with several important aspects of the state of the practitioner during making a diagnose and acupuncture treatment. This approach is very crucial from a perspective from Engaging Vitality but could also be valuable for anybody practicing acupuncture. Essential elements which have been discussed in the foundational classics like the Neijing will be discussed, like Shi (propensity) and Ji (dynamic), the ability to listen with your hands, having a certain amount of stillness, alignment , being without agenda, having a soft focus, having attention instead of intention and more. Also the actual art of needling will be discussed. This subject will also be discussed during the Rothenburg conference during the Engaging Vitality workshop. This will be given by Dan Bensky, Velia Wortman and Felix de Haas.
In my first article (Qi, Vol.31, p.53) I presented the principles of Engaging Vitality, a palpation- based approach to acupuncture developed by Dan Bensky, Charles Chace and Marguerite Dinkins. Engaging Vitality integrates palpatory skills derived from osteopathy into East Asian Medicine. In this presentation, I will zoom in on some very important prerequisites for proper palpation and needling, namely, the mental and spiritual state we need to be in during our acupuncture practice. This topic is not only of importance to this specific approach to acupuncture, but also in other treatment approaches.
Why is the practitioner’s state important?
If we want to palpate and treat at an optimal level, our own state as practitioner is very important. This principle is emphasised for example, in the opening chapter of the Ling Shu. Here, the practitioner is admonished to “attend to the spirit and not to the form” and “attend to the dynamic and not to the junctures.” From this, it is clear that the practitioner needs to develop a certain awareness to be able to discern the subtle changes that take place in the body.
The language which is used in the Ling Shu also reflects that of early inner cultivation literature such as the Nei Ye and the 12 Knob Jade Inscription. These can be considered the earliest meditation manuals; both emphasise a state of stillness and awareness in order to facilitate an optimal flow of qi in the body. Although we are still not completely clear how these ideas were formed during the Warring States and early Han Dynasty, we know that most of these ideas arise from the same environment.
Below, I wish to outline a few concepts which I believe are of fundamental importance in achieving the right state for obtaining optimal diagnosis and treatment.
Shi 勢
Shi -which we could translate as strategic advantage- is one of the most important concepts in understanding Chinese medicine. For Engaging Vitality, it means that we have knowledge of the terrain we are observing. Like a military commander needs to consider the geography, the positioning of enemy and the state of his own troops before going into battle, we need to consider the landscape of the patient’s body, his or her constitution, the current presentation (zheng) and the presence, nature and location of the pathogens. The more skillfully we can estimate the current situation (shi), the predispositions and incipient changes, the better we can plan treatment and anticipate any developments.
Ji 機
This is another very important concept described in the Classics. We can translate Ji as dynamic, or in this context, the qi dynamic. Only by paying attention to the qi dynamic one can successfully anticipate the subtle changes in its dynamic. The Ling Shu states that the “Ji is the axis of quiescence from which all activity springs” meaning we need ourselves to be in a certain state of stillness in order to observe the subtle changes. Many ancient and modern commentators such as Zhang Jie-Bin , Zhang Zhi-Cong and Guo Tian, have emphasised the importance of being in a state of high concentration and quietude to be able to observe the subtle changes in the qi dynamic.
Listening (ting) 聽
In Engaging Vitality, we often use the term “listening”, a term which is borrowed from osteopathy, but also an idea found in Chinese classical literature, especially with respect to internal cultivation. In osteopathy and in Engaging Vitality we “listen” through our hands when we palpate.
I like often to refer to the story in the Zhuangzi, in which Confucius is given the task to explain to his favourite student Yan Hui that he should not listen with his ear, but instead with his mind/heart, or even better with his qi! We can interpret this story at different levels, but at one level, we can use this advice in clinic; instead of using intention we use attention, or even at a higher stage, awareness. Using this concept in a clinical setting, it can mean that instead of projecting our thoughts and egos, we remain open and attentive and can observe all the subtle changes in the qi dynamic.
(For a more broad discussion on this interpretation on listening in the Zhuangzi, see Stephen Birch , chapter Jing Mai and Qi in Restoring Order in Health and Chinese Medicine.)
For Engaging Vitality practitioners, instead of wanting to move the qi using needles, we just facilitate the qi to do its job by remaining attentive and aware. The body’s qi has its own intelligence, if we just facilitate the qi to do its job, we can achieve far better results. Additionally, listening and awareness during treatment are also effective in preventing over-treatment. If we are able to recognise the signs of over-treatment, we can easily adjust treatment and quickly avoid causing damage.
No Agenda
So instead of having a planned agenda and certain expectations, we remain open to the multiple possibilities of diagnosis and treatment. My teacher and colleague Dan Bensky always says that we should be prepared to be surprised by our palpatory findings. Indeed, if you maintain this attitude, you will be continuously surprised in clinic. This is also a reason why I prefer to examine the patient before I do any history-taking. I will always do a proper intake later on, but I want to start the treatment session with a blank mind. If you have already made a diagnosis based on the symptoms, you might unconsciously project your ideas onto the patient, which might colour your findings.
By being open and aware, by paying attention to all the details and the subtle changes in the body, you will get a clearer picture what is going on in the patient at that moment. By being able to let the treatment unfold itself, by anticipating to all the subtle changes that take place in the Qi dynamic, one can achieve optimal treatment. My teacher Charles “Chip” Chace called it a “dance with the qi”, a very good metaphor for this delicate process.
My experience is that the dance takes often unexpected turns, and by being attentive and adaptive, you can respond in the most effective way for the patient. This is so much more rewarding than having a protocol- oriented treatment.
Stillness( jing) 靜
One of the fundamental requirements to be able to “listen” to the qi and to be attentive and aware, is stillness. You need to arrive at a certain level of stillness within yourself to be able to “listen”. We don’t need to be experts in meditation practice, but we do need to have stillness and emptiness to be able to observe the subtle changes in the qi dynamic.
This is clearly stated in the early Chinese medical works and in the internal cultivation literature as well. From an internal cultivation perspective, the optimal flow of qi and an eventual process of refinement and transformation can only happen from that state of stillness. The great 12th century internal alchemist and acupuncturist Ma Dan-yang said: ” Qi is difficult to control, swift like a galloping horse, only in stillness it can be altered (eased).” It is clear that stillness is very important when we are engaging with the qi.
Alignment (zheng) 正
A correct physical and mental alignment is fundamental to diagnosis and treatment. When we want to palpate and needle optimally, we need to be aligned to facilitate these processes but not necessarily in a certain position or stance, as required in practicing martial arts. For example, when you needle a point and you are bend over and have blocked your arms, there is no optimal flow of qi in your own body, which inhibits the dance with the qi of your patient during the needling. This rule also applies to palpation, where a mental alignment which enables an optimal flow of qi in your own body will also contribute to the treatment. Again, this is already emphasised in the very early internal cultivation literature:
“When your body is not aligned,The inner power will not come.When you are not tranquil within,Your mind will not be well ordered.Align your body, assist the inner power,Then it will gradually come on its own.”
(Nei Ye verse 11, tr. Roth 1999: 66)
Soft Focus
Maintaining a “soft focus” is also essential during palpation and needling. This approach ties into the previous discussion on intention versus attention. If our focus is too “hard”, the patient’s system will push us away, and the body will give us less information. Furthermore, a “hard” approach also can affect the qi. Feeling the Shape of the Qi is a very useful diagnostic technique which bears some similarities with feeling the pulse (see below). When our focus is too hard, we feel that the Shape of the Qi deteriorates, something that we also find in the pulse.Therefore, we need to be attentive but without having a too strong focus. This discussion of just a few concepts already shows us how important our own state is, and how much only our own focus can affect the qi even before having inserted a needle.
Fluidity
First of all our hands should be like water. From an Engaging Vitality perspective, whatever form of palpation we do, we need to have hands like water. We have different palpation techniques, depending the different aspects we want to feel. But in all techniques, we need a certain amount of fluidity. Not only in our hands, but our whole body should also be fluid and receptive.
Settle, Supple, Integrate and Open, the Shape of Qi
The so-called “Shape of Qi”, one of the palpation techniques we use in Engaging Vitality, consists of palpating for the effect of our treatment on settling, suppling, integrating and opening of the patient’s qi. A discussion of this important topic goes beyond the scope of this article, but I will be presenting this topic at the upcoming Rothenberg TCM Congress.
In the actual diagnostic process, there is a way to directly engage with the Qi. We can touch the big flat surfaces of the body and can feel different qualities of the Qi. This gives us an general impression of the Qi: is it floating or settled? Is it supple or tight? Is it integrated or is there stratification? Is there free flow or is it obstructed? These are very general remarks, but in practice we can get a very clear picture of the Qi dynamic.
But in order to be able to estimate the qualities of the Qi , we need a certain settling , suppling, integrating and opening of our own Qi, at least till a certain extent. If we are able to listen and observe attentively, we can feel also the changes of the Qi in response to our needling (or moxa or whatever techniques you use).
The Shape of Qi must improve during the treatment; if the Qi is floating too much it should settle, if it is to tight, it should become more softer without losing its borders, if it is stratified, it should become more integrated, if there’s impediment, there should be better flow and so on. This is an extremely valuable feedback, and will tell you if you are effectively treating. If the Qi is responding in a way which is not favourable, you can then alter the course during your treatment.
But the settling, suppling, integrating and opening of our own Qi is also fundamental. Only if our own Qi is settled, supple , integrated and open, we can listen optimally.
Tong 通
The last quality mentioned above is Tong通, which may be translated as openness, affording passage, penetration, passing through or communication. This is an aspect in Chinese Medicine which has been neglected in the West, but thanks to scholar-physicians such as Volker Scheid and Dan Bensky, there is a growing awareness of this key concept in Chinese Medicine. From an Engaging Vitality perspective it is fundamental that we as practitioners remain tong when we engage with our patients; tong might be one of the main objectives of acupuncture. We often talk about supplementation (bu 補) and draining (xie瀉), but actually opening up the channels and optimise the flow of Qi might be the most important goal of acupuncture.
Actual excesses or deficiencies, if present, might be settled by the reorganisation of the Qi itself. However, this doesn’t mean that we need to abandon these techniques altogether, but my own experience through the years is that simply allowing the Qi to do the job is frequently the most effective.
The Art of Needling
The actual needling process is a subtle interaction with the Qi of the patient, a dance with the Qi. The acupuncturist gives an input to the body and anticipates the patient’s reaction. Before starting to dance, we first of all need to know whether we can communicate with the Qi and for this, you need to select the “living” channels and the “active” points. Instead of selecting points according to a preconceived protocol, you can palpate for the points that are active at that moment in time.
There are different ways to palpate.; examples of these are Japanese styles such as Toyohari or Dr. Wang Ju-yi’s approach. In Engaging Vitality, we have different palpation approaches, including one which was developed by the French osteopath Jean-Pierre Barral. Dr. Barral named it Manual Thermal Diagnosis and in Engaging Vitality we have renamed it Qi Signal Assessment. With this form of palpation, we can find the active points and further on we have techniques to estimate the correct angle and depth of needle insertion needed to obtain an optimum effect.
While performing the needling itself we should have the sensation of meeting the Qi, in a way, we are “listening” through the needle. The process of feeling the arrival of the Qi (qi zhi 氣至)and obtaining of the Qi (de qi 得氣) is therefore, from this perspective, something felt by the practitioner but not necessarily by the patient. The awareness of such subtle experiences requires a high state of presence and awareness from the practitioner.
Pivot of Nothingness
If we can remain in a state of emptiness, openness and awareness, we can deliver effective needling. Thus, we become an extension of the needle, a “Divine Pivot“ or Ling Shu 靈樞. The great Japanese Zen master Dogen, talks about the Pivot of Emptiness, a state of being in the here and now. In this process of becoming a Pivot of Emptiness, the Qi reorganises itself along this pivot, so that even in the middle of a busy clinic, we can arrive at that state of stillness and emptiness.
Ignition (dian hua) 點化
When we are able to needle in such a way, we can create the optimal conditions for the system to reorganise itself. If all conditions are perfect, this may contribute to a great shift, which we call ignition, a term used in osteopathy and Internal Alchemy. In Internal Alchemy it is considered a sudden transformation, signalling the ignition of the primal Yang Qi, a process which is necessary for refinement and transmutation of the Qi.
In our clinical practice, we find that this might trigger the self- healing mechanism at a much larger scale. This is something the practitioner cannot force, at the most we can only create the right conditions. More often, there will be a much more ordinary occurrence during treatment which may feel like simply turning on the switch and suddenly having light.
Conclusion
In summary, we could conclude that the state of the practitioner is of utmost importance in acupuncture and that this is clearly stated in the early Chinese medical texts and later commentaries . In my opinion, this should be a cornerstone in acupuncture training. Whatever style of acupuncture we practice, our own state is of vital importance.
Literature /Links
An axis of efficacy (part 1) https://www.thelantern.com.au/product/an-axis-of-efficacy-part-1/
An axis of efficacy (part 2) https://www.thelantern.com.au/product/an-axis-of-efficacy/
Efficacy Born of Disposition (Shi 勢), A Broad Perspective on Treatment Strategy in Acupuncture Therapy – Charles Chace/Manuel Rodriguez Cuadras, https://static1.squarespace.com/static/59fbc57f29f187f1fa8a0664/t/5de54cca6e39282decb57a31/1575308492177/Shi-Efficacy-born-of-disposition.pdf
Restoring Order in Health and Chinese Medicine – Birch, Angel Cabrir Mir, Rodriguez Cuadras.- La Liebre de Marzo – 2014
Original Tao- Inward Training (Nei-yeh) and the Foundations of Taoist Mysticism- Harold Roth – Columbia University Press- 2004
Some reflections on Propensity – Felix de Haas