The Practitioner-Patient Relationship: Wisdom from the Chinese Classics
In 2015, my teacher Niki Bilton gave us this handout and said that it was something that we as practitioners should read at least once per week. At the time I thought, “Well that ain’t gonna happen!”. But since then I have indeed read this article once a week. It is a reminder that acupuncture is not just that act of putting needles into tissue.
Although these notes are meant for practitioners, I think there is plenty of wisdom to share with anyone who has had an interest in ancient aspects of medicine and healing.
Thanks for reading,
Erin
The Practitioner-Patient Relationship
Wisdom from the Chinese Classics
Notes from a seminar by Claude Larre, s.j., and Elisabeth Rochat de la Vallee (May 26, 1990)
Compiled by Edna M. Brandt, RAc with special thanks to Jeanne Anne Whittington, Chan Zang, Zoe Brenner and Sarah Stang. This article is transcribed from a. Copy of the Journal of Traditional Acupuncture, Winter 1990-91, pp 14-17 and 49-50.
Father Claude Larre,s.j., studied Chinese in Beijing and Shanghai and lived in Japan and Vietnam for many years. He has a doctorate in Philosophy and Sinology from the University of Paris and degrees in Chinese, Japanese and Vietnam studies and Languages. He has written extensively on different aspects of Chinese culture, specializing in translating Daoist texts and Chinese medical texts. He is the founder of the Ricci Institute in Paris and director of the European School of Acupuncture.
Elisabeth Rochat de la Vallee is the senior lecturer of the European School of Acupuncture and a member of the Ricci Institute. She holds degrees in Philosophy and the Classics and in Chinese studies. Elisabeth has worked with Claude Larre for nearly twenty years as a researcher and translator and has exceptional knowledge of the medical classics, grounded by her experience as an acupuncture practitioner.
The texts for this seminar are chapters from the Huang Di Neijing (Yellow Emperor’s Classic of Internal Medicine) which has two sections, the Su Wen and the Ling Shu. The Neijing is the oldest-known document of Chinese medicine. Its author unknown, it was compiled sometime between 200B.C. and 800A.D. Its contents are certainly much older, summing up the knowledge of many centuries.
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“The most important thing for healing is the relationship of the practitioner, the spirits and the patient.”
The Neijing tells us that the healing process is not just mechanical- it is not simply the placing of a needle. The most important thing for healing is the relationship between the practitioner, the spirits, and the patient. This relationship begins with the personal attitude and inner behaviour of the practitioner. Your own spirits and forces must be in good concentration in order to be able to evaluate the patient and to be able to rectify what is wrong in the movement of his or her vitality. It is your spirit which enables you to be able to make the diagnosis, choose the points, and give a feeling of rightness to the patient at a high level- without interfering with the patient’s freedom. The treatment always takes place inside of this practitioner-patient relationship.
Su Wen Chapter 39:
Huang Di speaks to Qi Po:
Those who are good at speaking of heaven must have experienced it in man.
Those who are good at speaking of antiquity must have made the junction with the present.
Those who are good at speaking of men must be satisfied with themselves.
When things are like this, one can follow the Dao without confusion or distress and reach the summit of essential rules/numbers.
That is called illumination/radiance of life.
I would like to ask how to succeed in having knowledge of diagnosis through rules: how to hear and ask questions, how to succeed in seeing, feeling and palpating, how through the deep examination of self one can be free of confusion and lift the veil.
Commentary:
Those who are good at speaking of heaven must have experienced it in man.
Heaven (tian) represents Nature, the movement of the four seasons, which are present in the entire life of each person. In our body is the same life that is in a tree or flower or in the weather. The differences depend on our species- the details are different but the organization is the same. If we can observe how all life is at work, this is the first level of knowledge: to have the consciousness to observe the natural order and find it again in oneself and in another. If you know how life functions, then you know how disturbances show up, because diseases follow this movement also. Heaven is the unseen power that is directing everything, and all discernment of health and disturbances begins with this knowledge of heaven. If you understand that you must be in harmony with Heaven, you will practice clearly.
Those who are good at speaking of antiquity must have made the junction with the present.
Antiquity (gu) was the time when the sages could see how life was organized, so they could help people know how to behave. The most famous commentator on this passage says that antiquity is the mirror for the present time, and if you cannot see how one applies to the other, then you are only able to apply recipes without real understanding. However, we also need to make the junction of antiquity with the present, which means that we must interpret antiquity to find the deep meaning of what was said in the past in light of present circumstances.
Those who are good at speaking of men must be satisfied with themselves.
This is the third level of relationship, a consequence of Heaven plus antiquity. The first level (Heaven) is the unity of life in each being, the second level (Earth), the continuity of life from antiquity to the present. The third level (Man) is the multiple individual lives and their relationships. If you do not have a good relationship with yourself, you are unable to have a good relationship with another. You first must have a deep understanding of your own life before pretending to know life in another, especially the disturbances in the development of life in another.
You also must not be blocked in yourself, or full of desire to heal. You have just to do your best, very quietly, and then let go. You must not have inner agitation or desires, even the best of desires; if you do not have desire, then you have a real relationship with the patient and are not forcing the patient to correct his spirits to please you. To be satisfied with yourself means to harmonize yourself. If you are quiet within- as you must be while doing calligraphy or archery- you will do good healing work.
Yet if you have the desire to be empty and quiet inside (for the free circulation of your heart), the desire itself prevents you from being empty and quiet. There is then something wrong in your spirit and in the fundamental axis of your life, and hence you cannot succeed. The best way to cure a patient is to remain in the natural expression of your own power of life. To desire too strongly is stagnation and blockage in your intent and will, and it diminishes your ability to cure. Do not grieve if you cannot cure; just try without tension every day to become what you are, let the life of the spirit grow in you, and bring this to every part of your work.
The texts never say that you must desire to cure. They repeatedly say to be calm and quiet without special desire. Wanting something is always dangerous, even if you are wanting the best thing in the world- the tension in you is bad. Note, though, that willpower is not the same as desire; willpower is the right orientation of your life, which you must have, and it is sufficient.
This, of course, is the ideal. Every practitioner feels good when the patient is better (it makes a cure in the practitioner too!), but if it lasts longer than just today, it becomes the beginning of disease in you. So, be happy about it today, but tomorrow forget about it.
When things are like this, one can follow the Dao without confusion or distress...
If you can realize these three levels, then the Dao is without confusion. You can follow and express your own way of living without uncertainty. You can know something- not because you know from the exterior but because you know from your interior. You are self-sufficient, well balanced, quiet, and calm in yourself. Hence, you can apply the Dao, which is also the art of medicine, to your patients without confusion.
...and reach the summit of essential rules/numbers.
In this state, you are able also to follow to the end the essential rules (shu). These are the models of all activities, between the level of Earth in each particular person and the level of Heaven where all is unity. The character shu means both rules and numbers (and also technical applications). Rules are derived from what is true and common from many particulars, finding the unity where things are the same. Numerology expresses these fundamentals- the great unfolding of life which all the universe shares.
In studying medicine, we get rules for particular cases, but we also have to be able to go to the level of unity through our own lives in order to be able to understand how the rules given from antiquity can be applied to a particular person.
That is called illumination/radiance of life.
To be in this state is illumination, understanding the patient through the light of knowledge between what you have learned and the pattern of life you experience in yourself.
I would like to ask how to succeed in having knowledge of diagnosis through rules, how to hear and ask questions, how to succeed in seeing, feeling, palpating, how through the deep examination of self one can be free of confusion and lift the veil.
Diagnosis through the sense organs relies on the deep examination of yourself. Through that examination, you are able to clear blocks in understanding and to make a good diagnosis- to lift the veil. Even the tools of diagnosis (fingers, eyes, ears) must be in perfect condition. To see, for instance, is not just having enough liquids and blood in your eye, but also having the presence of spirits there. The presence of the spirits is due to the inner position of your own life.
Su Wen Chapter 11:
Make an examination at the physical level and at the level of the zhi and yi to estimate the illness.
If one believes in gui shen, there is no possibility of expressing the virtue.
If one is loathe to be needled, there is no possibility of expressing clever skillfulness.
If one does not accept being treated and cured, do not treat him.
Commentary:
Make an examination at the physical level and at the level of the zhi and yi to estimate the illness.
The general meaning is that there is an examination of bodily form: face, pulse, orifices, functioning of viscera, and so on. Then there is also an examination of the inner willpower (zhi) and purpose (yi) as they relate to the illness in the person. The zhi is anchored in the kidneys at the bottom of the trunk and gives direction, continuity, and orientation not only in outward activity but also in the deep mental and spiritual levels. Yi is the image, the thinking or the elaboration of the shape given to the oriented strength coming from the will. All are under the authority of the heart (xin). The distribution of essences and qi depend on these three, which make the inner central axis of the person. The correct rooting of the axis allows the good functioning of the viscera and all the particular details of the person.
THE INNER AXIS
Heart (upper jiao) Heart shen
Spleen (middle jiao) Purpose yi
Kidneys (lower jiao) Will zhi
There is also a great importance given to the spirit of the heart (shen) and of the yi and zhi in the practitioner. You must be upright yourself to be able to discern the axis of the patient in order to diagnose not just the symptoms but the fundamental center of the patient. Only then can you appreciate exactly what the illness is. In other words, the illness occurs not only because the qi is weak or the blood is stagnated; it is not sufficient to diagnose only at this physical level. You must discern whether the central axis, which commands the physiology of the patient, is strong enough. When you can see both the qi/blood and the central axis together, you can obtain the correct appreciation of the gravity of the intuition. One or the other is not enough.
The patient needs to feel that she has a will and a purpose in life when she leaves your office. This is not only part of the diagnosis; it is part of the treatment too.
If one believes in gui shen, there is no possibility of expressing virtue.
Shen are the spirits of Heaven (through which the influx of Heaven comes to each person). Gui are the spirits of Earth (supernatural forces connected with the Earth). The meaning here is that if someone believes only in these external spirits and not in the spirit inside himself, he cannot be rectified. If someone is possessed by the idea of external spirits, and sees himself only at the mercy of those spirits, then his own spirit is not governing his life. Thus, he cannot be healed.
Virtue (de) is the activity in you coming from your deep relationship with yourself. If as a practitioner you are waiting for magic forces from outside to help you, you cannot express your own virtue because you cannot touch your own spirit. Thus, you cannot touch the virtue of a patient.
Great healers go straight to the point and lose no time- they solve the problem. If they are gifted, they can treat without much diagnosis because they have an authenticity that connects directly with the authenticity of the patient. Then there is joy in the practitioner (which is usually suppressed- it is not good to show how powerful you are) that is received with joy by the patient. If the spirits are adjusted well, the healing will hold and the results will be amazing.
When we needle a point or give herbs, we are doing a physical thing, but the goal is always to make a signal to reach the spirit of the patient. Only by signalling the spirit can we rectify the blood or qi.
Re-establishing the balance in any condition always depends on the spirit. Even if someone is wounded, there is not only pain and bleeding, there is always also an emotion of fear or surprise that puts a disorder in animation and thus affects the spirits. The spirits are not wounded themselves, but they are affected, because they work at the highest level in the person and thus are present at the tiniest level of life. With intact spirits, recovery will be faster. The classics say that life is conducted by the spirits- not just sometimes, but in all cases.
If there is no shen, yi or zhi, a person might have a successful operation and still die. The surgeon might have been perfectly correct in his action, but the surgery should not have been done. Without the cooperation of the patient inside, you cannot do your work. Psychology is part of the work to be done: assessed in diagnosis, seen to in surgery, looked after in recovery. Thus, become what you are as a human being, and it will be good for your patient. Healing is not nursing or mothering. The way to care for a patient is just to be yourself and be with him, looking into his eyes. When both patient and practitioner are in communication with their own spirits, the communication with heaven is open. Thus, making your own spirits powerful is sufficient.
If one is loath to be needled, there is no possibility of expressing clever skillfulness. If one does not accept being treated and cured, do not treat him.
If the person has a tremendous aversion to the needle, the strong focus on the needle disturbs the inner balance. Other texts say not to needle a person who is very emotional (angry or fearful, for instance), because the circulation of the qi is disturbed by this strong feeling, and thus the signal by the needle cannot be received very well.
If the patient does not accept being treated and cured, you cannot do anything and it is better to stop treatment. If he or she cannot accept cure, there is something very wrong in the axis. If the zhi is not well rooted, for instance, we cannot correct the circulation of life. You assess this rooting not by what the person says to you; you must diagnose whether the zhi is rooted or not.
Ling Shu Chapter 8:
The five zang master and store the essences, so they must not be injured.
If they are injured, they will lose what they have and the yin becomes empty (yin xu).
If the yin is empty, there is no more qi.
If there is no more qi, there is death.
When you needle, you must examine and consider attentively to the attitude of the patient and all the patient’s signs in order to know king, shen, hun and po.
Commentary:
For the Daoists, there is a difference between dying and perishing. Dying is not necessarily bad- you can die and still subsist in spirit after death. To perish is much worse- it is to separate from the spirits that make life in you. In an extreme case, a living person may have already perished.
If you are called to treat a dying person, you might not want to save the person at any cost. You might want to let the person go because he is ready to go in all parts of his being. Why should we disturb the natural process? You have to know destiny in this case, not just medicine. In other words, what is good for the patient can be seen differently from just keeping him alive no matter what, as is often our practice in the West. Knowing what makes the identity of a living person takes time and learning.
Su Wen Chapter 54:
Needling is like looking at a deep abyss, take care not to fall...
Your hand must be like a hand grasping a tiger. One desires a kind of firm strength. The spirits have no disorder coming from numerous beings. The willpower is quite full. See the patient without turning the eyes from left to right. Without rerouting the movement, you just desire the rightness or rectification of the spirit. Doing that, you succeed, in making qi circulate easily.
Commentary:
Needling is like looking at a deep abyss, take care not to fall...your hand must be like a hand grasping a tiger. One desires a kind of firm strength.
This chapter has some nice images of needling! Know that you are on the edge of the mystery of life. Walk on the edge of the abyss without fear, but have caution and circumspection (shen) not to fall. Many texts use the character shen, circumspection, for the correct attitude of the practitioner; it includes the character for heart plus the character for authentic.
As a practitioner, you must be deeply anchored and assured in your life. Yet the communication with the exterior passes through your prefixes and your hand, which is holding the needle like a hand trying to hold a tiger. The tiger is an image for vital power.
The spirits have no disorder coming from numerous beings.
Your inner state of mind must not be disturbed from the exterior. You must have good concentration and have no surprise. If the telephone rings while you are needling, for instance, you do not move your hand or the needle, you do not tremble in the least, and then you go slowly and calmly to the phone. If things happen in this way, it is proof that you are in a good state.
The willpower is quite full. See the patient without turning the eyes from left to right. Without rerouting the movement, you just desire the rightness or rectification of the spirit. Doing that, you succeed in making qi circulate easily.
As a practitioner you must be in a state of mind with the five wills from the five zang in rightness, quiet and calm. This state is visible in your eyes, which are the messenger of the heart and which have the power of emission (ears receive while eyes can emit). The pupil indicates the relationship between fire and water, between willpower and spirit, between heart and kidneys. All of these are best visible in the eyes of a person. (Ming men, “gate of destiny”, is a nickname for the eyes.)
As a practitioner, manifest your inner rectitude at the level of your eyes and hands in order to rectify the disturbance in the patient. Your regard must be straight and without deviation to the right or left, and your hands must be steady. Thus, your orifices and your needling manifest your own spirit. Your own rectitude inspires the feeling of rectitude in your patient. Your needle can then give the appropriate signal to the patient’s spirit according to the point you choose.
Ling Shu Chapter 9:
Close windows and shut doors. From this quiet place, the practitioner will take care of the hun and po and give the best expression of the shen.
Commentary:
Acupuncture has to move the patient’s spirit to be successful- it is not merely mechanical. Spirits are the “conductors of the chariot of life”, moving everything on the right path.
At the level of the practitioner, to close windows and shut doors means to close your orifices in order to keep your essences and qi at work inside, and not to use up your essences and qi in exchange with the exterior. Thus you use all your power for the expression of the zang at the level of the inner spirit of the zang (as in the Daoist texts), so you perceive reality in the inner world-with inner taste, inner hearing, inner seeing. You use your vitality to perceive your inner reality and to make the unity of your own life. Thus you concentrate your purpose, using your essences and qi internally, so you have an inner unity, which is the unity of your spirit. Then you have one shen; you are one with the spirits, and you are in unity through contact with the enlightenment of the spirits.
For the treatment room, to close windows and doors means that you need a room calm and quiet enough for concentration, so that you can stimulate the possibility of the relationship and unity between your spirits and your patient’s spirits. Through your concentration, you are able to put willpower in the needle, not forcing and violating the inner freedom of the patient; but communicating through the needle (of course with good technique at the right moment) and giving the patient a signal for concentration, quiet and calm. The result is that the spirits of the patient are moved.
Ling Shu Chapter 27 explains this movement of the spirits. Pain is the pressure of perverse energies. When the qi of wind, cold or damp enter the exterior of the body between the muscles (where the passages for meridians, luo, blood and so on, are found), they make pressure, and the normal body fluids in these passages are charged from good liquids to a kind of foam (a perverse state, something like phlegm). When these liquids are thus perverted, they cause trouble. If they encounter cold, they condense and create pressure in the passages, so that cracks are caused, which cause pain. The pain is a signal for the spirits to come. When the spirits are attracted, then the painful place gets warm, and the pain disappears. (Ling Shu chapters 1 and 8 and Su Wen chapter 27 have descriptions of the coming and going of the spirits in their assigned passages.) If you do not cure the reason for the penetration of the perverse energy, the pain will reappear elsewhere. Needles attract the spirits to rectify the circulation of qi, so normality is restored.
When you and your treatment room are quiet and harmonious, you make the needling more powerful and exact. Zhuangzi says, In the empty room white is produced. In the quietness of body/mind, the illumination comes. You need peace in the room in order for the patient to be at ease in order to dispose himself or herself to the acupuncture. This is difficult in our society where it is awkward to be peaceful- we are supposed to run around chasing money and goods. Yet, to practice good acupuncture, we must be peaceful.
The spirits move because all the surroundings of the treatment room encourage them to be moved in order to rectify the pattern of the vital animation of the patient. The spirits move also because the right signal is given by the point (which is chosen), by a needle technique or movement (which is also chosen), and because there is present in the practitioner a well-rooted and upright direction of her own life. All these operate together to try to give a pattern for the equilibration and calming of the essences and spirits in the patient. The only way anyone can be cured is by the movement of the spirits.
Remember, though, that you cannot make the spirits move. You can only let the spirits of the patient rectify themselves. If you create the correct conditions, the spirits will come. You can not force them to move- you can only make it an attractive alternative. (In other words, offer the spirits what they like!) The birds choose the trees, not the other way around. Just try to be the best possible kind of tree for the sake of your patients, and then leave it up to the spirits/birds to come.
Su Wen Chapter 14:
Huang Di: When the body is exhausted and the blood is exhausted, then nothing can be done, really. Why?
Qi Bo: The spirits are not acting.
Huang Di: What does this mean?
Qi Bo: The needles of metal (shen) and stone (shi) are the way (dao), but if the essence and spirits do not enter the way, if will and purpose do not work, there is no action. Then the disease cannot be healed.
Commentary:
If you just displace the qi in the treatment, you’re not doing much. But if you can entice the spirits back where they belong, then you are a great acupuncturist! You are caring for the ability of the spirits to return to make their beauty of ruling that particular life. Thus treatment is a question of the ruling of life, not of qi or blood.
Suppose you face a serious illness in a patient, but not an incurable one. Perhaps the treatment is good, but it does not succeed. Why? If the spirits are not operating, no treatment will succeed. Or, you may be able to make the patient a little better but not totally well.
“Needles are the way” means that they are the treatment and the technique (recipe) of the treatment. When the essences (jing) and spirits (shen) cannot enter or offer something, or if the purpose (yi) and zhi (will) cannot govern or rule, then the patient is unsuitable to offer to herself a response from her own essences and spirits. Often this situation comes when there is too much emotion- desire, craving, concern, worry, sorrow, or the like- in the patient. It is fine to have these feelings sometimes, but when there is no limit, no break from them, the incessant blows finally bring about the departure of the spirits. You as a practitioner may not be able to adapt a treatment to this person. If you cannot put your own will power in the needles to rectify the spirits and give the patient an opportunity to re-enter into possession of herself, or if you make an error or misinterpret something or are not perfect, then the treatment will not succeed.
The end of Chapter 14 says that the practitioner and patient are like the branches and root of the tree- the same image as the branches and root of diseases. The patient is the trunk, the situation. The practitioner has to become like the high branches of the tree and be in that intimate relationship with the patient in order to understand the real situation of the patient and to assist him.