The person who comes for acupuncture is asking for help, usually with a specific problem. Most often at this juncture in the evolution of acupuncture in the West, it is a physical ailment. However, whether the goal is physical or emotional, in the beginning the acupuncturist should make a spoken contract with the patient, stating specific therapeutic objectives. This contract involves an understanding of time and money considerations involved in reaching that goal.

After that initial contract, the therapeutic relationship can go in one of several directions. In one direction the goal is reached successfully and the contract terminated. The patient may never return. However, even if the result is not perfect, if the respect emphasized over and over in this book is observed by the acupuncturist, the patient will consider returning if a new problem arises. If the acupuncturist’s intention is healthy and his or her energies are correctly directed and intersect with the patient’s, they will both have gained something ineffable that now bonds them, often unconsciously. This is so even if they never meet again, though sometimes, years later, the acupuncturist will hear from the patient, who has reached a new level of awareness about what has transpired.

The second possibility is that the contracted goal is not reached. The patient is unlikely to consider returning. However, in the context of respect and acceptance, the same appropriate energetic exchange may have been sufficiently beneficial to the patient to set them on a path to healing unknown to both the acupuncturist and patient. In fact, if set off in the right direction, healing goes on beyond the termination of the contract and contact. More rarely, but it has happened, this person will have an epiphany regarding the positive aspects of the experience, and sometimes even communicate that.

General

Basic to the therapeutic relationship, as to life, is contact. Contact means communication, touch, touching another. Human beings cannot survive without it. Apart from the uncertain contribution of heredity, human personality is shaped by the nature and by the quality of contact with other people. If the contact is constructive, people are able to cope well with the stresses of life. If it is destructive, people cope poorly or not at all.

How do we define contact in a therapeutic relationship? It means all communication, verbal and non-verbal, that contributes to human growth: the transmission of feeling, sensation, and thought. It is characterized by certain qualities: by sensitive, respectful attention and care. It is characterized also by its form: listening and response. We refer to the qualities of contact as its “how,” and to its form as its “what.”

We will consider first the “what”—the technical means, the form and craft of the therapeutic relationship. Then we will explore the “how”—the quality of our contact with a patient. Of its two aspects the second, the “how,” is primary, but the first, the “what,” guides us along ground on which we stand and move as we work. Both can be learned, but the “how” is more subtle.

The Techniques of Contact

Awareness

As practitioners, we learn to develop skills in communication, which we can think of as having three aspects. The first is the reception of the signal, the second the processing of the signal (our interpretation, our comprehension), the third the response to the signal. (Let us keep in mind that we are describing a unitary experience: listening, response, exploration, cooperation, collaboration are one.) Again, there is what we do, and how we do it. Both involve a variety of signals that we give and receive.

Signals may be verbal or non-verbal. The “how” involves non-verbal signals—an empathetic look, a touch, an affectionate gesture—these often mean more to the patient than words, particularly if he or she is a person who distrusts words. The non-verbal signal can represent a giving of oneself in direct and immediate response to the other person’s “felt” need.

Total, direct, immediate contact with whatever is in our environment is a gift that few of us are blessed with, and towards which all of us must strive. The talented observers, whose senses and awareness are unfettered by inhibition, or indifference, stand out among us, as do Darwin, Galileo, or Copernicus for example. To be completely in the here and now, with as much of ourselves as possible, is an expression of completeness, satisfaction, and fulfillment. Some of us will be more immediately aware with one or another sensory faculty (in the spectrum that ranges from hearing to intuition). We identify and use the best we have as we live and work. We also simultaneously develop that which lies dormant or undeveloped. Our effort “to be” is the soil in which those who depend on us may also grow. Our purpose, our attitude towards being, and our awareness is the hope on which those in despair may begin to find affirmation of their own being.

The Different Techniques in Turn

Asking

Asking is one of the four principal methods of knowing in Chinese Medicine (CM). There is a formal aspect to it that is necessary to obtaining the diagnostic data studied and practiced in schools of acupuncture. The patient will provide information within the parameters of what he or she feels comfortable to share with another person. From other diagnostic tools such as the pulse, or from body language, eye contact, voice, and our intuition, we may be aware that our patient is not telling us the entire story. And everyone’s life is a story waiting and needing to be told.

Here we are concerned with the informal aspect of how we meet that need in a fashion that enhances the therapeutic relationship. Therefore, what we ask for in this context is always considered within the framework of the patient’s sensitivities. For example, noticing that something changes in the patient’s demeanor, voice, or color when the subject of children arises, one can approach the subject indirectly by saying: “Wow, you have five children and I am having trouble raising just one,” or “You have one child, and one difficult child can feel like 10.”

With some people, the acupuncturist will probably engage their deeper hidden feelings by just “rapping.” What is love? What is a friend? What is work, or learning, or one’s relation to authority? What is one’s place in the world? Who are we, and what about God? We call this rapping, because we alternative practitioners do not have the final answers to these philosophical questions. We can serve as a useful sounding board for others who are looking for thoughtful responsiveness in a permissive, non-dogmatic atmosphere. Often we learn a great deal.

Listening

Content is the most obvious aspect of listening. However, the art of listening involves sensitivity to the relationship between what is being said and how it is being said.

The “five element” school of CM teaches the practitioner to listen for what is usually indirectly expressed in order to identify the phase that is central in the patient’s life. Frequently, these signs indicate possible disharmony. In that system, the sound of the voice allows us to identify that phase. The groan is associated with water; the moan with metal; the shout with wood; excessive laughter with fire; and the singsong voice with earth.

Each phase is associated with a different primary issue. For fire we hear or feel that the innermost issue is warmth; for earth it is comfort; for metal it is self-esteem; for water it is reassurance; and for wood it is direction. Though I no longer totally subscribe to the “System of Correspondences,” it is instructive as a way of knowing people, their personality, and their problems on all levels of being.

Feeling is another mode of listening. As we “listen” with all our senses, we become aware of our own feelings—our sadness, or anger, or fear, or affection, sympathy, or antipathy, in response to the other person. And we may discover that we react to certain kinds of people in specific ways: an aggressive person, a smothering person, a dependent person, even an independent person may evoke strong feelings in us, favorable or otherwise. The psychoanalysts refer to these as counter-transference, a term inferring distortion based on the therapist’s previous life experience. Naturally, we must question ourselves generally and specifically and take this possibility into consideration. This requires considerable introspection.

While our emotional responses may offer clues, and may suggest much that is valid about the other person, it is also possible that our biases may distort what we hear. We may be listening in a way that refers to our own “images of the past” and not to the patient. And, if that is the case, our emotional responses, and the inferences we draw, will not be valid.

Frequently, we respond emotionally to matters that involve values. To those people whose values agree with ours, we tend to listen carefully and generously. To those whose values conflict with ours, we tend to let our differences interfere with attentive listening, to a greater or lesser extent, depending on the strength of our convictions and the emotions attached to them.

So, another caution is in order: though we are used to thinking of values as objective, as ideas they are more closely related to belief than to reason. They emerge, as do our emotional responses, out of our own past. Needless to say, we must explore our emotional responses to our patient. If our reaction is extreme, whether sympathetic or antipathetic, and if we cannot modify it, we must consider giving up our work with that particular person. Whether we choose to separate ourselves, or whether we choose to make this situation an opportunity for mutual learning with our patient, we are again confronted with the importance of knowing ourselves and accepting the knowledge, however unpleasant that may be.

These feelings, these responses of ours, are therefore to be respected as guides in our relations with other people, which become especially useful as we come to know ourselves better.

Intuition

Feeling must be distinguished from “intuition,” which is an indefinable reaction to another person based on nothing as plausible or identifiable as a “feeling.” We are informed correctly or not about the other from a place deep inside ourselves that has no other language than that of the “gut.”

The person using his or her intuition comes in time to know it and to trust it as a fine tool, becoming free to use it as an artist uses his or her medium. But intuition borders on the mystical and unknown aspects of our lives. It must, therefore, always be used with humility and balance, and with respect for its fragility. It is a gift that illusions of omnipotence and ambition will destroy.

When our actions involve another life, we must trust our intuition as a guide, always to be carefully validated by concrete evidence.

Looking

When we use our eyes, what does the patient’s body language tell us? Do their words match their physical gestures, or are they at odds? Are they saying how “cool” things are and, at the same time, ripping their nails from their fingers—or how open and relaxed they feel, while they twist their body into pretzel shapes?

As we watch, we see some familiar gestures and expressions that we have ready words for: uptight, choked up, two-faced, tight-fisted, starry-eyed, wry, twisted, pained. Do the person’s eyes make direct contact or do they seem vacant? Are there tremors, sweating, agitation, or an unreal calm? These physical gestures and attitudes are indicators of underlying feelings and personality.

Reception and Processing (Thinking)

The link between reception and response is the inner processing of information that we have harvested by listening. This harvest becomes transformed by the use of our mind into usable knowledge. It is, so to speak, changed from the raw product into an edible, digestible food for thought. Thinking organizes our contact with reality, our experience.

We listen intuitively, emotionally, with our senses and our feelings. We pull all of our impressions together with “thinking,” or that part of our minds that we associate with reason or logic. As we listen, we wonder how certain things go together: why does this young man, who says that he resents his home, return to it over and over again? Why does this woman talk endlessly about how badly her mother treats her but never mentions her father? Our mind tells us that the balance is off, that things do not add up or make sense. We realize, from what she says, that one person is as she is; that another person is avoiding telling us his whole story. Logic tells us that something is missing.

We begin with an assumption, a premise: birds fly; humans do not. We add another: we are human. We conclude, logically, that we cannot fly. So, logic is one way of approaching a problem, another tool. It, too, must be used cautiously, for it does not necessarily yield truth. Consider, for example, the premise based on general experience that liquids get dense as temperature decreases. It should follow logically that water is denser at 0 8C than at 4 8C. But that is not true; water at 0 8C is less dense than at 4 8C, as experiment bears out. So, our premise about liquids is not universal, and the generalizations we build on it may not yield the truth.

Logic is important, primarily because it helps us to raise and formulate questions. It helps us to see when something is out of place; that something may be missing in an otherwise complete picture. It leads us to ask whether the person speaking is telling the truth, or deceiving him- or herself as well as the therapist. These questions that logic leads us to, we must remember, imply judgment; they are aids to understanding.

Derogation

It is possible, as we have already noted, for two people to say almost anything to each other, provided they say it in a way that does not “put down” the other person. Derogation, putting down, is an attempt by one person to control another, or to enhance him- or herself by making the other person seem less worthwhile. When the patient greets our caring with repeated skepticism, that is derogation. It is one of the most commonly used weapons in human encounters, a weapon that destroys people and relationships. If you, the practitioner, are tempted to use this weapon, if you sincerely feel you are “better” than your patient, stay out of that therapeutic relationship.

These involve humility, validation, and clarification (including repetition), questioning, reframing, interpretation, insight and perspective, and working through.

Humility

Of the many challenging tasks we are faced with in life, learning what is in another person’s mind and heart is perhaps the most difficult. From the outset, we must accept that we know a good deal less than we imagine about almost everything, and especially about another person. Recognizing our inherent limitations to know “the other” is the safest posture we can assume as therapists both for ourselves and for the other person. One must depend on the confluence of many approaches to knowing before acting. Too many in our time believe too strongly in the accuracy of whimsical impulse and too little in the hard work necessary to mine the truth. There is truth in the statement, “Trust (oneself) but verify.”

Validate and Clarify the Data

Above all, we must be certain that we have perceived correctly. We must check and re-check our perceptions with the patient, to be certain that we agree on all points and to ascertain that he or she knows that we are listening carefully and getting accurate information.

Repetition is an exact replay of the message we have received. It is a way of ascertaining that we have heard correctly, an important aspect of communication that we discussed earlier in relation to logic and premises. If we hear faultily, we may adopt false premises on which to base our reasoning and our conclusions. Then, everything that follows between practitioner and patient is, to some extent, based on misunderstanding.

Clarification can be accomplished when ideas are played back, sometimes as we go along and sometimes by way of summary. As well as using repetition to keep the record straight, we play back in order to establish agreement, and to encourage the sense that this work is a mutual endeavor. Not only does the acupuncturist make sure that he or she understands, but also that the patient knows this. Then, when the matter we have agreed on is raised again in another context, we can return to the original earlier agreement for confirmation and support. Of course, agreement, understanding, and comprehension do not happen all at once.

We should strive for early clarification of certain salient questions. What, in the patient’s life, is a problem to him or her at this time? What would he or she like to change? What is his or her motivation to change? If we cannot make sense of what we have heard, or if we repeat it inaccurately, we need clarification; and we should invite it, for the very effort will bring into the open many aspects of the issue that were not immediately obvious. Thus, the work of clarification is sometimes an integral part of the work of change. And it is basic to the art of communication.

Communication between people is an endless series of corrections (of errors of perception or understanding or interpretation). This kind of exchange strengthens and deepens all relationships. It is, in all of life, a never-ending activity. If it can get started in the therapeutic relationship, the process can carry over to other relationships (and will, of course, benefit the therapist as well as the patient).

Naturally, a part of each one of us—not only the patient—wishes to avoid clarification of our problems. In the service of repeated clarification, it is helpful for the acupuncturist to summarize at the end of each session what they think they have heard, so that the patient and the acupuncturist may be sure that they have been listening to the same things. The differences may be more significant than opening new areas to explore.

At this stage, when our relationship with the patient is growing, it is of great value to them that they make statements. It helps strengthen them from the inside. They take a risk when they make a statement, which they have not taken when they ask a question. Accepting that risk, daring to look inside, they begin to feel responsible for what they see, what they once feared too much to see.

Once we are clear about an issue, it is difficult to avoid the next step: to act. Often the action that follows clarity is fraught with risks that we fear to take, judging them to be threats to our security. Once we act, we are responsible, visibly committed to steps that others may respond negatively to. If, for whatever reason, we feel that we cannot stand on our own, that we cannot live with disapproval, we will avoid, first of all, the clarity that leads to action. Therefore, it is vital that the therapist explores with patients the consequences of acting on their clarity or new insights before they do so.

A patient I was treating with acupuncture had a sudden epiphany one day that one reason he did not like his wife was because she had fat ankles. Before I could stop him he bolted from the room, ran home, and disgorged these feelings to her. She was understandably devastated and equally understandably dissuaded him from continuing to work with me. We never had a chance to process this insight in terms of what it meant about him because he “acted out” rather than contained his new awareness.

Question the Data

Most often, the problem with the accuracy of data is less in the specific details of events and more in the interpretations of these events at the time of their occurrence or later. If there is one subject that overshadows the rest in terms of the focus of most psychotherapies, it is this process of delineating the observed from the interpretation.

It has been my experience that the best and sometimes only way this can be untangled is within the framework of the therapeutic relationship. When this is a significant discomforting issue in the person’s life that might be identified by the patient as one source of their pain, it is wise to anticipate, with the patient, that this issue is bound to occur during one or many acupuncture sessions, and is “grist for the therapeutic mill.”

Over and over again, the observation and the interpretation must be sorted, until the patient begins to initiate the process on his or her own. The incentive is the relief of pain. While it is true that some people only know that they are alive if they feel pain, most would rather live without it and are willing to consider changing entrenched patterns rather than continue to suffer.

In the most serious conditions, the observation of an event is interpreted and distorted even before the event unfolds. Here the person’s fear is too great to reconsider the only safety he or she has ever felt. He or she is capable of and willing to endure the inevitable accompanying hurt rather than endure the threat of being involved in changing this seemingly life-preserving system.

However, with patience, even the most entrenched maladaptive system is susceptible to change if keeping it is clearly associated with the pain in a person’s life. The openings into a place in the system where the patient has even the smallest doubts or awareness is sometimes enough.

One example is that of a person whose experience of being hurt by others involved not what was said but the inflection of the speaker’s voice. She voluntarily acknowledged her sensitivity to sound when the subject was raised, creating the possibility of re-examining the events leading to hurt and alienation. The practitioner could question her interpretation of the inflections of voices without challenging her perceptions, but by exploring the subject of her auditory sensitivity from other areas of experience.

Reframing is an essential feedback device, a restatement of the issues with a new viewpoint. This means injection of a new, yet related, idea into a set of al-ready-known related ideas. We play back the new arrangement to the patient in the hope that the new element will illuminate the other, familiar ideas. And that, we hope, will lead to redirection of thought and activity.

People who seek help need this readjustment of perspective, for their focus is narrow and they cannot see how they are “stuck.” They cannot see that their attitudes, perceptions, feelings, and behavior have trapped them; they need to find out how they have brought this about. Our restatement is a clarifying device, and it will help them to come “unstuck.” It may be that they have focused on what is not a problem, and overlooked what is. It may be that they are driven in two opposing directions. Or, it may be that their expectations are unrealistic. When they understand how they have reached an impasse, they can begin to break through it.

Example