BODY, MIND, AND US.
(First published on MediCina, 1994)

Very often the patient sitting in front of us comes and goes between 'somatic' and 'psychic': the mixture is already plain in what he or she tells, in the kind of expectations, in the request under it all.
To move inside the space of the psychic disorder can therefore mean that the illness is already recognised as 'affective-mental', or instead that the question that the patient puts leads to an uneasiness of the spirit, independently from the symptoms given in the first place.
And first of all it means we should get clear of some stereotyped and commonplace criticisms. We do know that the western bio-medical system is an expression of the thought based on cause-effect, a result of a method that studies through separating and sectioning, a fruit of the lack of interaction between patient and therapist, but it is a shared self-deception that a horizontal-analogical thinking belongs only to the East.
In Europe, the form of the medical thinking was not structured since ever according to the anatomical-clinical method: still in the XVIII century the placing of illness was inside a space of sympathies, correspondences, similarities, and analogies.
Not even the continuity between physical and psychic treatments belongs only to Chinese medicine: also European medicine, until the XVIII century, talked of spirits. Among the treatments we find remedies that "consolidate the spirits to avoid the irregular movements"; prescriptions of bitter components as one of the forms of purification - act that addresses both to soul and to body: attempts of "provoking in the patient a regular movement, which reflected the movement of the world, in order to overcome agitation, obstruction, stasis".

On the other side, if it is true that Chinese medicine, like many traditional medicines, is both psychological and physiological, it is also true that descriptions and syntaxes of feelings and emotions appear rough and coarse to our eyes: finesse and deepness seem to pertain to the sphere of meditation practices, to the work on qi. Knowledge of oneself comes not so much through a work of introspection, but recognising and building a self as part of universe.

TCM and psychodynamic approach:
Said this, it is true that personally in some cases I use side by side a psychotherapy and traditional acupuncture. And I think this possible first of all because the two perspectives share a few grounding elements.
I find for instance the same quality of path. Dao, right life, means to follow, to know our nature: as the psychoanalysis it does not give indications, but unfolds like an adventure of freedom. I recognize the same width in the concept of man: in the genesis of the universe man is together with heaven and earth, with the yin and yang principles. I see the same quality in the space of listening: the traditional doctor listens with an "empty heart" (Zhuan zi) and in analysis one stays "without desires nor memories" (Bion).
Also in the process of healing there is an overlapping: both in acupuncture and in psychoanalysis one works on oneself, causes of illness and suffering are not thought as being outside, solutions are not sought somewhere else.
And in both disciplines we find the need that the doctor must go through an interior transformation: in Chinese tradition he must cultivate some virtues, be in synchrony with the natural movement of the universe, and in the western sphere the only 'institutionally' recognised practice that comes close to this concept is the personal analysis through which a psychoanalyst has to go.
I would like to remind that, as in acupuncture we try to get qi flow, to restore an energetic balance, so the goal of clinical psychoanalysis is getting not so much any more the uncovering for example of traumatic events, but the searching of new meanings and the restructuring of what had no chance of developing during the course of life and of the past relationships.

Unlike psychiatry, that identifies two separated ambits, organic and a psychological, and that treats both as fixed objects to analyse, in Chinese medicine, and in psychoanalysis, the symptom is not static, but it speaks, it is a universe. We know that the psychic trouble has somatic equivalents, that the body talks, but not in a positivistic sense, that is through a tight correspondence, but in the width of reference, in the concept of symptom as a metaphor. And symptom is not only the trouble said by the patient, but it is all the signs which show.

In clinical practice, Chinese medicine offers some precious elements both in observing the patient and in acting to modify the situation: we do have the possibility to integrate the different signs and symptoms in a picture that produce sense, without having to separate somatic and psychic, and without having to presume priorities on one side or the other.

At the same time one should remember that, as there is the risk of 'medicalizing' uneasiness, troubles, fatigue of living, there is also a tendency to 'psychologizing' the pains we suffer.
There are two points to underline: not every suffering requires therapy automatically, and psychotherapy is not the only existing answer to psychic illness.
And also: there is a wide area in which western pharmacological medicine has little meaning, but also where hypothesis of analytical therapy have little indication, or are contraindicated. Or else, the patient might not consider them as valid hypothesis: because of a different interpretation of the world, say in social-political terms, say because he prefers other ways to work on himself and his health.

About clinical experience in TCM:
Chinese medicine is an energetic medicine: we work on qi, and this simple fact changes the field of intervention.
Acting on blockages and stasis, rebalancing excesses and deficiencies offers us a strong support and can produce solutions also specifically in psychic disorders. And this is true both in case one decides to use exclusively TCM or to put it side by side with a psychodynamic treatment, with its own references and its rules.
From the work of discussion on our clinical practice in TCM a few points of both theoretical and clinical interest came up.
Paolo Bruno reminds us one main motivation that pushed us towards TCM - and keeps us practicing and studying it - was the search of an inclusive view of the human being, both in his somatic and psychic aspects. But he underlines also how difficult it is for us to set psychic disorders starting from Chinese classical texts. For instance, the description of signs of 'madness' totally mixed with 'physical' symptoms in Stomach and Urinary bladder channels can appear disconcerting. An hypothesis is that Chinese thought never made that separation between body and mind on which - starting from Socrates - are founded the assumptions of western culture.
If this synthesis of material and spiritual aspects is very clear in the theory of TCM, still in practice problems are neither easy nor straightforward, as Giovanni Moretti says. An example is the trouble that some foundations of Chinese medicine give us in the daily practice, that is for example the circularity between cause and effect, subject and object, therapist and patient. Representations of illness and therapeutical actions most of the times are of a linear type: to a cause it corresponds an effect, we end up expecting results in a deterministic way, and often the doctor-patient relation belongs to terms of subject-object, beyond our good intentions.
Of us, who works with a specific attention to a systemic perspective like Gianfranco Morelli does, knows very well that the type of relation that links the subject to people and situations that are important to him can form an "exterior" from which illness originates. Without underestimate the internal weakness of the patient, it is of great importance to be able to see which energetic system is blocked or altered by these relations, to be able to act in a coherent way.
Other perspectives favour instead a direct correspondence between the alteration of an organ and psychic activity. Like far traditions - as Egyptian, Galenic and Islamic - put in relation different parts of the body to divine images, so Adler sees that an organic system (throat and swallowing, breathing, knees and bending, the skin) can become a point of minimal resistance, the image on which all our psychic attention concentrates. The ill organ has therefore all our attention, it talks of us, it becomes a part for the whole, representing an endless mine of material, right because our attention makes it a place of the greatest potentiality. The place of least resistance is of course the place where our resistance gathers into defence, where one is most easy to be hurt. In therapeutical treatment it is not a matter of throwing down defences, but to understand the need of these manoeuvres.
But now we are trying to understand if and how much the universe of interpretation and of intervention of traditional acupuncture is consistent in it and self-sufficient. It is our shared experience that TCM does not need to lean on other psychological models: our work keeps showing us that somatic and psychic troubles are expression of the same energetic unbalance, so that very often we can act on specifically psychic symptoms through a correct diagnosis, that takes into consideration mainly somatic signs.
An example from Morelli: a man, 65 years old, suffering of depression since one and a half year, with little appetite, belching, thoracic and epigastric oppression, abdominal distension after meals. He also wakes up many times, has moderate dizziness, tremors in his legs, frequent sighs; his tongue is purple, with cracks, and a yellow, dry, thick coating; his pulse is rapid, a bit slippery, large.
Even if there were problems in his married life and a strong attachment to his daughter, the choice was to use a modified Wendan tang, to treat heat-phlegm in the middle Jiao, with stasis of blood, without working on the Shen as a first step, and without choosing a relational analysis. The cause of the obstruction at the middle Jiao could have been an obsessive thinking, 'si'', a tendency to worry, but in this case the work regarded more the 'biao', the manifestation, and the results were quite good on both levels.
Another example is the high frequency of deficiency and stasis of blood in women: if we tonify and move the blood, we can solve also purely psychic symptoms, like generalized anxiety disorders or phobic disorders, that present or become acute in relation to the menstrual cycle.

Therefore the diagnosis must be decided according to classical rules: examining pulse and tongue to see if there is an emptiness or a fullness, and of what. In our experience the prognostic precision is more difficult: to know if and how much our treatment with needles and/or herbs will modify the situation is not easy.
This succeeding of TCM is by now a common experience to all of us, on condition that we can make an energetic diagnosis, while results are poorer if there are no signs to frame the situation energetically. Already in Suwen, ch.77, the emperor says that when "the doctor has no element at Zang level, nor there are modifications in the body... diagnosis is full of doubts", and at this point it is necessary to ask questions about the patient's conditions of life, otherwise "one can say only the day of death".
Grazia Rotolo speaks furthermore of syndromes apparently very different (anxiety, depression, obsessive-compulsive) with no more signs then a typically red tongue and a thick yellow coating, in which often needles do not move anything. It is true that a heat-phlegm obstructing orifices is well known as hard to treat: maybe for more efficacy we should take into more consideration the head-points: for instance the treatment of prof. Zhang Mingjiu, psychiatrist of Nanjing (personal communication June 1988) was based on two 'general points' and two points of the head, treatment used also by Maciocia and other authors.
At the same time it is true that the lack of an answer is not due only to a poor diagnosis or in to a wrong choice of points: the symptom is set anyway inside a wider universe of reference, that can be the Qiantian space, or a more trivial recognition of the secondary advantages of symptoms.
The TCM etio-pathogenesis of mental illness, which mostly sees an unbalance of qi or xue, of fire, tanyin, xu, belongs to Huotian, and it is inside this space that we work. Very different are the interventions inside the Qiantian (see the article on Li Xiaoming and Shen); of which by the way we can recognize many analogues in far away cultures.
All of us agree with Grazia Rotolo on some important points: to alleviate the symptom means to break a vicious circle, to interrupt the spiral of suffering which risks a self-feeding. Restoring an energetic balance means that one will be able to use the available resources in a better way. And the modification of the energetic situation leads the patient to feel different, that is to have a real experience of the chance of perceiving oneself in a different way.
And this creates the opportunity of using the encounter with the therapist, as much as using the events that life suggests.

The doctor-patient encounter
According to classical Chinese texts, the doctor is a neutral, detached point of reference, a sort of pivot that does not let to be dragged around, and in this way he lets the patient find himself again; while we, may be not to fall in a distance that reminds us of indifference, too often let us be involved by patients. The emotions that patients stir up in us as a matter of fact are purely our unsolved knots, and interfere with our evaluation of symptoms and with our work.
Barbara Rossi recalls the image of those good Chinese doctors we all met, who have always the same attitude to patients, calm, with no anxiety.
The state of the therapist should be like the one of qigong, the serenity of emptiness. And in fact the practice of qigong is really helpful.
Classics say about "closing doors and windows" (Lingshu, ch.9), that is about creating a state of concentration and of recollection, in which Shen can move.
In TCM these conditions are true in any clinical picture, while in our culture we use only in psychoanalysis the indication to create a 'setting' (which is nothing more than a space and a time different from the daily one, in which might be possible to move together in that area called unconscious).
The Qigong master Li Xiaoming says that in mental illness "the encounter with the Shen of the therapist favours the return of the patient Shen", and in Suwen, ch.54 we read: "As though on the edge of a cliff, careful not to fall, the hands as though holding a tiger, grasp it firmly, the shen does not allow itself to be distracted by things, observe the patient with a calm mind without looking left or right, to do it well one must needle straight, without deviations, one must rectify his own shen in order to rectify the shen of the patient, the doctor must look him in the eyes, if the shen is fixed qi flows with greater ease.”
All this does not mean that 'attitude' is everything needed: on the contrary, psychic sphere broadens the complexity of energetic analysis and of therapeutic choice. As we saw in the article on dr. Zhang Shijie and his use of the point Taixi, the moment of synthesis can come only after a detailed analysis: anyway simplicity follows great knowledge.
We add information, practice in attention, diagnostic ability, knowledge on the choice of points, skill in moving the needle-instrument we use, and so sometimes the arch, the arrow, and the target (butt) become a real whole.