European Journal, vol.3 n.2, 2000

THE SPACE SHARED BETWEEN PATIENT AND ACUPUNCTURIST
The dynamics of the relationship and the concepts of empathy and neutrality

Elisa Rossi

Research on texts and original translation from classic Chinese to Italian by Laura Caretto

Translated by Amelia Mills

In treatment it is no longer rare to be aware that something has not worked quite independently from a correct diagnosis and choice of points. A patient's unexpected question, an unusual gesture which is different from the normal course of a session, can cause our thoughts to become clouded, blocking our ability to think clearly. If we have doubts when we start this profession, many more can build up with experience.

The exploration of the practice of medicine and its methods is strongly reflected in my personal story. After graduating in philosophy, I studied acupuncture in the Su Wen School (Van Nghi - 'French method') and went on a training course in 1983 in Beijing before graduating in medicine in Milan.During my work I faced the fact that, apart from patients who were evidently 'difficult', I often did not know what was happening, what the person sitting in front of me was really asking me. My personal choice was then to go on a 'classic' psychodynamic training course of a Jungian type, and I have now specialised in Clinical Psychology and qualified as a psychotherapist. Chinese medicine, however, still remains my great love and last year I went back to China for the fourth time.

The more I work with patients, colleagues and pupils the more I feel the need to maintain a little space in my thoughts to reflect upon what happens within the consultation room. The rules we follow in our daily practice come from experience, from mentors and from our personal style. These norms are mostly implicit; they are habits that have not received attention or been developed. The aim of this article is to show how every method of working implies a choice and has consequences, and to be aware of how some of the dynamics of the therapeutic relationship may help us and the treatment. The article does not intend to suggest definite rules, nor to suggest what is correct. We all have our own personal style, but it is worth reflecting and questioning oneself: a debate rather than a rigid structure which helps us to deconstruct some situations.

Beyond the obvious, but not simple, search for truth about ourselves (knowing our own personal structure and our motives for choosing this profession; being aware of our fantasies of omnipotence and so on), it is important to follow some 'good practice' methods. This article is a starting point for a discussion on the space in which the acupuncture session takes place, a space that covers mental dimensions and bodily space and the relationship between two people.

Very often the patient sitting in front of us fluctuates between the somatic and psychic. The questions that a patient often asks us - beyond the initial symptoms - convey a spiritual unease. These are cases where benefits and risks connected to the relationship are more powerful, but in every clinical relationship there are dynamics at play.

Chinese medicine

We will not dwell on the importance of the mental, emotional and psychic aspects in traditional medicine which - based on mind-body interdependence - consider emotions as possiblly strong etiological factors and therefore attribute great value to psychic process. We need to review the classics which refer to the shen of the doctor, the shen of the doctor relating to the patient, and the shen in the acupuncture situation.

In classical texts, we find several passages that are strikingly lucid in their perception and examination of those aspects of medicine that pertain to the doctor-patient relationship and to the internal attitude of both patient and therapist. They are very concise and extremely dense passages, and we report some from the Neijing that are particularly interesting. Despite the objective difficulties in interpretation, for which not even the contemporary Chinese versions present a total correspondence, these passages are infinitely rich in theoretical-practical material about the space belonging to doctor and patient.

Lingshu, chapter 1: 'The unrefined doctor (only) pays attention to the form (xing), a superior doctor sees shen.' The 'foundation' of the classics - by defining the difference between an amateur worker and a superior one (cu gong and shang gong) - reveals the importance of perceiving, looking, evaluating that phenomenon which unifies and goes beyond the manifestations more immediately defined.

Suwen, chapter 11: 'To those who believe in demons and ghosts it is useless to speak of the power of medicine. To those who detest needles it is useless to encourage with words. It is useless to treat a person who does not want to be cured, he will not heal despite the efforts of the doctor.' On demons and ghosts (gui mo) we have to remember that the Neijing regards itself as superior to shamanic medicine, of which there are still traces, but which it discards in favour of beliefs more akin to the natural world. Within our cultural references we could understand 'demons and ghosts' not only as superstition, but translate it as equivalent to a thought that sees illness as pure external accident. It is therefore an idea that refuses to perceive illness as an expression of disequilibrium, change or energetic chaos, resulting from a complex interaction of internal and external forces.

The following quote guards us from ideas of omnipotence. There are cases in which it is useless to try and convince a patient, where all the efforts and skills of the doctor are in vain. (The centaur who taught Aesculapius medical art had an incurable wound, a visible sign of the limits of his power.)

Suwen, chapter 14: 'What happens when the form (xing) is defective, the blood is consumed and we don't achieve any results?' Qi Bo anwered: 'It is true that shen does not explain its action.' Huangdi 'What does it mean?' 'Acupuncture is dao. Jing and shen do not go any further, zhi and yi are not in order, the illness is incurable. If jing is exhausted, shen is running out, rong and wei are not recoverable, and because limitless desires and endless preoccupations consume jing, they make rong qi coagulate and expel wei qi, by consequence shen disappears and illness is incurable'.

'Defective form' and 'consumed blood' are very serious conditions, and we are discussing here a case in which there are no results. We are losing everything, zhi and yi are in disarray, jing qi coagulates, and wei qi is exhausted and shen disappears, and the causes are limitless desires and endless preoccupations: in other words a sick psyche can profoundly destroy every resource and can be stronger than any therapeutic intervention.

Suwen, chapter 5: 'There are five requisites for a good acupuncturist. Many acupuncturists ignore them. The first is to regulate shen. The second is to know the art of the 'nourishment of life'. The third is to know the property of substances. The fourth is to know how to prepare the point of stones of various measures. The fifth is to know the diagnosis of zang fu qi and xue'. Therefore, a doctor has to know what is happening (to diagnose), to have the technical ability (to prepare the points of stones), to know the medicines, to practice so as to nourish life (e.g. qi gong), but the first requisite to be able to regulate shen. Shen is to be understood in a total sense - shen of the therapist (knowledge of one's own motivations, one's own structure and dynamics at play), shen of the patient, shen of the situation that is created.

An equivalent concept appears in Suwen, chapter 5: 'He who uses needles knows the other through himself', thus using the practice on oneself, one knows how to act on the other; knowing one's own energy is to know that of the other. In our culture somebody said a long time ago that first of all you have to 'know yourself'. It has been repeated in many ways and in very different contexts. I would only like to add my gratitude to those who pointed out how my failures and my blind spots which, once recognised, could become a step towards finding and dealing more sensitively with patients' knots.

Further, in Suwen, chaper. 25: 'In order to practice good acupuncture one has in the first instance to govern shen, not prick before having determined the state of the organs and made a balance of the nine pulses. When the moment comes one has to act quickly, and manoeuvre with extreme attention, the prick has to be easy and regular; in a calm state of mind we observe the reactions of the patients, what is hidden, that of which we don't know the form: qi arrives like a flight of birds, it spreads as if in a millet field. It moves like a flight of birds and we don't know where it is coming from, thus the doctor has to be ready like the archer who is setting a trap and has to be ready to loose an arrow when the moment comes'. We note how in this passage the phenomenon of the arrival of qi is described in terms certainly closer to the recent physical theories of chaos, rather than the consequentiality and the predictability of classic physics. We also note how one cannot needle before having estabilised shen and having clearly assessed the clinical situation (expressed in terms of 'organs' and 'pulses'); thus the event of needling is the final act, like the action of the calligrapher or the archer.

This uniqueness of the moment is mentioned in another well known passage, in Suwen, chapter 54: '[when one pricks] one has to have the same attitude that one has at the border of a precipice. To move with caution in order not to fall. In handling the needle one has to hold it like one holds a tiger, to grasp it tightly to keep control of it. Shen does not let itself be distracted by things; with a calm mind one observes the patient attentively without looking left or right. To do it well, one has to prick straight without deviations. To rectify the shen of the patient the doctor has to look at him in the eye, if shen is fixed qi flows with more ease".

Lingshu, chapter 9: 'When he pricks, the doctor has to be in a state of deep calm, has to come and go only together with shen, do as if he were with doors and windows shut, hun and po are not dispersed, yi and shen are concentrated, jing and qi are not divided, he doesn't hear the voices of the people around him, so that jing is collected, shen united, then zhi is concentrated on the needle.'

Suwen, chapter 13: 'The consultation has to be in a quiet and secluded place, the doctor has to ask the patient and cover all aspects of the illness in order to understand its meaning. He who achieves collection of shen is successful, he who lets it go is lost'.
There is no need to add any comments to words that so explicitly invite definition of a 'special' space, in which to stop, and enter into a relationship with a patient, collect the energies, and create the possibility for the needle to have an effect.

The needles and the body

Many patients fall asleep during the session. I remember getting anxious and alarmed when this first happened. What will happen to the needle in nei guan if this gentleman who has fallen asleep moves his arm? In reality, nobody ever moved in this strange sleep. Many patients, during the second session, tell us that after acupuncture they felt 'strange, like walking on clouds', others tell us perhaps that the symptom for which they came has not changed, but they are surprised they can sleep well or that they suffer less, and so on. People who are more accustomed to being aware of their own sensations define the acupuncture session as a moment in which 'the head is cleared, the breathing becomes open, sensations get cleaned out, the chest - or the belly - become calm'.

A fundamental part of our clinical work rests in touching the patient: we try the shu points, we penetrate with a needle, we look deeply there and then we touch something called qi - what this qi is, is still lost to us, but it is something. The needle gives a minimal stimulus, that nevertheless has the capacity to go deeply. In our culture the body itself has a dark aspect - and with the needle we go even further into the flesh, further away from the word that brings order to the world. The verbal definition of the sensation of the patient and of the doctor remains vague, despite being a very precise perception in itself. The perception that the patient has of the needles and the changes that take place during the session, and afterwards, are subjects that require more articulate reflection. Whilst in this space, I will focus my attention on some aspects that may appear marginal with respect to the theory and practice of traditional Chinese medicine, but which may sometimes be useful to remind ourselves of.

We know from classical Chinese texts that the heart has to be empty and that emptiness is what allows movement. We know that well-being equals the free flowing of qi, and the consultation room has to be kept free too. As doctors, we are paid to enable a therapeutic change to happen, and we are satisfied when this happens. But patients are such because they feel ill, and being ill has invasive qualities even towards the doctor. To be submerged does not let one breathe, whereas recognising how we are drawn into this state of illness helps both us and the patient. Many are the things that confuse and muddle us. In any therapeutic process there are moments when we do not understand. We wait; a good technique is to be in a state of floating attention, in order to reach the point which allows us a way in. But some ways lead us towards therapeutic change and others drag us down.

In other words, the relationship with the patient's pain and the efforts to alleviate, run the risk of 'contaminating' the doctor. In fact in non-biomedical cultures the healer is protected by a rite. Illness is a strange presence, a dark force in the order of the cosmos that can still be approached and tamed. The rite takes it back to the sacred order and utilises the forces to produce a new equilibrium - of the individual and of the community and the cosmos. In our society, where there are no longer gods to protect humans, the management of illness tends to be left to external and impersonal mechanism, and suffering becomes a deeply extraneous and uncontrollable event. In this scenario, in which often the ill subject is reified into an interchangeable object, with an alienated body in separate parts, a negated spirit or an unbalanced psyche, the patient who consults non-conventional medicine has expectations that concern not only the specific therapeutic methods, but also the image of the healer and the relationship that will be established.

The relationship

The attention given to the relational aspect is fundamental for anybody working in areas in which relationships belong to a particular order in respect to daily life - teachers, priests, magistrates - because these are asymmetrical and circumscribed relationships, specifically aimed at one objective. If the relationship is polarised between the need of the patient and the competence of the doctor and the pivot is the therapy, perhaps what is at stake is even tighter. It is known that an important part in the exercise of non-psychiatric medical practice is, in fact, unaware psychotherapy.

In western culture, psychotherapy has specifically investigated the therapeutic relationship in its different forms: precisely because it is a method of treatment based on relationship, it has researched the dynamics that develop inside the analytical couple, shedding light on the risks, finding a way of using them, and reminding us how these knots are the raw material on which to work. The richness of psychoanalysis is in using the therapeutic relationship towards transformation. For us acupuncturists, working with the patients, approaching the situation in different ways, but always spending enough time to allow things to happen, these things have - must have - quality and density that are different from normal life.

It is obvious that our society and our culture do not overlap with either classical or contemporary Chinese society. We are not talking about psychotherapy here, but I would like to mention some fundamental aspects that belong to psychoanalytical theory and practice, and have some mutual aspects that may be a precious source of reflection. Psychoanalysis and acupuncture may have some common concepts, shared in acupuncture treatment. There are also other elements that are consciously used. I will dwell in particular on the concepts of transference and countertransference, the setting, therapeutic alliance, empathy and neutrality, contract and recovery. I will focus on some 'good manners', on how we may prevent ourselves from making errors arising from the deeper dynamics of the relationship, and thus avoiding, at least in part, any possible anti-therapeutic responses.

The dynamics of the relationship - transference

The meeting between patient and acupuncturist - beyond the specific components of traditional Chinese medicine - is a meeting where we come to know each other, where the affective components of each party, with all the complexity of their internal worlds, come into play. We all have patients who make us sigh or cross just by hearing their names: these are the 'impossible', 'unbearable' or 'hateful' patients: they can be moaning or aggressive, we think of them as people who only pretend to co-operate, or do not want to be cured, or those that stick to us like leeches.

In other cases we easily feel incapable and what we do is never completely right, or - on the contrary - we think of ourselves as great clinicians, like magicians, and in any case indispensable. During the course of the treatment 'strange things' can happen: a patient who initially seemed to admire us and trust us becomes hostile and obstinate, at first enthusiastic and suddenly despairing. He may have realised the obvious: that the doctor is human and is neither perfect nor omnipotent, or may be overcome by the projection of negative aspects that belong to other people, other relationships or times, that, without realising, the patient projects onto the healer. This mechanism is present in all human relationships, but especially in a doctor-patient situation - a delicate situation, in which a person is more obviously fragile, confused, suffering and therefore full of expectations. The doctor tends to acquire different types of projections: this is physiological, but there is a continuous risk of a reciprocal chaotic and confusing invasion.

Transference consists in living present situations as if they were re-lived from other situations lived in the past, or - in other words - ancient/old relationships are transferred and overlap onto those present, real. Transference 'designates, in psychoanalysis, as the process in which the unconscious desires are played out on determinate objects within a determined relationship established with them, and first of all within the analytical relationship. It is a repetition of infantile prototypes that is lived with a strong sense of actuality.' (Laplanche Pontalis, 1967).

In every personal relationship transference and countertransference movements come into play, the instinctive pulls, and the defence mechanisms rooted in the past are played out and confront the reality of the external world and one's own internal reality: the problem is when these images overlap and are substituted repeatedly onto external events, not allowing diversity. Chinese thought teaches us that rigidity does not allow movement. Psychotherapy fully utilises the transference mechanism; however, as acupuncturists, what is important is to remember that it exists, so that it is easier to recognise and to behave accordingly.

How do we recognise it? When, for example, we perceive what is happening as something that 'does not belong there', when we think 'what is he telling me now?' 'why is he behaving like this?' this is transference, something that exists beyond the real situation, as if something extraneous were 'overprinting'. How should we react?
By not responding in the way that may be expected. The therapist has to stay away from the process of the patient, of identifying the new objects - the people and the situations that he encounters - with the old ones that have produced problems in his development. Being sympathetic does not imply that we are letting ourselves be involved in the patient's emotional game; if the patient projects love or hate, the therapist does not reciprocate.

It is not very useful to act like a relative or a friend; there are enough real people in the life of the patient who do that. In more 'Chinese' terms: we must function like the empty centre of the wheel, without filling it with what the patient expects us to do, or with what we feel. When the battle rages, the emperor stays put like the mountain. The next step - though this belongs to psychotherapeutic work - is a transformational listening to the suffering of the patient, which means not only to tolerate attacks from the patient on the therapeutic alliance, but to transform them into useful communication in order to understand what is happening in the relationship.

And what about us? Also, the doctor can introduce something in the relationship, something that does not belong there. Something in the patient or in the way in which the relationship develops can remind us of another person or another situation that has hit us deeply in the past: in reality our response is not to the real situation - or only in part - but to a transference that has more to do with our past objects than with the present situation. The problem is that transference is such because it is unconscious, is generally very well hidden or camouflages, and that we find good excuses for being angry or sad, aggressive or disappointed.

How can we recognise what is happening? The same principle applies: be very careful, especially of anomalous or excessive emotions, of answers in which you can recognise a deviation from what one can expect from the situation, of behaviour in which one feels that one is doing something that does not come from us, as if the patient was pulling us. It is worth stopping for a while when, for example, we realise in any of these situations that:

- the involvement is so strong that it does not allow that small distance from the patient, to the point of infecting the mood or even the symptoms
- we have the impression that we are behaving according to the negative expectations and the fears of the patient
- there is repetition in our emotional response; for example we always feel wanted, or always attacked and devalued, or we function well up to a certain point, but always miss the complete resolution, and so on
- we feel absolutely indispensible or totally incapable, or deadly angry, or impossibly bored
- we understand that we cannot tolerate at all a certain type of patient or some specific situations.

For the sake of completeness let us remember the distinction between the transference of the therapist (primary emotion towards the patient) and the counter-transference (the emotive response to the patient's transference). Counter-transference is 'the ensemble of the unconscious reactions of the analyst towards the person analysed and in particular to his transference' (Laplanche Pontalis, 1967). Freud considers this the effect of the 'influence of the patient on the unconscious feelings of the doctor' (1910).
How should we react? We will touch on more specific aspects further on - the concept of neutrality, the rules of the setting, the reflection on the motivations of the therapist. However, I believe it is important to remember here the saying 'why do we have two ears and one mouth? In order to listen twice more than we speak'. To speak means also to act.

If true transference can be utilised only by those who have worked with it very specifically, there is a non-specific transference which belongs to the doctor-patient relationship. The doctor is in fact 'the drug more often used in general medicine'. A concept I find fundamental is that of the therapist as 'container'. This term is given by Winnicott, when, as early in 1960, he stressed the necessity for the therapist to allow the patient to develop his 'real Self', avoiding to invade him during certain phases of the therapeutic regression. The optimal function of the therapist in these conditions is that of an object that 'sustains', a role akin to that of the mother for those patients who never had normal motherly care. With his intuition and his empathic understanding, he is more useful than verbal interpretation, with its disturbing and intrusive effects.

The perspective of Bion centres mainly on the 'intuitive fantasising of the mother', whose reverie allows her to take on in herself the experience of the frustrating moments, primitive, fragmented and dispersed, that are projected from the infant, and to reconstruct back. The mother's intuition thus acts as a 'container' that organises the projected content. The analyst is used as 'container' of those aspects that the patient cannot deal with to experiment in himself.

I have recollected these thoughts because they show the importance of integrating cognitive and affective aspects, contrary to the stereotype that identifies psychoanalysis as the 'revelation of the trauma' and its interpretation. The acupunture doctor can then 'be', mentally and affectively - not overcome by deep emotions and by the dynamics that are at play. This is without confusing it with pseudo-psychotherapeutic work: one cannot and must not interpret, nor attack the patient's defences, nor can one allow identification, transference or regression.

The work space - setting

How should we behave? By giving attention to these and other possible dynamics, but also by taking into account certain useful formalities to build a good workspace, understood in the wider sense of the word. The setting is the definition of workspace, and by regulating and containing it allows the development of the therapy, helps the process of change. It has a mental significance and concrete aspects. It is the space-time frame, inside which the therapeutic act takes place. The frames are boundaries, they delimit and limit, but, as painters know well, they do give relief to the painting. A frame-maker is good when he has got an eye for the right frame for a specific painting. It is a 'mental place', that is founded on empathy, is traversed by the therapeutic alliance, expects neutrality, and has concrete correlations that concern the definition of space and time and manifest in them.

Therapeutic alliance, empathy and neutrality

In order to do anything together it is necessary to establish a relationship of trust between people, to find a common base and to build a working alliance.
In any therapy there are at least two persons. The two persons relate to each other with the aim of achieving something good, that is they work together to change a state of things that is causing dis-ease at least to one of them.

In the acupuncture setting the situation is extremely delicate: 'I really feel like a hedgehog' or - in the more refined version - 'I feel like San Sebastian' are phrases that patients commonly use to undramatise and defend themselves in an anomalous situation. The internal act of handing oneself over, to give themselves, is in effect enormous. It can be explicitly declared, it can be hidden behind statements about the 'wickedness' of us acupuncturists (the act of 'pricking' could be explored further) or finally camouflaged in the generic anxiety about needles, but certainly an act in which the needle breaks the continuity of the body, penetrates and produces strange sensations, does not introduce any external substance, so that it has to rely on its resources. In short an event of this type, if not unsettling, is at least rich in unusual nuances.

In a relationship, the 'empathic' component constitutes a step beyond the elements of
trust and alliance. Empathy is the 'capacity to understand, feel and share the thoughts and emotions of another in a determined situation'. The empathic attitude is characterised by availability, attention, seriousness, warmth, acceptance, interest, kindness, sympathy and support, and each of these terms has a value and a significance. On the other hand, the therapy has aspects of care, abandonment and taking charge, as well as aspects of detachment, separation, limits and departure. The problem then, also in non-analytical circles, is to recognise the line that separates excessive proximity (identification, overlapping, fusion, impossibility of movement) from excessive distance (incomprehension, coldness, indifference, solitude and again impossibility of change).

The concept and practice of neutrality may help us: neutrality which is not coldness or rigidity, or indifference. 'Neutrality' is not the absence of warmth or empathy, but a means to maintain an equal distance between the forces that determine the intrapsychic conflicts of the patient. Every psychotherapy requires from the therapist at least the capacity to express authentic warmth and empathy, but empathy is not only the emotional and intuitive awareness of the central experience of the patient at a determinate moment; there must also be a capacity to feel empathy for what the patient cannot tolerate in himself'. (Kernberg, 1984).

In a more generic therapeutic sense it is, however, useful to remember that the ability to listen and to welcome are also related to a suspension of ethical judgment.
The discourse on 'neutrality' has become one of the most heated, and is one where there are various positions. Some of the issues are:

- It strictly involves dealing with our daily practice, in which we are constantly being asked to intervene, directly by the patient or non-ontologically by the clinical situation
- it is linked to our internal image of doctors and acupuncturists, and it is correlated to the deepest motivations that make us do this job
- It is subject to fundamental theoretical contradictions such as wuwei, 'not acting' in Taoist thought, and the fact that Chinese medicine recognises pathogenic behaviour.

If, on the one hand, we know the risks of eating cheese for TCM and the advantages of the practice of the qi gong 'seven sounds' we cannot but agree, on the other hand, with the uselessness of the 'mission or apostolic function' (the term with which Balint understands the vague idea that every doctor has of the behaviour that a patient must display in the case of illness, from which there derives a sort of duty to convert incredulous patients to the faith. Like reassurance, it is not negative in itself, but it is dangerous to apply it crudely and without awareness).

Perhaps we have less vague ideas, but I think all of us have long and frustrating experiences of the quibbles with which the patient responds to our proposal to modify his behaviour, or of the total absence of change after our explanations, or even - rarely, thank goodness - of 'undesirable effects' after putting a suggestion into action.
Not to mention the feeling of the 'theatre of the absurd' if we start speaking about familiar and affective relationships: these are cases where we only listen to parts of the discourse and we construct an obviously completely useless solution, or our good sense comes out badly shaken.

Then we ask ourselves what we are up to. Do we want to be mothers? Welcoming, warm and always available, someone the poor patient can cuddle up to, and from whom he will never go away, in this way reassuring the doctor-mother that he is needed by somebody, that is he exists and is good. What can these wounds be which we are trying to deal with through the control over the patient? Or do we want to be a priest-guru? One who knows everything, has unquestionable knowledge, who belongs to another world in which the other has no value or existence. And what are these gaps that do not allow me to look at the other? Or do we prefer to be a judge? To decide judgments and punishment. What old sorrow makes unbearable any mistake?

We understand that a therapist is not a mother, or a priest, or a judge. We know that for a therapeutic change we need the 'seed' of the patient, the terrain of 'technical knowledge', the rain empathy, the light of the doctor's motivations; but if we work on these motivations, we discover that they have everything in them (e.g. power and sadism, abandonment and care), that more than light they are like manure that fertilises. It is essential not to negate these motivations; only once they are recognised can they produce richness.

We remember that only the saints, of whichever tradition, know in an absolute sense (or at least we hope that they know). But the fact is: who are we to say something about life? But that we are there, as doctors, to say something. What are we to do? The solutions are many; the fundamental point is that there has to be maximum awareness of what we are doing. We can bring the patient to reflect, to see, for example, that reality does not have only one aspect (and thus for example different behaviours could be thought and acted out with better profit); we can inform (and therefore find together a solution that can be acted upon); we can prescribe ('the doctor ordered this for me', a medicine, an exercise, a diet, anything, but defined in an extremely precise way - you cannot prescribe life), but one must be clear when, what and how to prescribe.
Sometimes it even happens that the patient gets to say the prayer (attributed to different sources): 'God, give me the patience to tolerate the things that I cannot change, the strength to change the things I can change, and the wisdom to distinguish between them'.

Frames and limits

So far we have considered essentially the mental and emotional order, and some of the dynamics between the two characters that appear within the work space. We can see now how these aspects manifest, how they produce and are influenced at the same time by something more concrete. We may start from the realisation that within the time and space of the treatment things are different from those outside this space and time: the setting defines a place and time different from all others. There are things that are, and have to stay, outside the shared space. To build and maintain a particular space is therefore fundamental in a therapy like acupuncture in which one moves at the level of energy and in which the body - somatic and ghost-like - as well as the relational aspects, carry great weight.

In different cases (with a child, a project, a healing process) boundaries are necessary in order to build a stable basis, and to have a greater degree of freedom. In contemporary China the rules are not explicit, but even us foreigners can easily capture their existence. Even if we only roughly understand the practice, and the gradations are lost to us, we certainly recognise their importance. All psychotherapy treatments - from classic psychoanalysis to cognitive techniques to psychodrama groups - recognise that the setting influences the therapy and therefore follows particular rules.

We must remember that the boundaries of a territory are useful in two ways: they protect from outside influences, but at the same time they avoid spilling everywhere what is inside. The containing function goes both for the patient and the therapist.
To identify this space, one needs some process, some limits to what can happen, i.e some rules of behaviour. I do not think it is possible nor makes any sense to try to define absolute rules, also for contingent reasons: we practice acupuncture in very varied circles, the doctor's clinic generally has characteristics different from those of a consultant's, frequently acupuncture is not the only therapeutic approach used; our training is different, the structure of the clinic varies (one or more rooms, presence or absence of a nurse).

Once again the principal element at play is attention: the awareness that the place, the time, the style of speaking, interruptions, etc. influence the therapeutic process, generally in a more consistent way the stronger the psychical nuances. Therefore, if we do not intend here to codify rules of behaviour, it is however possible to focus on some themes relating to this shared space.

The physical space is characterised by light, sounds, colours, objects, spaces in the rooms: this is also qi, similarly the movement and the gaze of the therapist.
The acupuncturist can be physically with the patient all the time during the session or only in part, but it is important in any case to realise how long, and how, one stays. To go out of the room does not only mean doing something else in the meantime, but it also means leaving some space for what is happening: too often the patient is distracted by chatting, or counters the work of the needles on qi by thoughts, trying to find words and concepts, holding on to anxious thoughts.

It is important to decide how much disturbance can be allowed, i.e. how much that is ouside can be allowed in. In the psychotherapeutic session, external interruptions or the telephone are certainly not allowed, but this rule is not so strict in the acupuncture clinic. It is fundamental that the level of interruption allowed is clearly defined, that one is aware of it, and that the limit is maintained.

On the time of the session

It is worth remembering that the more the time is precise and defined, the more it has a containing function. In psychotherapy, therapist and patient know the timespan reserved for their encounter, by implicitly recognising that there is time but it is not unlimited. As acupuncturists, we can more or less keep to the time of the appointment, and therefore we expect that the patient does the same (or not keep to it, and expect instead that the patient does), we can keep an amount of time at our disposal, we can have the courtesy to tell the patient how much time we have, or when it is about to finish. But beyond the amount of time another fundamental variable exists - that is quality. The time we have, a 'dense' time, an empty time, empty in what way.

The quality of the language

The quality of language has a tight link with the quality of time in the session, that is if we manage to listen, if we talk or chatter, if the words uttered are significant, if the gestures make sense or increase confusion. We observe qi In many ways. The four methods of investigation (sizhen), the eight diagnostic rules (bazheng) tell us this, and therefore why we work also on a level of non verbal communication, the tone of voice, the position of the body and the gestures. How do we respond to excess verbalisation, or to the impossibility of saying things in words? Naturally there are no valid rules here for the doctor: one can be silent and bring density to actions, one can be light and, through irony, move and transform a little.

The clarity of limits

With their containing function, limits imply a whole series of behaviours (home telephone calls, rules for payment, punctuality of the sessions, various interventions of third parties, the family in the therapy, initiatives with other doctors and therapies). It is important to have explicit agreements on the sessions, with reciprocal rights and duties (including, for example, reassurance to the patient about the sterility of the needles), and to keep agreements. It is not necessary to establish rules for the majority of patients, but with some we discover too late that something has escaped our control - these are the patients that not only make us sigh when we hear their names, but also the patients with whom we are so involved that we do not know how to extricate ourselves or where to turn next. In these cases, a prior definition of the rules of relationship are also fundamental for the success of the treatment.

The conclusion of the treatment

This is a delicate moment, both in the case of brief and long treatments: if sometimes it seems impossible to stop some therapies, the end of the relationship is in any case a separation, and these are experiences that can be to a degree difficult. We must specify that there is the possibility of further contact, but first of all, in the case of major disease or chronic illnesses, one must recognise the possibility that the patient will need to live with some discomfort.

The words of the doctor

In psychotherapeutic consultations, at the end of the session we anticipate a moment of 'giving back': after the patient has spoken to us and therefore given something of himself, it is important that we also give something through words. In our case, 'giving back' can mean, for example, speaking about the problems ahead, about the time necessary, and asking if there are any questions.

For an acupuncturist, the problem of prolonged talks is also important, because through these you penetrate into intimate life, with all its miseries, its small but deep fears, frustrated hopes, that give one feelings of shame and impotence. The problem is when to stop, to be aware that the patient may feel defrauded or cheated instead of being understood or relieved. There has to be a balance between giving and receiving; perhaps it is sufficient to distribute the same material over more conversations in order to offer the patient the possibility of restoring this balance.

There is a great temptation - as was mentioned earlier when we talked about 'neutrality' - to assume that the doctor, through his experience, has been able to acquire 'good sense' in psychology, so that he is able to confront the patient's psychological or personality problems. Even if the advice or the reassuring words are not entirely or necessarily wrong, the use of empirical methods acquired through daily experience is, unfortunately, too fragile a guide to be trusted. Since we do not know the underlying dynamics, the possible suggestions (which other people with common sense have already offered) are 'shots in the dark' (Balint, 1957).

The attitude of acupuncturists with respect to verbal communication, whether about
energy evaluation, or explanations about acupuncture or about a specific treatment, span a wide range; from those who keep mainly silent to those who talk about the specific functions of zang-fu. If, on the one hand, what we say depends also on the expectations and the mental state of the patient (for some people it is important to try and understand through more 'rational' methods, through words, whereas for others knowledge comes more directly in a somatic way), and if it is counterproductive to stiffen up or to be silent when confronted with questions, I think the major risk we face is that of imposing our own explanations, recycling the conscious formulations to which we are most used. It is, however, very important to leave as great a space as possible for the channels of perception that work in particular ways when we use needles, to become familiar with recognising a different terrain of action, and learn to give it prioirity.

Conclusion

A profession which aims to cure illness and suffering is a delicate one. This is even more true for acupuncturists, who work on the level of energy, trying to disentangle ourselves between the 'official' medical perspective, therapeutic traditions to which in fact we do not belong, and requests from our patients that are often complex. In a treatment there are areas not covered by strict medical knowledge (diagnosis, choice of points, insertion of needles): a clear starting point - but also a point of arrival - is not to take anything for granted, but to stop, to listen to the patient, to feeling for oneself, to think with colleagues. I hope that this article can be a starting point in this direction - of thinking together.

Bibliographical notes

A 'classic' is used as a reference text for all subsequent authors, object of citations, commentaries, new editions, compilations, and therefore continually lives in time as it brings 'sense'. The choice of consulting texts in the original language stems from the need to dig into the roots of a thought which has in its written text (in the writing) its most peculiarly expressive form.

For the translation we have consulted commentaries of the same text from different times, sometimes discordant, and we were confronted by the need to make constant choices. The criteria that have guided our choice of translation, more than those of a strictly phylological type - that would have lain outside our expertise and the aim of this work - have been 'sense' criteria, that is among the great range of the possible levels of interpretation, we have chosen those that would give us an answer more rich in 'sense' in interpreting the text.

Huangdi Neijing Cidian (Dictionary of Neijing Haungdi) edited by Guo Aichun, Tianjin kexue jishu chubanshi, Tianjin 1991.

Huangdi Neijing Suwen Jiaozhu (Critical annotated edition of Neijing Suwen Haungdi), edited by Guo Aichun, Renmin weisheng chubanshi, Beijing 1992.

Huangdi Neijing Lingshu Jiaozhu Yuyi (Critical annotated and translated edition of Neijing Lingshu Haungdi), Tianjin kexue jishu chubanshi, Tianjin 1989.

Huangdi Neijing Suwen, translated and edited by Husson, 'Meridiens', Paris 1973.

The Yellow Emperor's Classic of Medicine, edited by Maoshing Ni, Shambala Publications, Boston 1995

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