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Classical Five-Element Acupuncture.The Skill of Traditional Diagnosis

By Neil Gumenick

The initial consultation, also called the Traditional Diagnosis, is an opportunity to bring all of our diagnostic skills into play: seeing, asking, hearing, feeling and smelling. The goal of the Traditional Diagnosis is to arrive at the underlying elemental Causative Factor (Fire, Earth, Metal, Water or Wood) of the patient's disease, the level of the imbalance (physical, mental or spiritual) and exactly what the patient needs in the treatment.

If we all functioned in harmony with the Tao, in accord with natural law, illness could gain no foothold. But, there are internal and external factors from which on one in invulnerable. These upset our balance and that of our patients. Many patients are born with their primary imbalance already in place. Others acquire it in the traumas of the first years of life. In either case, this imbalance creates weakness throughout the entire system and manifests through unnatural signs in behaviors that strike us as inappropriate. Therefore, every patient interaction provides us with opportunities to note what is inappropriate by its excess or lack. The behavior relating to the Causative Factor will be a recurrent theme detectable in everything the patient says and does.

In the wood element, for example, the sound of the voice is shouting or lack of shouting. The shouting may or may not be loud in volume, but there is a characteristic demanding, "telling you off" quality to it. The lack of shout is most evident when the patient is recounting experiences in which you would expect some anger and self-assertion in the voice, yet is strangely absent. The emotion of wood is anger or lack of anger. Like all of the five emotions, anger is a necessary and healthy expression in a given set of circumstances. We have all experienced the frustration and fury of not getting our way. Our plans have been thwarted and our decisions derailed. It is natural to feel anger in such situations. It is the health assertion of wood energy.

In the Traditional Diagnosis we guide the patient through a wide range of questions, which will elicit the range of emotional responses. We can then determine if the response is appropriate. In the case of a wood imbalance, the anger will be present in situations in which we would expect a patient to express happiness, sadness, fear, grief, or other emotions. In the other extreme, the anger may be strangely absent when describing situations in which we would expect there to be some measure of frustration and assertion of those feelings.

Among the inquiries I make in a Traditional Diagnosis are the following: Tell me about your main complaints, how long you've had them, and what you've done about it. What effect does it have on your life? These kinds of questions do not ask simply for a yes/no or one-word answers, but open the door for a wide range of information about the unique individual who is before me. I am more interested in how the patient answers than the word for the purposes of diagnosing the cause.

Many patients come to us as a last resort, having been unsuccessful with or discarded by other systems of medicine and are understandably angry and frustrated. We can empathize and acknowledge the patient's anger and expect, once it is unloaded, it will die down. But, if it goes on and on and carries into other areas of questioning, it is clearly an excessive response and may well be pointing to the Causative Factor. In the extreme, the patient who justifies and makes excuses for the ill-treatment he/she received, whose anger is so suppressed that it cannot be expressed, points to the same imbalance.

Here, we must remember that all patients (like all of us) wear "masks" and do not openly reveal their true feeling, but only those which they wish to be seen. This is where the skills of rapport are so vital. If we can quickly win the patient's confidence and treat, they will allow us to see who they really are behind the mast. Then, we are well beneath the level of physical symptoms, at the level of the core and can direct our treatment at the underlying cause. Penetrating the mask and finding the real source of imbalance is much more than simply asking and listening. We must, at times, actively and deliberately test and elicit the patient's emotions. This means we must stretch ourselves beyond our own emotional comfort zone and find the places in us where we can sincerely provide love and joy, sympathy, acknowledgement and respect, reassurance and assertion (the basic emotional needs of Fire, Earth, Metal, Water and Wood). How does the patient react in the presence of these emotions when we provide them? When we withdraw them?

Many people are able to rise to the occasion of joy and laughter when it is offered. Joy is, to some degree, a socially acceptable and comfortable emotion. Can the patient initiate joy, humor, and warmth on her own? When you don't provide it? Can he sustain joy when you withdraw it? Are joy and laughter the predominant emotion and sound expressed regardless of the subject? Does the patient giggle and joke throughout the session, striving to create the Fire and warmth they need to survive? Can he/she muster this emotional at all, or is everything expressed as flat, somber, serious and gray?

One area in which the state of the elements is particularly revealing is in the area of present and past relationships, particularly with one's partner, family member, and children. No one feels neutral about these relationships. Often, the experiences of childhood are carried into adult relationships. What one lacks in him/herself may be what one seeks in a partner. Rather than yes/no questions, I ask open-ended ones like: Tell me what your early childhood was like. Tell me about your relationship with your mother/father/siblings(s). As the patient describes these relationships, what stands out? Warmth and enthusiasm? Fear? Contempt and hatred? Note the words but more importantly, how they are expressed. What is the facial expression and body language? Does it match the words? Do the words match the sound?

With the amount of ground that we cover in a consultation, there will be expressions of all five emotions (joy, sympathy, grief, fear and anger), but our skills of detection must be developed so that we can know which is the major imbalance. In describing an important relationship, does the patient make fun out of a tragedy? Does he/she continually pull on you for sympathy and understanding - complaining and whining (characteristic of the singing voice of the earth?) Even if sympathy is offered, does it seem the emptiness is incapable of being filled? If you stop giving sympathy, does the patient hunger for more and more? In a situation in which you would expect a patient to be fulfilled with the harvest of his life (a long-term committed relationship, money in the bank, children well reared and self-sufficient, etc.) does he still manifest a state of internal starvation? In the other extreme, the imbalance may show as the extension of sympathy toward others, taking care of everyone else's needs, but ignoring one's own.

Other patients may be holding only grief of a past separation or loss long after the fact. We all must grieve in a given set of circumstances. Death, separation, and loss are visited upon us all. The emotion of metal with its sound of weeping enables us to let go, eventually piece our lives together and, recharged by new inspiration, go forward. Yet, some patients go through life as if looking in reverse - filled with regret and remorse over the past, what was missed, in a continual state of "if only . if only ." Others seem to be unaffected by loss, past or present, that a reasonably balanced person would find it impossible not to grieve about. This we characterize as lack of grief.

Fear (the emotion of the water element), like all the five emotions, can manifest by inappropriate excess of lack. We all need to exercise due caution in avoiding danger and at times, we need to manifest courage and will power. The sound of the element is groaning. In relationships, here you are apt to find patients whose inner reserves are so weak that every interaction is a cause for concern and alarm. These people may stay in bad, destructive relationships out of fear of leaving to face an unknown future. They may be afraid to express what they feel. These patients tend to need continual reassurance, but once given and given again, it is never enough. In the other extreme, the denial of fear may be so extreme that, like those who relish jumping out of planes or driving at reckless speeds, such patients may, with the same abandon, jump into or out of relationships without concern of the consequences.

To identify the predominant inappropriate emotion and sound in a patient means nothing less than developing the power and resources within us. Conjoined with the ability to see the colors on the face and smell the predominant odor, we can, with certainty, identify the cause of a patient's disease, regardless of its label. Understanding this, we know what the patient truly needs. We can then employ the natural laws which determine the most effective points to restore balance and harmony to body, mind and spirit.