Vol. 15, #2

Acupuncture And Empowerment:
Transforming The Therapeutic Relationship
To Facilitate The Flow Of Qi
Michael T. Greenwood, MB (MD)

ABSTRACT
There is an emerging consensus in medicine that patients should be more involved in the clinical decision-making process and that they be empowered to act as full partners with their physicians in their health care. But despite the consensus, empowerment remains an elusive goal. The author argues that this is so because the current medical paradigm is innately disempowering, and that empowerment might better be facilitated with acupuncture through an application of Five-Element principles in the context of a transformed therapeutic relationship.
KEY WORDS
Acupuncture, Empowerment, Five Elements, Therapeutic Relationship, Transformation

INTRODUCTION
In a previous article, I discussed the limitations of an objective evidence-based approach to evaluating acupuncture and suggested that a more appropriate approach would involve the study and transformation of the therapeutic relationship.1 At first glance, this might seem curious. After all, the ethics of the patient-physician relationship are well defined, and physicians generally do their best for their patients. So one might wonder what, if anything, there might be in the therapeutic relationship that could be changed.

In this article, I argue that the nature of the therapeutic relationship has a profound impact on the flow of Qi, and that to facilitate that flow, the power differential between physician and patient needs to be brought to full awareness and ideally, eliminated. Though I take a critical view of hierarchy in the patient-acupuncturist relationship, my remarks should not be misconstrued as a denigration of otherwise conscientious physicians. On the contrary, the existence of hierarchy in the conventional context is usually appropriate. But there are energetic consequences to the customary power differential that can obstruct the flow of Qi, an appreciation of which can only be beneficial for physician/acupuncturists who want to optimize results.

Empowerment as a Therapeutic Initiative
One of the many extraordinary features of Oriental medicine is its innate ability to empower patients in a way that seems to elude conventional medicine.2 With evidence accumulating that patient responsibility improves outcomes for difficult clinical problems,3 much is being discussed today about trying to empower patients to be full partners in the therapeutic relationship.4 Family medicine is in the forefront of this trend, virtually defining itself as guardian of the ideal patient-physician relationship.5 For example, one emerging ideal is the patient-centered paradigm which is geared to recognizing patients' beliefs and values rather than the physician,whose usual emphasis is on defining pathology.6 The idea is to encourage patients to be active participants in the decision-making process so that they feel more directly involved in their treatment.

Much of this shift in thinking is being fueled by the emergence of informed consumers, frequently Internet-educated, who often have a plethora of information and appear to want to be more involved and responsible in their health care. However, according to some investigators, more information and empowerment are not interchangeable. Studies show that the desire for more information does not, in fact, cor-relate with the desire for more responsibility. It appears that despite what one may say, most people remain emotionally powerless in health matters and still prefer to be told what to do.7

Power Dynamics of the Patient-Physician Relationship
While medicine's concept of a good patient-physician relationship may be appropriate in the usual practice setting, a patient-physician power differential may not be so functional when applied to the acupuncture relationship. After all, the experience of Qi flowing and the experience of empowerment are virtually synonymous because the Qi is itself the source of power. Thus, at some pivotal point in the therapeutic process, the notion of powerlessness has to be exposed as false if the Qi is to flow freely. Yet the notion of patients' lack of power is regarded as so self-evident by governments, medical organizations, and the public that it is built into the phrase health care and forms the legal basis of medical ethics.5 This means that the current legal and ethical framework for the patient-physician relationship may actually act as an impediment to the free flow of Qi.

Table 1. Characteristics of the Conventional Patient-Physician Relationship and the (Mature) Relationship that Reflects the Empowered Patient

Conventional Relationship
(parent-child or hierarchical)

Mature Relationship
(equal or non-hierarchical)

Patients are helpless

Patients are powerful, but do not realize it

Physicians hold the power of healing

Patients are their own healers

Physicians are responsible for their patients

Patients are responsible for themselves

The physician is the responsible party in the relationship

Patient and physician are equally responsible for the relationship

The physician acts, the patient complies

The patient acts, the physician witnesses

Limited confidentiality

Absolute confidentiality


In the traditional patient-physician relationship, hierarchy is simply assumed; the physician is defined as being in the position of power vis-à-vis the patient (Table 1). The explanation for this assumption is that physicians hold the power of medical knowledge and that patients surrender their power through the act of asking for help. To support this argument, proponents point out that patients are required to self-disclose, disrobe, or even surrender their consciousness (e.g., under general anesthesia) while the physician maintains a relatively non-disclosing position through his/her professional distance. According to this view, the relationship inequality leaves patients at a potential disadvantage and open to the possibility of manipulation or even abuse. Such thinking has led to the imposition of rules regarding the therapeutic relationship that tend to infantilize the patient.8

With the idea of patient powerlessness so institutionalized, it is difficult to conceive of empowering patients without simultaneously proposing a non-hierarchical patient-physician relationship together with a dismantling of regulations that define the relationship as unequal. However, such a dismantling is not likely to happen soon.

The difficulties of attempting patient empowerment within the existing model of illness have been pointed out, but few have offered any practical solutions. Canter9 examines the concept of medical power and concludes that giving power back to the patient would not be as easy as the rhetoric would suggest. With "power" defined as a means of controlling the outside world, i.e., the authority by which one person persuades another to do something, Canter suggests several different kinds of power which he calls "first, second, and third dimensional."

First-Dimensional Power
As Canter defines it, first-dimensional power is coercive, i.e., "do this because I tell you to." This kind of power, though eminently practical for many situations in practice, has been criticized as patriarchal and is basically what the patient-centred approach is designed to change. Though such an outward change might satisfy some, it would not change the root issue of hierarchy in Canter's view. He points out that such power is straightforward, honest, and open to observation. Canter cautions that we should be careful about erasing it because it will simply be replaced with something more manipulative.

Perhaps less acknowledged is the fact that patients use this kind of power too. In the era of third-party payment, many patients believe they have a right to procedures or tests they might not request if they were actually responsible for payment. The patient who demands an antibiotic or who wants some marginal laboratory testing regardless of medical necessity is acting out of first-dimensional power. One family physician, lamenting the vicissitudes of frontline practice, commented about an informed consumer who demanded annual colonoscopy screening for colon cancer instead of the usual occult blood testing. The physician wondered how he could avoid being coerced by worried patients informed of the latest trial results.10

Second-Dimensional Power
Canter defines second-dimensional power as manipulative. He says it occurs when an interaction is maneuvered or influenced by one party to effect a certain outcome. Because physicians are usually in familiar surroundings and in control of the interview, they conceivably have the power to direct the visit in certain ways. For example, treatment options might be presented with a bias toward a certain intervention or procedure. Also, time pressures can be amplified or interruptions can be used to change the course of a visit.

A familiar example of a useful manipulative technique is one commonly used with children, in which the physician gives the child an apparent choice such as: "Do you want me to look in your left ear or your right ear first?" It gives the child a choice but subtly removes the choice of not having the ears examined at all. Usually the child does not notice, which is what makes the strategy so effective. Similar techniques can also be used with adults, i.e., the physician might say to a patient with a sore throat: "You may well have strep throat. Are you looking for some penicillin, or do you want to tough it out?" Such a question gives the appearance of choice while subtly implying the existence of a pathogen. The point is, regardless of the reason for the sore throat, if patients think they have a pathogen, they will often opt for a prescription while believing erroneously that they have exercised free choice. Such an interchange can facilitate speedy visit closure while absolving the physician of lengthy time-consuming explanations.

A variation of second-order dynamics is the power of professional charisma, as seen on popular radio and TV talk shows featuring a charismatic personality. Professional charisma can influence patients in many conceivable ways which may be acceptable if the physician is acting in the patient's best interests. However, Canter points out there is no guarantee that such will be the case.

Conversely, patients are adept at second-dimensional dynamics as well. As any physician knows, patients often use the "sick role" to manipulate their physicians, families, insurance companies, and government agencies. The sick role can be used to collect sick pay, get free prescriptions, justify drug addiction, access cheap accommodations, obtain travel vouchers, incur sympathy, avoid working, or win insurance payments.11 Some patients can become so skilled at this kind of manipulation that it becomes a general life strategy. Indeed, the plethora of imaginative strategies that people envision can sometimes be staggering. Furthermore, patients are rarely held accountable for such behavior. Usually their strategies are excused because of the collective agreement that patients are helpless and disempowered, which implies they should not be held responsible for anything related to their illness.

Third-Dimensional Power
In Canter's classification, third-dimensional power refers to context, the larger dimension or paradigm in which the treatment takes place. Here, both physician and patient may think there is free choice, but the choices are limited by a medical model expressed through a physician constrained by evidence-based regimens. In the current medical paradigm which emphasizes drugs, surgery, and various procedures, there is often no place for alternative approaches such as acupuncture, homeopathy, or herbs. For example, a patient with cancer might be given the options of palliation, radiotherapy, chemotherapy, surgery, or a combination. However, all the options rest firmly within the medical model which only gives people choices within an allopathic context. In such a milieu, patients are given a range of choices about which particular agent they can use against their symptoms. But rarely is there the choice to move outside allopathy altogether and opt for a holistic approach.

With third-dimensional dynamics, usually both physician and patient are unaware as to the influence of contextual dimension because the collective context is common to both parties. Physicians may not realize they are influencing the outcome unless they become cognizant that their world-view is also part of the dynamics of the interview.

The Cartesian World View
The world view that eludes the awareness of physician and patient has been called Cartesian, after René Descartes, who first enunciated the dualistic notion that mind and matter are different. Yet Descartes did not invent dualism. Its root actually lies in the primary existential split that gives rise to Western man's sense of alienation, which long predated Descartes.12 In summary, Western man's sense of being a unique, separate individual results in a subliminal "we and they" attitude that colors and directs his actions. This attitude is so deeply rooted in the collective consciousness that it goes largely unnoticed and is considered the norm, even though it is fundamentally false. Indeed, such basic medical dualisms as the assumption of the separate existence of patient and illness or diagnosis and treatment are so fundamental to medical practice, and seem so self-evident, that few physicians or patients are ever likely to consider the dualistic stance, which forms the foundation of allopathy, to be an issue in the choice of approach to healing.

But we cannot be so complacent when it comes to practicing acupuncture because the art is rooted in Taoism; and if the Tao encompasses all things, then dualism is illusory and there is no real separation between physician and patient, patient and illness, diagnosis and treatment, or any other such dualism we might assume in conventional practice. In the words of Confucius:

    From the point of view of the differentiation of things, we distinguish between the liver and the gall, between the Ch'u State and the Yüeh State. From the point of view of their sameness, all things are One.13

The point is that if we succumb to the allure of dualism, which is perhaps fundamentally false, then any action will inadvertently interfere with the smooth and free flow of Qi. Such an understanding has profound implications for acupuncture practitioners because, in addition to demolishing the previously mentioned dualisms, it simultaneously negates anything that separates such as the presumption of hierarchy in the therapeutic relationship.

The Cartesian Anomaly
Consider how the current medical paradigm inadvertently disempowers both patient and physician. Based on objective studies and statistics, scientific medicine intentionally depreciates patients' power (self-healing potential) by invalidating the placebo response.14 Indeed, the gold-standard randomized double-blind trial goes to great lengths to rule out subjective influences, implying that such influences do not constitute real medicine. The inference is that "real" medicine must involve something other than the patients themselves. Such a stance diminishes personal power by a definition that, while certainly appropriate for drug trials, has unfortunately been widely misapplied as a general principle for medicine. Furthermore, trial data requires statistical analysis and interpretation by experts who decide what constitutes the best treatment. So, power that has already been removed from the patient is simultaneously taken from the physician and transferred to a scientific manuscript or filed away in some theoretical location in cyberspace.

The writing off of the placebo effect by scientific medicine has been called the Cartesian anomaly. Heron states:

    ...With its "therapy hat on," modern medicine wants to deliver purely physical remedies for what it assumes to be purely physical defects. Yet with its "research hat on," it also has to acknowledge and allow for the dynamic influence of mental belief on this mechanism which it names the placebo effect. For the guiding rule of effective and reliable research, the very reason for controlling the placebo effect by experimental design is that the body is not a self-contained physical system, but one that is pervaded by and subject to the influence of mental events.14

This is indeed a weird anomaly, i.e., the proven effect of mental belief on bodily functioning, the placebo effect, is acknowledged only so that it can be discounted in research and ignored in clinical practice; and the contradiction carries on unchallenged even though the effects are disempowering to patients and physicians alike.

Acupuncture
Acupuncture can be a wonderful tool to facilitate medical re-empowerment because the theory, practice, and rituals are so foreign to conventional practice that it can simultaneously address all 3 levels of power.15 I begin here with third-dimensional dynamics because it is here at the paradigmatic level that change must occur if it is to effectively end the hierarchical behaviors and manipulations of first-and second-dimensional dynamics.

Third-Dimensional Dynamics –
The Tao and the Development of Illness
Third-dimensional dynamics involve the contextual or philosophical base of the therapeutic relationship, i.e., the sea in which the fish swims. Previously, I have discussed the holistic basis of acupuncture and how the potential for illness and ego-development are related.16 To summarize, in Oriental medicine, illness is understood as arising from the sense of separation (from the Tao), which occurs progressively as the ego develops. As the ego loses touch with its original nature, it creates a false sense of self and the mind rigorously suppresses anything it deems unacceptable to the developing self-image.17

The habitual suppression of unacceptable energies leads to Qi and Blood stagnation which is characteristic of the disease state.18 The implication of holistic thinking is that a disease is a material manifestation of the energies an individual has blocked from spontaneous expression. Symptoms are therefore pointers, signposts back to a lost self.

Perhaps it is immediately obvious that the philosophical base of acupuncture is profoundly empowering. Because it is far from being an anomaly requiring treatment, disease is understood to be a crucial part of the self, a pivotal guide on the journey to rediscovering wholeness.

The Loss of Heart
Another fundamental attribute of acupuncture is the notion of a Heart-Mind split, discussed in a previous article.19 In summary, Heart (Heart Yin) and Mind (Heart Yang) originally exist in a state of undifferentiated wholeness, a state of Yin-Yang fusion. With the dawning of self-awareness, Mind and Heart differentiate as Yang arises out of Yin. This differentiation is not a problem as long as Mind recognizes that it is the child of the deeper principle of Heart Yin.

When Heart Yin and Heart Yang are in harmony, Mind (Yang) acts in the service of Heart (Yin), while Yin supports and gives nourishment to Yang. In terms of archetypes, the masculine principle (Yang) should be in service to the feminine principle (Yin), while the feminine principle provides nourishment to and restores the masculine. Or, to put it in terms of conventional medicine, medical science (Yang) should be in service to the people and society (Yin). If not, it loses its ethical base and becomes an agent of disharmony.

If Yang forgets its origin in the Tao and disassociates from Yin, then it loses any meaningful context for its activity and ends up in service of itself. In the individual, this presents as a loss of the Heart center; in medicine, this results in being a science driven by economics rather than altruism. Such science becomes morally and ethically questionable when its prime motivation is to market health-care products rather than empower people to heal themselves.

Five Elements and the Therapeutic Relationship
In the cycle of the Five Elements, the therapeutic relationship has a lot to do with the dynamics of the Earth and Metal elements. The traditional patient-physician relationship is archetypically child-parent, with the physician and medical system taking on the roles of the Great Mother/Father. Specifically, the medical system takes on the role of the Great Mother, providing nurturing in times of stress; while the physician becomes the Great Father, providing guidance, counselling, and direction as to how to proceed toward healing. Clearly, at the start of a therapeutic relationship, a parent-child relationship is almost inevitable, but it becomes increasingly pathological if the patient is never challenged to grow up and become independent. If codependency develops or becomes entrenched, the relationship can become a stagnating counterforce to the spontaneous flow of Qi rather than the healing influence it is supposed to be. Such a relationship actually blocks any possibility of a resurgence of original energy that might lead the patient toward healing.

A move toward an equal partnership is essential to the re-establishment of energy flow in the cycle of the Five Elements. However, 2 energetic diversions frequently occur to block this process. In the first, the energies of the Earth element become redirected and used for the maintenance of the parent-child relationship instead of being used to establish a safe crucible for transformation. In Jungian terms, this could be regarded as the negative side of the Great Mother, in which the Earth energy becomes a smothering influence instead of encouraging its offspring toward independence. In medical practice, this is the energetic situation behind patient dependency and much chronic illness. We can also see this imbalance on a collective level in many countries that have espoused a Medicare model, which inevitably consumes increasing amounts of the gross national product. (In Canada, many provincial governments are now spending 40% of their budgets on health care.20) Such a process leads paradoxically toward the very chaos it is trying to avoid, and can be understood as the Earth energies being diverted away from Metal into the Water sector (Figure 1, Medical Dependency).

In the 2nd scenario, the Metal energies, which should be used to lead people into the transformational cauldron of the Water energies (the void), become diverted into the Wood sector where they are used as vehicles of power and control. In Jungian terms, this might be said to be the negative side of the Great Father, in which the power of healing that properly belongs to the patient is appropriated by the physician and the medical system (Figure 1, Prescription Medicine).

These energy diversions arise because the transitions through Metal and Water sectors involve skills that are unpalatable to the ego – those of letting go (Metal), and being out of control (Water). Indeed, the difficulties of this passage are so great that they have been likened to a constriction in an hourglass, a psychic narrowing that has been called in Oriental philosophy the Metal Gate, or the Golden Gate21 (Figure 2). As patients approach the constriction, the anxiety generated from a sense of impending ego-annihilation increases until either they surrender control or they balk and divert the energy into another sector to avoid passage. Failure to negotiate the constriction is marked by ego-based denial and disease progression, while successful passage results in a radical personality transformation, characterized by varying degrees of ego-transcendence and often accompanied by disease regression.16

Because of the potential difficulties of this passage, scientific medicine generally seeks to avoid the Metal and Water sectors altogether by putting its energies into interference with the mechanism of production of symptoms. From an energetic perspective, such strategies amount to shooting the messenger, and run the risk of driving the illness deeper into the body where it can stagnate until resurfacing as a more ferocious pathology. Symptom suppression then becomes confused with healing, and outcome studies that measure the degree of symptom relief become the yardstick of best treatment options. Furthermore, guidelines that deny the validity of transformational techniques become the norm. This somewhat calamitous mistake has permeated the whole of scientific medicine and shows little sign of being seriously challenged.

Figure 1. The Distortion of Earth/Metal Energies in a Hierarchical Relationship

Figure 2. The Location of the Golden Gate

Changing First-Order Dynamics
The shift from codependency to a mature independence in the therapeutic relationship is accompanied by a termination of first-dimensional dynamics which, in turn, facilitates the flow of Qi because the patient is no longer blocked by waiting for someone to tell him/her what to do. In a non-hierarchical relationship, physicians don't have patients, and patients don't have a physician - because the very idea of having patients or having a physician implies both dualism and dependency. Interaction in such a relationship is fluid and experiential, with total openness to allow the flow of Qi to go wherever it will. The acupuncture ritual forms a context through which the Qi can flow and Spirit can manifest. The physician becomes a facilitator and gives up the role of an expert who controls treatment options and takes responsibility for outcome. Patients are their own healers and totally responsible for their input intention, dynamism while in the void, and output manifestation. The physician, rooted in Heart Yin, offers compassionate presence and acts as a witness to the transformational dynamics but does not attempt to direct, manipulate, or otherwise influence the process.

Changing Second-Order Dynamics
Similarly, when the contextual base is altered, manipulative strategies generally end because there is no need for them. After all, many of these strategies arise as a consequence of the hidden security needs of both parties in the traditional relationship. One expression of this fundamental shift is an elimination of outside players such as insurance companies, compensation boards, government agencies, etc. Unfortunately, the advent of 3rd-party payment schemes has had unforeseen energetic consequences, one of which is an interference with a healthy energy exchange between physicians and patients. Obviously, energy exchange is not much of an issue if the patient is having an appendectomy, but it cannot be regarded as irrelevant in energy medicine.

Interference with patient-physician energy exchange by 3rd-party arrangements formalizes patient powerlessness and entrenches the diversion of Earth and Metal energies into the Ko cycle. The cycle of giving and receiving (characteristic of the Earth energies) and the appreciation of value (characteristic of the Metal energies) both become compromised when patients make no personal contribution to the therapeutic relationship. Rightly or wrongly, things that are free are often considered worthless, and medicine is no exception. Clients need to contribute something meaningful (though not necessarily money) to the relationship to demonstrate their commitment; without appropriate respect for the profound nature of the work of healing, they often do not have the necessary earnestness to engage the transformational process.22

Empowerment and Intention
The non-hierarchical patient-physician relationship has other benefits too, not the least of which is a facilitation of appropriate intention, which is necessary to unblock the flow of original energy.16 The reason is that empowered patients generally do not expect to be treated in the commonly accepted sense and are more open to exploring their symptoms in a non-judgmental way. They tend to be less frantic about their symptoms and more inclined to learn from them instead. Moreover, because the acupuncture ritual is an expression of the mutual intent of the physician and patient, the non-hierarchical relationship provides an optimal contextual framework in which intention can be reversed from its usual direction of pain avoidance and redirected toward entering the void.

Therefore, intention and empowerment go together. Empowered patients understand that their symptoms have meaning beyond the structural diagnosis and are willing to experientially explore them. On the other hand, powerless patients simply want someone to take their symptoms away and often do what they can to avoid taking responsibility for their illness. Thus, the nature of the therapeutic relationship has a huge influence on the directional vector of the interaction, determining whether the treatment session will prove to be superficial and symptomatic or deeper and more healing. Ignorance of this fact is a major element behind suboptimal results; for example, in situations in which acupuncture never seems to get the Qi moving, despite much effort and many different point combinations (Figure 3).

CONCLUSION
Oriental Five Element theory provides an elegant theoretical foundation for a more effective therapeutic relationship that is empowering to both patients and physicians. When systematically applied, it can help patients trying to navigate the difficult road through the Metal and Water elements to rediscover their original energy. Physicians may find it particularly relevant for tackling chronic multifactorial illness, in which an attitudinal transformation is necessary if the patient is to have any chance of improving. In such situations, the physician's Earth and Metal energies should not be used to bolster ego control. Rather, Earth energies should provide a crucible for the transformational process, while the Metal energies should act synergistically to encourage the patient to let go of control sufficiently to traverse the Golden Gate and enter the chaos of the void.

Figure 3. Empowerment, Relationship, and Intention

The secret to patient empowerment lies in experiencing this transformational void of the Water element. Because, through the void experience, patients realize that healing emerges spontaneously from the self when they surrender to what is. And in a similar fashion, physicians paradoxically experience a therapeutic empowerment when they surrender control in the therapeutic relationship. The outcome is that the Qi flows when we let go, and a sense of empowerment arises simultaneously for both parties. No longer dependent on external treatment, patients can become free of medicines, physicians, and the terror of their disease. Meantime, physicians are freed of protocols, regimens, and rules, and they have an opportunity to develop their intuition as a reality of everyday practice.

ACKNOWLEDGEMENT
Graphics designed by Dr Greenwood's son, Richard Greenwood.

REFERENCES

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AUTHOR INFORMATION
Dr Michael Greenwood is Medical Director of the Victoria Pain Clinic, a residential facility in Victoria, British Columbia, Canada. Dr Greenwood specializes in chronic pain/chronic illness patients, developing techniques integrating the body, mind, and spirit. His books, Paradox and Healing, co-authored with Dr Peter Nunn, and Braving the Void, reflect this interest.

Michael T. Greenwood, MB (MD), BChir, CCFP, CAFCI, FRSA*
Victoria Pain Clinic
365 Hector Rd, RR#3
Victoria, BC, Canada V9E 2C3
Phone/Fax: 250-595-1486 • E-mail: michaeltgreenwood@shaw.ca
*Correspondence and reprint requests

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