Patients with Issues that Resist Treatment (Part II)
By Neil Gumenick, MAc (UK), LAc, Dipl. Ac
In my previous column, I examined several factors contributing to situations in which a patient's symptoms/issues seem to resist our best efforts at treatment. Among the factors discussed were realistic expectations; length of time the patient has had the symptom(s); focusing on a single symptom; energetic blocks to successful treatment; reaching the cause; and frequency of treatment.
Now I would like to examine four additional factors, any of which can also be of major impact in turning the tide on conditions that resist treatment.
Using Points for Their Spiritual Connotation
Any point can be used for its spiritual connotation. The point name, translated from the Chinese calligraphy, leads us to understand the unique mental or spiritual gift that the specific point is capable of delivering. While there are different translations of the point names, I have found those English translations taught by my teacher, J.R. Worsley, to be very effective in leading me to understand the spiritual uses of the points. Most important, the names allow me to translate the needs of the patient, whether expressed verbally or non-verbally, into a specific treatment plan that will precisely attend to those needs.
In the classical five-element tradition, points used for their spiritual connotation are usually chosen (with certain exceptions) from the meridians corresponding to the patient's primary elemental imbalance (the causative factor, a.k.a the cf). Thus, we would not choose Liver 14 Gate of Hope, for its spiritual connotation, on a patient unless he/she was determined by traditional methods of diagnosis (odor, color, sound, emotion), to be a Wood CF. For a patient who had lost hope, and was diagnosed a different elemental CF, we would chose points from his/her CF meridians to restore hope. Staying with points on the CF will produce far more profound changes than choosing points from meridians at random, simply because the names sound inviting.
ARe You Reaching the "Level" with Treatment?
In my 30-plus years of practice, I have never seen a patient who was only imbalanced at the physical level. My article, "Diagnosing the Three Levels of Imbalance" (AT August, 2005, Vol. 6, Issue 08), covered this topic extensively. Simply put, if the patient's physical symptoms have been caused (wholly or in part) by trauma at the mental and spirit levels, these non-physical levels must be addressed in treatment actually to heal. Otherwise, improvement, at best, will be temporary.
There are exceptions to limiting the choice of points to the CF meridians for their spiritual connotation. These include the upper kidney chest points, outer bladder points on the back, the conception vessel (Ren), governor vessel (Du), and Heart 1 - any of which can be conjoined with treatment on any element.
For example, Kidney 24 Spirit Burial Ground may be used on any patient, regardless of CF, who has been so heavily burdened or traumatized that he or she has virtually given up. It is as if the spirit is deeply buried and unreachable. The patient may appear in a state of deep depression, quietly resigned, or conversely, loud and out of control. He may be able to, move, talk, and even reason. He may even try to appear as if all is well, but it is a facade. When questioned, we may perceive the patient likened to an empty shell, without the inner spark of life that brings real joy, enthusiasm, and meaning. Kidney 24, in a category of its own, has the ability to "open the ground", resurrect, restore, and revive the spirit itself.
The Patient's Lifestyle
In any situation where the patient fails to thrive, we must consider what the patient is doing with their time away from us that may be undermining the success of even the best treatment. This includes a wide variety of possible human activity, all of which we must know about and consider in evaluating the success of our treatments. This is important information to use in counseling patients and assigning homework designed to orient the patient in the direction of health and balance. Changing inappropriate behavior, which is detrimental to a patient's recovery, is often accomplished through homework. Additionally, homework engages the patient as a partner in his/her health care.
We cannot do it all. We have the patient for a single session, perhaps once a week. They have themselves for the rest of the time. We need to know how they are spending this time - what is enhancing or diminishing the balance we are hoping to create with treatment. Some patients will need to change their eating and/or sleeping habits. We must know, therefore, what those habits are. What, if any, medication is the patient taking? What are the side effects? Usually, we learn of these, and many other important details about the patient's life, in our initial interview and office visit. This is a good time to assign appropriate homework and engage the patient's cooperation right from the start. However, if a patient, at any time in the treatment process, fails to improve or begins to "nosedive," it is time to ask questions about lifestyle and consider setting or altering homework.
In assigning homework to a patient, it is advisable to give enough to be substantial, yet also be such that the patient can successfully accomplish it and, thus, feel the experience as a "win." The homework must also be appropriate to the needs of the patient. We must be careful not to advocate choices for the patient that may be appropriate for us as individuals or for other patients in our practice, but not for the patient in question. J.R. Worsley was fond of quoting the saying, "One man's meat is another man's poison." Your choice of diet may not be best for the patient before you. The same goes for your choice of exercise, spiritual practice, recreational activities, etc.
Determine what areas of a patient's life are most in need of change and begin there. Some patients need to rest more. Others need to get busy. Some need to have fun and recreation. Others need to get to work and get serious. Many patients are dehydrated and need to drink appropriate amounts of water. Others need to adjust their lives to be more congruent with nature's cycles. Living according to nature's cycles or the circadian clock is critical in terms of adjusting times of sleeping, eating, defecating, and other vital activities, to achieve more optimal functioning.
If we have missed the precise location of the acupuncture point, we have not done the treatment, nor can we expect results, in spite of our best intentions. When the needle makes contact with the point, there will be a "grab" or "pull" which we can feel when we withdraw the needle, even slightly. This is often accompanied by the patient feeling a dull ache sensation at the insertion site.
If the needle comes out like it is being pulled from soft butter, we can conclude that we need to relocate the point and re-needle. Do not be shy or apologetic about re-needling a point you have missed. The patient will be thankful for the extra care. Rapport and trust will be enhanced.
Asking for Help
Ask for help when you need it. Do not fear bringing a colleague or a senior practitioner in for consultation on a patient with issues that resist treatment. The patient will appreciate your humility and care in placing their welfare above your personal vanity. Sometimes, being able to stand back, watching another practitioner with your patient, opens new doors of your own perception, and what had been a mystery suddenly becomes obvious. Sometimes, another practitioner will pick up on the very diagnostic piece you had overlooked.
Do not fear referring a patient to another practitioner or modality. If the patient is not responding and you cannot help him/her, do not assume that the situation is beyond all help. In some cases, it is appropriate to continue as the primary healthcare provider. In some cases, it is best to withdraw. There is no one system of medicine that can do all things for all people. We can, ultimately, only give our best. If we cannot help, let us give the patient every chance to heal by availing him/her of alternatives. Have a resource list of other practitioners and healthcare providers that you respect: Eastern, Western, and everything in between. Again, the patient will welcome your placing his/her welfare first. You will also likely enjoy cross referrals from the other practitioners with whom you have such relationships.
To read Gumenick's previous article see, AT December 2010, Vol 11, Issue 12 at www.acupuncturetoday.com
Click here for more information about Neil Gumenick, MAc (UK), LAc, Dipl. Ac.