Thoughts on Needling Within the Clinical Encounter
By Skya Abbate, DOM
Diverging from my normal writing style on needle techniques and protocols, I thought that I would provide the reader with a reminder about the broader perspective on the art of needling and where it fits into the clinical schema.
Modest tips and thoughts are proffered to the practitioner that illustrate the elegant simplicity of treating within the Oriental medical model. In 1988, I embarked on my first trip to China with the express purpose of improving my needle technique. In analyzing my abilities at that time, I felt that diagnosis and point selection were easy, but that my needle technique was less than adequate. For the most part, patients returned and got better, but the act of needling was not satisfying to me.
Corresponding with the experiences of most practitioners who have traveled to China, it is not surprising that there I also witnessed a strong needling style. Large gauge needles; a de qi sensation that would bring patients to tears; vigorous tonification and dispersion methods; and a general needle retention time of about 20 minutes regardless of the condition being treated, were typically witnessed. For six weeks I was taught to practice that form as well on patients whom I couldn't communicate with, except in rudimentary Chinese modified by my strong New England accent. I'd query, "Do you have qi?" or "Do you feel pain?" or more likely, "Do you feel soup?" since I'm sure the word for pain (tong) sounded more like soup (tang) when I said it. No wonder they looked at me askance shaking their heads in distrust and disbelief. Nevertheless, perhaps it was because of such cultural barriers that I was uninhibited enough to develop a decent Chinese needle technique in contrast to the one I had before going to Beijing, which was to hit the insertion tube, turn away from the patient, and emit a sickly scream!
Not all patients were treated this way, however, in the Chinese hospitals. I fondly recall the case of an elderly gentleman who had just recently had a heart attack. When he came in for a treatment, the doctor positioned him on his stomach and, with a quick in-and-out technique, needled Bladder 15 (xinshu), the back shu point of the heart. A colleague commented to me that this different needling style must have been selected in consideration of the patient's serious condition so as not to drain his heart qi. Suspicious of this observation, we asked the doctor if that was what he was doing. All present in the room started laughing at our na€ve conclusion, and the doctor matter-of-factly stated that this was not the reason. Rather, he had done this type of treatment because the patient had to leave early to catch the bus!
The first day upon my return from China, my husband relayed to me that he had injured his back while I was away and had resigned himself to accepting its residual pain since he had tried many therapies with limited success. Deftly, I pulled out a 30 gauge Huato needle, stuck it in Small Intestine 6 (yanglou) in the direction of the meridian, and twirled it dispassionately and painlessly, yet evoking so much qi that his consciousness literally altered and his pain completely disappeared. He then said to me, "You did learn how to needle!" I now appreciated everything about the needle that made it effective: its length, its thickness and the power I knew it possessed if properly engaged.
That same week, I had the opportunity to study with a Japanese scholar visiting at the college of which I am the dean. During those few days, the exact antithesis of Chinese needling methods were demonstrated. The thinnest # 1 (36 gauge) Seirins were the needle of choice. They were only inserted 0.1-0.5 in. on the average, superficially and obliquely or even transversely, and no qi was solicited. Points were tonified or dispersed by angling the needle in the direction of the meridian versus other manual methods. Patients were hardly aware of the presence of the needles, and the results were immediate and efficacious.
Witnessing such dichotomous styles of treatment back-to-back was a turning point for me. Both Chinese and Japanese styles were opposite in execution and feel, but each was grounded in the same ancient theory. This 180 degree gamut represented the range of needle options one could select from for a wide range of disorders and patient types, and they have served me well for over 14 years. Three technique books (see bibliography) grew out of my clinical experience with both approaches, and I am grateful for those educational opportunities that prepared me to teach and write about needle technique.
In reviewing this educational odyssey, a few basic ideas remain in the forefront of my mind concerning needling. My basic contention is to not make treatment more complex than it needs to be. One way to do this is to not unnecessarily needle excess points on patients, especially Americans, who already have a bias against needles no matter how small. This practice not only can cause discomfort to the patient and discourage them from returning for more needed visits, but more importantly may not target the patient's major complaint precisely enough. Symptoms may be prioritized over the root of the problem. Too many needles scatter the therapeutic intent of the treatment and disrupts the patient's equilibrium. At the risk if oversimplification, to correct this dilemma, I advance the following advice:
When we begin to treat, we may feel that there are so many things to address that we don't know where to begin. In regard to actual treatment execution, I believe it is better to proceed slowly than with too much vigor so that the patient's response to treatment can be properly evaluated.
Establish a clear, concise diagnosis. The treatment plan will follow from this and should be as apparent and succinct as the diagnosis. Unless emergency treatments are administered, in which there is a need to treat life-threatening manifestations (symptoms), the diagnosis should address the root, which is usually not multifaceted.
Select points to needle that accomplish the express purpose of the treatment plan: that is, points that treat the root. By logical extension, they should also address its manifestations.
Choose points with multiple, powerful energetics to assist in an economy of points to be needled.
Do not be redundant with point use. Choose points based upon their unique energetics. Additional points can be elected to reinforce the treatment, but redundancy leads to the utilization of too many points.
Use the best quality needles available for acupuncture (in my opinion, Seirin needles). A quality needle can do wonders in making up for a less than perfect needle technique and enhances patient tolerance and satisfaction with treatment. If you employ a needling style such as a Chinese one in which you solicit qi, it can still be obtained with the finest needle. If you prefer a Japanese technique where, for example, qi is contacted superficially via the minute luos, and tonification and dispersion achieved by way of inserting needles with or against the flow of the meridian, these needles are ideal for such shallow insertions to reduce pain.
The cumulative effect of this system of needling is multifold:
Few points are needled as painlessly as possible. Patients like this.
The root is thereby treated through the clarity of the points selected. This exponentially increases therapeutic effectiveness.
Correspondingly, treating the root generally decreases the length and course of treatment. This can save the patient time and money.
Patients are more likely to continue with therapy because the needling is not discomforting and they are experiencing improvement.
Competing signals are not given to the body by way of too many needles about what needs to be corrected in treatment.
Looking at this strategy in relation to the classics, the brilliant scholars Paul Larree and Elisabeth Rochat de la Vallee agree. As they wisely point out:
The Neijing tells us that the healing process is not just mechanical - it is not simply the placing of a needle. The most important thing for healing is the relationship between the practitioner, the spirits, and the patient. The relationship begins with the personal attitude and inner behavior of the practitioner. Your own spirits and forces must be in good concentration in order to be able to evaluate the patient and to be able to rectify what is wrong in the movement of his or her vitality. It is your spirit which enables you to make the diagnosis, choose the points, and give a feeling of rightness to the patient at a high level - without interfering with the patient's freedom. The treatment always takes place inside of this practitioner-patient relationship (Larre and Rochat de la Vallee, 1990-1991, p. 14).
Larree P, Rochat de la Vallee E. The practitioner-patient relationship. Journal of Traditional Acupuncture, Winter 1990-1991, pp. 14-17 and pp. 48-50.
Gardner-Abbate S. Holding the Tiger's Tail: An Acupuncture Techniques Manual in the Treatment of Disease. Southwest Acupuncture College Press, 1996.
Gardner-Abbate S. The Art of Palpatory Diagnosis in Oriental Medicine. Churchill Livingstone, London, England, 2001.
Gardner-Abbate S. Auricular Medicine in Clinical Practice. To be released 2002.
Gardner-Abbate S. The Spiritual Practice of Clinical Medicine. Currently being written.
Click here for previous articles by Skya Abbate, DOM.