Medical Acupuncture
A Journal For Physicians By Physicians

Spring / Summer 1999 - Volume 11 / Number 1
"Aurum Nostrum Non Est Aurum Vulgi"

five phases

ACUPUNCTURE AND INTENTION:
NEEDLING WITHOUT NEEDLES
Michael T Greenwood, MB

ABSTRACT
     With the current focus on evidence-based medicine and outcomes research, other unmeasurable forces in medicine may be overlooked. One such important force is intent on both patients' and practitioners' parts. This article reviews the principle of intent, including discussion of self-integration, the Five Phases and Elements, and transformation. The subjective component of healing is emphasized, and the author encourages physicians to make patients aware of the subjectivity so they can work together with mutual intent.
KEY WORDS
     Acupuncture, Intent, Five Phases, Elements

INTRODUCTION
     The process of studying medicine never quite prepares us for the reality of the clinical encounter; we soon discover that the real patient never fits the textbook description. This principle applies equally well to the clinical acupuncture encounter, where we are confronted daily with the complexities of Oriental diagnosis and the limitations of point descriptions and protocols. Nevertheless, it is possible to become so focused on pattern recognition, point locations, mechanisms of action, endorphins, evidence-based approaches, etc, that we sometimes forget another intangible principle altogether may be at work.
     The notion of "intention," in conjunction with needle insertion, is an example. We can learn a point's location and with a modicum of training, almost anyone can insert a needle into a correct location. But is that all there is to it? Are correct diagnoses and treatment formulas the foundation of acupuncture? Or is there something transpiring behind the ritual of the acupuncture that accounts for many of the effects?
     For millennia, practitioners have alluded to this problem, and many have concluded that the intangible qualities of the patientphysician relationship can never be written or taught. In the preface to Acupuncture in Practice: Case History Insights From the West, Kaptchuk resorts to paradox by saying: "...The tension between theory and practice is necessarily resolved by an absence of resolution,"1 and suggests that we must find our own way on the issue.
     We can go a long way toward acquiring those intangible skills of practice through a deliberate cultivation of principle of intent. It may take a long time to master the intangible, but let us not assume its impossibility and rely entirely on point prescriptions and formulas.
What Is Intention?
     What do we mean by intention? Why should it be so important? Superficially, intention appears obvious: patients request relief from their symptoms. Thus, our intention surely should be to relieve those troublesome symptoms. Logically, if our point location is accurate and our technique is correct, we should be able to obtain reproducible results. That is the thinking behind the "science" of acupuncture. In a blinded trial, point location is the key issue because it is the only measurable one. If we want to know if acupuncture works, then we will want to design specific treatment protocols and study their effects in the absence of subjective bias.
     But what if intention is the whole key to the success of an acupuncture treatment? And what if the needle insertion is simply an expression of that intent? An illustration is depicted in the following story, taken from the same preface of Acupuncture in Practice, referring to a patient of Zhang Zi-he (1156-1228).

After a detailed and eloquent description of a shouting, angry, destructive, and even dangerous woman, he immediately sends words to two assistants to enter the patient's bedroom and pretend they are eccentric prostitutes. The patient laughs for the first time in months. To continue the laugh therapy, Dr. Zhang tells his assistants to dress as animals for the second day, and so on, until the patient recovers in a matter of days. He intentionally [my italics] does not use any therapeutics that can be learned through books. The case itself seems to say that healing is ultimately life itself, and the doctor sometimes needs to provide it! Therapeutics is merely an expendable minor part.1

     Here, the acupuncturist used no needles at all. He simply intended something: "needling metaphorically" through psychodrama. In this circumstance, it was clearly the correct course. But it was an intuitive leap, not a treatment regimen for a condition. The clinician saw where the energy needed to go, and provided a means for it to go there. He ignored point protocols and acted intuitively.
     If the above story can occur simply with practitioner intent, what startling things could happen if both practitioner and patient were to shift their intent? And if so, in what direction would they shift it? This article will begin to answer these questions.
Moving Toward Symptoms
     The idea that illness/pain carries a message, that it might be a call to expand our awareness, is not something generally acknowledged in medicine. We may pay lip service to the idea, but even in acupuncture circles in the end, there remains a prior assumption that compassionate relief of symptoms is the goal. Experience teaches differently, however. The patient is now encouraged to move toward, rather than away from symptoms, even though that is often the last thing they want to do. In other words, we intend to explore, rather than rid, the symptom complex. Experience teaches that such an approach can help us move toward Oriental medicine's highest potential, referred to collectively as the "hidden traditions" (Table 1).

PHILOSOPHICAL BACKGROUND

     In Oriental medicine, grounded in Taoism, illness is understood as arising from the sense of separation (from the Tao), which occurs progressively as the ego develops (Figure 1). The separation is said to start with "naming," after which the mind begins to interpret life events in such a way as to prevent spontaneous behavior.2 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. Thus, the process of ego development is accompanied by the establishment of a "denial state," in which we habitually suppress energies we dislike. This state might be understood as a virtual illness, or an illness waiting to happen. Later, if symptoms begin to manifest on a material level, we continue our denial by labeling the symptoms as a disease (diagnosis), and then trying to root the disease out, as if it were an alien invader.
     The difficulty lies in the effort of maintaining a false self against the spontaneous movements of the Tao, which is tension-producing and energy-draining, so that at some point, the surfacing of physical symptoms becomes inevitable. When the symptom threshold is reached, pain arises from the chronic tension; fatigue arises because vital energy is consumed in the struggle (energy or Qi depletion); depression arises as we directly experience our alienation. If we truly knew this mechanism, we would not struggle so much against symptoms as allopathic medicine encourages us to do. Rather, we would try to retrieve any lost or buried energies and integrate them into a new, more authentic sense of self. The implication is that our disease represents aspects of the self that we have lost (Figure 2).
     Healing, then, becomes something quite different from what we imagine it to be. Relief of symptoms, though superficially compassionate, becomes a reinforcement of denial if not placed in the larger context of healing. If, as physicians, our unquestioning intention is to relieve symptoms, then we are inadvertently directing our intention away from healing. Perhaps such an approach is not smart because: (1) it guarantees a continuation of the disease process; (2) it draws us into the energy vortex of the patient's illness, creating a codependent relationship in the process; and (3) it makes us an instrument of the patient's denial. Apparently, to engender healing, we would need to shift intent by almost 180^o.
Regression/Integration
     It is worth emphasizing that the healing journey is not a simple reversal. The conventional adult ego consciousness is a stage of development situated between the infant's preconscious state and the superconsciousness of the sage (Figure 3). The move toward wholeness is therefore a progression, not a regression; an expansion rather than a contraction. It is not a return to a prior egoic state, but rather a move toward a new state altogether, one that generally involves some degree of ego transcendence. If we regress at all, we return only symbolically, through inner experience, to the place where the energy split off. We recapture it, channeling it creatively with our adult awareness to progress to a new superconscious state.
     When we become mired in illness, it is usually because we do not recognize its transformational potential and resist the changes it demands. Consequently, despite what we might say to the contrary, our intention remains firmly committed to maintenance of denial.
The Integration of Treatment and Healing
    Although from a rational perspective, the directional vectors of treatment and healing appear opposed to each other; it is possible by accessing a more integrated state of consciousness to bring the 2 together in a larger embrace (Figure 4).  The integration of opposites can be understood philosophically as an expression of the principle of complementarity expressed in the familiar Yin-Yang symbol. The symbol suggests that the various apparent oppositions of treatment and healing, objectivity and subjectivity, allopathic and Oriental medicine, must simply be alternate ways of perceiving the same phenomenon (Figure 5). The challenge then is to move beyond any perspectives we currently hold and find the positionless position that embraces all perspectives. Such an integration can be accomplished through regular introspection or meditation, and returning to a state of perception prior to the imposition of pattern recognition (beginners or Zen mind), prior to the split between objective and subjective, a state referred to as the void.3, 4

     Many of us became interested in acupuncture in part because of a desire to remove ourselves from the excessive rationality of conventional medicine. As practitioners of both conventional and Oriental medicine, we are in a unique position to incorporate both poles of the dialectic into our practices. However, the danger because of our scientific bias as physicians is to objectify acupuncture and reduce it to a rational diagnosis and treatment model that would be no different philosophically from conventional medicine, a problem that has already occurred in China with the development of Traditional Chinese Medicine. If we do not consciously enlarge our perspective, then our intention habitually gravitates toward symptom suppression.
     The polarity/antagonism of these 2 contrasting world views points to a schism in Western consciousness, a schism that we need to heal both individually and collectively. Acupuncture can be a remarkable tool to help our patients heal their split, but the onus is on us to heal our own first.
Intention and the Void
     The void, or simultaneous inner/outer awareness, bridges the subjective/objective antagonism and accesses a more inclusive state of consciousness in both practitioner and patient. By consciously entering that state, and encouraging our patients to do the same through intention, as part of the treatment, then the stage is set for implementing the intent to explore.
     The implication is that if we want our patients to shift their intent toward exploration, we should first alter our own state of consciousness as a prelude to the acupuncture treatment, a statement that might seem a bit odd at first. However, the problem is that it can be very difficult to activate a shifted intent while patient and physician remain in rational consciousness; the rational mind simply cannot let go of the habitual. It is, after all, the rational mind that structured denial in the first place, and the ego simply refuses to move toward symptoms, no matter how compelling the argument might be to try.
Five Phases and the Ego Cycle
     The application of the Five-Phased model to the stages of growth, development, and ego transcendence (Figure 6) allows us to picture the process in a spiral rather than linear format. In the spiral model of ego development, the personal constitutional type exists within the larger context of a cycle of ego construction, degeneration, and renewal. Going around the circle, the Yang phase, the phase of ego construction, tends to be associated with conflict/power struggle, while the Yin phase is associated with wearing out, disintegration.
     With this understanding, we can surmise where people might be in the larger scheme of things when they present with certain kinds of illnesses; such an understanding can profoundly affect the directional vector of our intent. For example, it may be less important to intend transforrnation with someone in the Yang phase (who is busy building an ego), than for someone in the Yin phase (who must reintegrate buried energies or remain in chronic ill health).

Five Phases and the Void: The Golden (Metal) Gate
     Most patients with chronic symptoms, regardless of the specific pathology, face an issue of letting go if they are to reach transformation, ie, they must relinquish an outmoded way of being, and find a new way of functioning that is not so tension-producing. Thus, patients present in the Yin phase, in the region of the Metal element. From there, they move forward into the apparent chaos of Water (Figure 7). This is so frightening that most people become paralyzed in their symptoms, desperately trying to reconstruct an ego that has outlived its usefulness. But move forward they must if they want to find healing ... through what is essentially their own resistance, a psychic narrowing that has been likened to a constriction in an hourglass. In Oriental philosophy, this constriction has been called the Golden or Metal Gate (Jin Men), the Mysterious Pass, the Door of Death, and the Gate of Birth, so variously named perhaps because passage invokes a radical transformation.5
Intention and Transformation
      Ultimately, we cannot avoid passage, although we can certainly delay it until we physically die. The challenge of healing is to pass through the gate while still alive, creating a more authentic sense of self in the process. As practitioners of acupuncture, we want to help patients negotiate the passage. The difficulty is that for patients to pass through the gate, the patient-physician dyad must intend it without reservation. It is almost as if we were going to die, although obviously it is only psychic death being contemplated, not physical. This is a crafty proposition unless we have experienced it ourselves, and know the way. Perhaps this is why the ancients suggested it was only a sage in whom the intangible faculty of intuition was fully activated.
     At the very least, we can begin to explore the whole idea as a means of beginning the process of "cultivating the intangible" within ourselves. The principle of intention is very simple, and passage through the gap is essentially automatic once the impediments to intention have been removed (Figure 8). The principles are: moving toward, silence, transformation, and manifestation:

1. Moving toward ... the directional vector that represents symptom exploration.
2. Silence a state of quiet witnessing.
3. Transformation ... the automatic shifting dynamics of the gap.

4. Manifestation ... the subjective reality that emerges from the gap.

   

Intention and Practice
     It is one thing for the practitioner to have cultivated a healing intent, but quite another to engender a similar intent in the patient. Yet without a shift in their intent, patients remain passive victims of their illness, waiting for us to perform some kind of miracle that will "fix" things for them. That attitude is unrealistic and needs to change, the sooner the better. One practical solution to this conundrum is to engage the patient actively in the therapeutic process as quickly as possible. Ideally, the practitioner moves from Yang to Yin (ie, becomes less active), while the patient moves from Yin to Yang (ie, becomes more active).
     As this reversal develops, the practitioner moves increasingly into witnessing the Yin aspect of the void (silence); doing so intentionally grounds the transformational mechanics of the gap. Meanwhile, the patient becomes more active, the Yang aspect of the void (transformational dynamics). From this point on, the subtle workings of the Tao decide what form the manifestation will take, which actually has nothing to do with what we think should happen, and often takes a completely surprising course.
     Simply, we cannot force change to occur in our patients. However, if we understand the mechanics of transformation, we can set up an appropriate context in which change naturally occurs. This is the magic of intention, the art of facilitating change without force. Without it, needle placement and circuit designs are generally less effective; with it, needle insertion is often a frill, and is sometimes not even necessary.

PRINCIPLES OF INTENTION
     (1) Centering: establish compassionate Heart-centered awareness; (2) Rapport: relieve symptoms, not as an end in itself, but as a way of establishing rapport; (3) Context: provide a safe context for the emergence of transformational energies; (4) Exploration: encourage patient to explore symptoms without preconceptions; (5) Attitude: maintain a detached calmness when/if transformational energies emerge; (6) Trust: trust the body's wisdom, and trust that outcome will be appropriate; (7) Manifestation: the phenomena that emerge from the void.
1. Heart - Centering
     Modern research confirms something healers have always known: that physiological rhythms associated with certain states such as love, peace, and appreciation are conducive to activating the healing response. Practices that intentionally center attention in the heart area can lead to a calm, peaceful, harmonious, and highly intuitive state, in which the practitioner can become aware of the minute currents of energy flowing through the body. The Heart-centered state is associated with a coupling or entrainment of a variety of biological rhythms, including respiration, heart, autonornics, the patient's biological rhythms, and even environmental rhythms (Schumann resonance).6 Such energetic coupling between physician and patient can provide sufficient rapport for the patient's and physician's intentions to become congruent.
2. Rapport -Validation (Metal)
      Metal relates to Water through the Sheng cycle. The Metal element is associated with Fall, of letting go. It requires the affirmation of honoring and validation before the descent into chaos can occur. Such validation can be very difficult to achieve in the context of a causeeffect model of rational medicine; the energetic approach of Oriental medicine is generally better equipped to validate variegated symptoms because of its patterned thinking. Patients need to find meaning in their experience before they are free to move on.
     Needless to say, an effective way to create rapport is to relieve symptoms, which returns us to the role of treatment (Figure 4). The idea of relieving symptoms, not as an end in itself, but simply as a way of creating rapport to secondarily reorient the patient's intent, sheds a completely different light on the role of treatment. It allows us to intend both treatment and healing simultaneously. With such an approach, the relief of symptoms falls within the sphere of healing rather than running in opposition to it, so that the directional contradiction is resolved.
3. Context - Safety (Earth)
     A safe environment is necessary to permit the descent into chaos. The Earth element relates to Water directly through the Ko cycle, and Earth controls Water through "safe containment" (Figure 9).
     A residential setting generally provides a "safe" container. Although safety can be provided in other contexts, it can be difficult in the busy physician's office. The problem is that insufficient safety compromises intent. The busy physician needs to somehow find a way, even if it means structuring treatment sessions outside of regular office hours (Table 2).

4. Exploration
     The intent to explore without preconceptions gives the patient permission to experience the total flow of his/her energy without reservation. The idea is to help patients move toward their pain rather than away from it, to embrace rather than reject.
5. Attitude (Silence)
     Detached calmness is an essential tool for practitioners and can be cultivated through regular introspection or meditation. When transformational energies emerge, they can be quite frightening to both physician and patient. Any anxiety on the part of the physician alters intent, and thereby compromises and distorts outcome. Symptoms may arise (such as asthma or chest pain) that, as physicians, we have been trained to treat in other ways. To hold back and trust outcome in such situations can be challenging.
6. Trust

a) The patient-physician relationship should be based on mutual trust, which demands absolute confidentiality. This is a difficult task in an era of third-party funding for medical services. However, without confidentiality, fear enters the picture and distorts intent away from exploration toward suppression of symptoms.
b) Trusting the body's wisdom requires an attitude shift on the part of both practitioner and patient. The extraordinary aspect is that the body knows what it needs to do to heal itself. If we act on that assumption and encourage the patient to do the same, then the mystery of healing can unfold quite naturally with minimal effort.

7. Manifestation
     Trust in the outcome, even though that outcome is unpredictable and unknown, removes performance and outcome anxiety and frees the energy to move where it desires. The current love affair with outcome studies and evidence-based medicine points to a colossal collective misunderstanding of the healing process. Outcome cannot be controlled without compromising intent; the very attempt introduces a destabilizing factor that interrupts the freedom of energy movement.

Unlocking Blocks to Intention
     All things being equal, moving toward should flow quite naturally into manifestation, provided there are no impediments. That it does not do so speaks to the presence of unconscious blocks to the natural flow of energy, which have diverted the intention. As already stated, the 2 most common distortions involve a diversion of intent away from healing toward relief of symptoms, and a shift of context away from total safety toward fear and mistrust. Using the Five-Elements analogy, we can identify the deeper issues on a theoretical basis and take action ahead of time to remove such blocks to reestablish the natural flow. Here, the focus is on the 2 most difficult energies, sexuality and aggression, which are universally suppressed, and indeed, often contaminated with each other. Then follows short examples of patterns involving the other elements in turn. Readers should take the following descriptions as examples only, not as an exhaustive list of possible energetic patterns, which can take almost any recognizable form.7
Wood - Aggression
     Anger is a difficult energy to work with; so difficult, in fact, that as physicians, we have skillfully protected ourselves by becoming objective, relying on technology, and reducing touch. Indeed, in some places, touching a patient is almost illegal. But the objective defense, though apparently the safer course, changes intention away from the transformational gap by suppressing a potentially healing energy. The problem is that suppression of anger leads to chronic muscular tension. Rather than avoiding the issue entirely, patients need to access their aggressive energy and then learn to channel it creatively. The main difficulty for practitioners, and the reason we avoid it, is that when aggression first shows up, it often gets projected onto the practitioner, which makes us understandably reluctant to facilitate its appearance.
     If we wish to work creatively with the energy, it helps to spot the possibility of projection ahead of time to avoid being a target. The phase model suggests honoring patients' rage, while encouraging them to own it (Metal controls Wood).
     A colleague told a story of being interrupted by a telephone call, inadvertently leaving a patient in the treatment room with needles in place a bit longer than he would have liked. The patient angrily left the office, and went on to speak badly of him. No doubt she had a Wood imbalance, in which case treatment had been very effective because the Wood energy surfaced. But the practitioner's experience wounded him because her anger was successfully projected. We have all had such experiences but as a result, if we habitually opt for avoidance, the reluctance to provoke anger compromises intent.
     Suggested and employed if anger is a suspected issue is to tell patients ahead of time that they are free to feel their rage, but that they should strive to keep it impersonal regarding the practitioner. Then deliberately revealing a bit of oneself, the practitioner may add: "because if you should get personal, I won't feel safe."
     The advantages of such an approach are: (1) It gives patients the freedom to get angry. (2) Everyone feels safer. (3) If they do get angry, patients often conclude that the physician is smart for spotting it ahead of time. The result is that the physician winds up looking good. (4) The deliberate revealing of the physician's humanity prompts the patient to assume some responsibility for his/her feelings. This actually supports intent rather than detracting from it.
Chong Mo - Sexual Energy
      Almost everyone has sexual energy blocked to some degree, but it may be the key issue in patients with low back pain, stiff or tight pelvises, and those with a history of physical or sexual abuse. In these days of zero tolerance for sexual transgressions by physicians, the idea of working with sexual energy can strike terror into the heart of a practitioner, and understandably so. But again, the defense of objectivity and emotional distance only compromises intent; we are left in a quandary with no easy solution. The important thing is that our sexual energy, being our primary energy, can be extremely healing if the energy is allowed to move. The problem is: how to facilitate its movement without getting into trouble?
     One answer, much the same as with aggression, is that we need to find a way to let the energy move while keeping it impersonal. The key with sexual energy is to encourage the patient to allow the movement of the pelvis, and at the same time, maintain a lighthearted matter-of-fact attitude. It is the movement of the pelvis that is important, with the intention being to retain the energy in the body. Such an approach opens the flow of kundalini and often produces very dramatic results, with general enlivenment, lifting of spirits, and improved general health.
     Suffice it to say that this is an extremely delicate area of practice. For practitioners who wish to explore this dimension, it is highly recommended to work with a chaperone whenever the client is of the opposite sex. The rewards can be well worth the effort.
Water - Fear and Terror
     Many Water types are paralyzed with fear and need heavy doses of reassurance. Often they refuse to have needles at all, which makes them difficult to work with. In such cases, moxa often tends to be invaluable, often obviating the need for needles altogether (the FiveElement technique of super-gold moxa applied directly to the skin is recommended because cigar sticks can be cumbersome and smelly). When the energy moves, it often begins with a fine shivering, which the patient often misinterprets as a feeling of being cold.
     The key here is to resist the temptation to stop the shivering with warm blankets and hot tea, but rather to use the opportunity to have the patient create a new referent in their minds for energy movement to differentiate the experience from shivering.
Fire - Joy and Sadness
     The eruption of joy or laughter during treatment does not usually pose any difficulties. Sadness, the flip side of the coin, can be something the Fire person is more reluctant to feel. One technique useful is to encourage patients to go deeply into the laughter until they spontaneously cry (or vice-versa). When the opposite emotion emerges, as it usually eventually does, the suggestion is then made to allow themselves to experience the 2 poles simultaneously.
     The intent here is to plunge patients into a cognitive dissonance that forces them, on the basis of their direct experience, to reevaluate the strategy of separating their highs from their lows.
Earth - Sympathy
     Of all the Elements, the author finds this one the most distasteful. Oftentimes, these patients will have anxiety attacks designed to draw attention and sympathy, and they often have a history of frequent vis its to the emergency department for various reasons. These patients crave codependent/nurturing relationships, and intent quickly becomes compromised if we give in to their demands. The difficulty is: how do we provide sympathy while avoiding being dragged into the quicksand?
     Here is a case for unbending intent; the call for help from some of these patients can be hard to resist both personally and professionally. One useful approach is to take them immediately into the anxiety attack, provide sympathetic support for them while they negotiate the terror, encourage them to set boundaries by assessing their rage (often at their mothers), and then suggest they imagine their own adultself nurturing the abandoned child within. By encouraging them to do their own nurturing, the practitioner is dissolved from the responsibility.
     Such an approach can place them in a peaceful place within minutes, but this approach needs to be repeated as a daily meditation or else the call for help is repeated.
Metal - Grief
     While the need to grieve may be readily acknowledged by patients, the act of releasing tension in a more general sense can be very difficult for people of a Metal constitution. These are the obsessive-compulsive types who repeat their various health problems, often involving their bowels. Maintaining focus in the face of such never-ending complaints can pose a real challenge. Resorting to "trickery" is needed at times to help these patients "lighten-up" (bringing Fire to Metal). The author wishes to relate a case reminiscent of the story at the beginning of this article.

The patient, Tim, appeared to be in an endless loop of wailing so noisy and annoying, it was hurting my ears. In the process of looking for earplugs, the only thing I could find within reach was Kleenex. Without thinking, I promptly rolled up a couple and stuffed them into my ears, leaving myself looking like Mickey Mouse. It was at this critical moment that Tim opened his eyes to see me looking like something out of a cartoon strip. He howled with laughter and could not stop for a half-hour. That experience helped him to lighten-up a bit and turn the corner on his chronic anxiety.

CONCLUSION
     In many ways, the acupuncture experience is an elaborate healing ritual. Backed up as it is by thousands of years of collective experience and belief, the power of the ritual goes far beyond what is demonstrable by science and touches on aspects of reality that we are only beginning to understand. Interestingly, science has consistently shown us how enormous the influence of the subjective actually is, and how hard it is to remove from scientific trials. Philosophically, we could predict that the struggle to remove the subjective would be an impos sible task and therefore, in the long run, destined to fail. Why not accept that reality and work with the subjective rather than against it?
      Much of the healing power of acupuncture lies in the intangibles of the patient-physician relationship, with the act of needling being simply a physical expression of the energetic vector emerging from the interaction. Perhaps it is a great mistake to put too much credence on the physical act itself simply because it can be observed, and pretend that is all there is. Unfortunately, the drive to integrate acupuncture into medical practice in a way acceptable to the scientific community is pushing us all to compromise some very fundamental philosophical principles to make acupuncture research fit the requirements of what is essentially an inappropriate investigational model. This mistake has been described as a "category error," and it is time the problem is addressed.8 Meanwhile, the collective belief in the mystical power of acupuncture has too often left patients in a powerless place, unaware of the meaning of the ritual and their own participation in it.
     Far better, perhaps, to mystify the whole process and let the patient in on the secret. When the patient is no longer baffled by the mysterious workings of "Oriental" medicine, the stage is set for the conscious establishing of mutual intent. It is an expression of the mutual intent anyway, whether or not we are aware of it. We have not taken the time, for the most part, to ensure that the mutuality is both conscious and congruent. With intent pointing at ways other than healing, is it any wonder that we don't consider its effects to be significant? Time spent on this issue is worth many acupuncture sessions, leads rapidly to patient empowerment, and provides gratifying freedom for the practitioner.

REFERENCES
1. MacPherson H. Kaptchuk T, eds. Acupuncture in Practice: Case History Insights From the West. New York, NY. Churchill Livingstone; 1997: xiii-xxi.

2. Jarrett L. Constitutional type and the internal tradition of Chinese Medicine: part 1. Am J Acupuncture. 1993;21:19-32.

3. Greenwood MI Braving the Void: Journeys Into Healing. Seattle, Wash: Gordon Soules Book Publishers Ltd; 1997:27-36.

4. Greenwood MT. Energetics and transformation: insights on the paradoxical opportunity presented by chronic illness and pain, part 11. Am J Acupuncture. 1998;26:271-276.

5. Jarrett L. The loss and return of original nature: the law of Husband/ Wife. Am J Acupuncture. 1994;22:29-45.

6. Oschman JL. What is healing energy? the scientific basis of energy medicine. J Bodywork Movement Therapies. 1987; 1(3):179-194.

7. Hammer L. Dragon Rises, Red Bird Flies: Psychology, Energy and Chinese Medicine. Barrytown, NY: Station Hill Press; 1990.

8. Oschman JL, Oschman NH. Readings on the Scientific Basis of Bodywork, Energetic, and Movement Therapies; Part D: Evolving a Science of Relationship. Available from Nature's Own Research Association. In press.

AUTHOR INFORMATION
Dr Michael Greenwood is the Medical Director of the Victoria Pain Clinic, a residential facility in Victoria, British Columbia, Canada. Dr Greenwood's specialty is in working with chronic pain and 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 in healing and complementary medicine.

Michael T. Greenwood, MB, BChir, CCFP, CAFCI, FRSA
Victoria Pain Clinic
365 Hector Rd., RR#3
Victoria, BC, Canada V8X 3XI
Phone/Fax: 250-595-1486 - E-mail: Mgreenwood@islandnet.com

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