Charles A. Moss, M.D.
Five Element acupuncture as practiced in the West is a distillation of traditional concepts from Chinese medicine which emphasizes treating the whole person: body, mind and spirit. Many of the current practitioners of this healing art have been trained by J.R. Worsley, who has captured the essence of this remarkable system and brilliantly applied it to the dilemmas and challenges of modern life. This article reflects the training I had with Worsley and my experience of applying it over 25 years in a primary care medical practice.
The Five Element acupuncture system, rooted in Taoism, is over 2000 years old yet in many ways is more applicable today than ever before. Five Element acupuncture brings a vision and understanding of how to assess and treat the roots of illness, whether on a body, mind or spirit level. In today’s culture, with its emphasis on striving for material wealth, as well as the overwhelming mental stimulation, there is little to nurture the spirit. This has led to the clinical finding that many individuals today have the origin of their health problems on the spirit level.
The Tao Te Ching discusses protecting the spirit through the state of desirelessness (wu wei). (1) The knowledge that addressing the spirit is critical is also found in the earliest writings in Chinese medicine, the Nei Ching Su Wen "the first method of acupuncture is to cure the spirit, the second was to give knowledge of how to restore the body. In order to make acupuncture effective one must first cure the spirit. (2) The gift of Five Element acupuncture is to make available the wisdom and understanding of these classical concepts of acupuncture for the challenges of life at the brink of the new millennium.
TAO AND THE FIVE ELEMENTS
The goal of Five Element acupuncture is to enhance personal alignment with what the ancient Taoists called the Laws of Nature. When living in accordance with these Laws, the health of the body, mind and spirit is supported. These Laws include the concepts of Qi, Yinyang and the Five Elements, the three key components of traditional Chinese philosophy . Qi is described as the vital life force which animates all living things. In the Five Element system, Qi is defined as Energy which is conducted through the body in the meridian pathways which supplies the organs and the body, mind and spirit. When the Qi is balanced a person remains well, when imbalanced illness can occur.
The Yinyang concepts originated in the fourth century B.C. and explained natural phenomena as the "ceaseless rise and fall of opposite yet complimentary forces" (3). Yin and Yang are strictly translated as the shady side of a hill (yin) and the sunny side of a hill(yang). The Yin qualities of cold, interior, dark, stillness and potential and the Yang qualities of light, heat, exterior, rising and activity exist in relation to each other. Yin and Yang are continuously interacting and are interdependent and transformative of each other. A dynamic balance of Yin and Yang is characterized by health, an imbalance by disease.
The characterization of phenomena into two aspects of correspondences (Yinyang) was further expanded in the Five Element system. The Five Elements represents the universal consistency of systematic links. (4) The Laws of Nature direct all movement within these Five Elements. Nature and man are the macrocosm and the microcosm of these Laws. These Laws organize the movement of Qi within the individual and provide the structure for diagnosis and treatment in the Five Element system.
In the time of the Han dynasty (200 B.C.), living in harmony with nature as a way of maintaining health was an obvious need. If the cycles of the season and climactic conditions were ignored, famine and illness certainly would follow in the agrarian society of China. The Nei Ching discusses the relationship of the natural laws as follows, The interaction of the Five Elements brings harmony and everything is in order. At the end of one year the sun has completed its course and everything starts anew with the first season, which is the beginning of Spring. This system is comparable to a ring which has neither beginning nor end. (5)
In Chinese philosophy the natural laws that organize the cycles of change in nature, such as the seasons, are the same laws that organize human experience. Paramount among these laws is the Law of Five Elements (Wu-Hsing). The Five Elements divides human experience into five distinct groupings. These Elements act as maps that reflect all levels of human function, including, but not limited to, the anatomic and physiologic functioning of the organ systems. The levels of function range from biochemical processes to the function of the person as a whole ranging from behavior, psychological state, emotions, spiritual state and intellect to relationships and career. The Five Elements include Wood (liver and gall bladder), Fire (heart, small intestine, triple heater, pericardium), Earth (spleen, stomach), Metal (lung, colon) and Water (kidney, bladder). Using the Five Element ëmap,’ dysfunction occurring on any of these levels can be placed in the appropriate context.
The Nei Ching states "A person is not sick because of a disease, they are diseased because they are sick." (6) When the vital energy (Qi) is balanced in body mind and spirit, there is resistance to disease and an ability to adapt to the ever changing demands and challenges of modern life. The ability to be flexible in mental functions such as beliefs, emotions and attitudes, as well as being adaptable in our biochemistry and immunology, brings a higher level of well being.
Five Element theory has been part of Chinese Medicine from the 10th century B.C. These concepts first appeared in several books on philosophy such as the Shu Ching, the Li Chi and the Guan Dzu. (7) The first medical writings on the Five Elements were found in the Nei Ching Su Wen written around 200 B.C. Further discussion was found in the Nei Ching Ling Shu and the Nan Ching. The Five Element concepts are part of not only medical theory, but are an integral aspect of all ancient Chinese cosmology and philosophy. (8) The principles of the Five Elements were used in aspects of society ranging from agriculture to affairs of state. (To understand the history of Five Element acupuncture in the West, I refer the reader to the excellent book, In the Footsteps of the Yellow Emperor by Peter Eckman.) (9)
To impart an understanding of body, mind and spirit was part of the Taoist physician’s approach in utilizing the wisdom of the Five Elements and Tao. Living a life of balance and harmony within oneself and in the society was the mark of living with Tao. The goal of the physician was to assist patients in treating illness and to educate them in the ways in which they were not following the Tao. Herbs and medicines were frowned upon because they hindered the understanding of the true reason a person got ill. "The concept of acupuncture differed from that of drug application in that it constantly reinforced the system of correspondences, providing stimuli only when man had not been able, owing to his own negligence or external conditions, to balance his existence in the proper way." (10)
FIVE ELEMENTS AND THE CYCLE OF LIFE
The clinical application of the Five Elements is based on the system of correspondences. The correspondences include seasons and climactic conditions, as well as correspondences within the person. (Figure 1)
Each Element has correspondences, including organ systems, sensory organs, tastes in food, color, emotional state, physical and emotional symptoms, disease tendencies and a general orientation toward life. (Figure 2)
Selected positive qualities corresponding to each Element are illustrated in Figure 3.
The correspondences are used to organize the diagnosis which incorporates the history and physical findings to identify a root or causative factor. The causative factor is the Element that, under internal or external stress, becomes imbalanced and initiates a state of dis-ease. (11)
To understand what these Elements represent in man it is helpful to see each Element in relation to its seasonal correspondence. The Wood Element corresponds to Spring, which is a time of new growth, increasing activity and longer days. In the individual, Wood corresponds to having a vision of the future, having the ability to organize, plan and initiate action, and to express emotions, including anger, in a healthy manner. Wood includes the function of the biliary tract, liver, ocular system and musculoskeletal system. When not in balance, the Wood Element correspondences include difficulty in making decisions, high levels of frustration, excessive need for control, inappropriate anger, difficulty relaxing, anxiety, chronic muscular problems such as fibromyalgia, headaches (including migraine) and visual problems.
The Fire Element corresponds to Summer. This is the time of greatest warmth and light, the longest days, the greatest activity and luxuriant growth. In the individual Fire correspondences include the ability to establish relationships, express love and sexuality, expansiveness, enthusiasm, passion, playfulness, joyfulness, warmth and relaxation. The organ systems include the heart, small intestine, pericardium, and sympathetic and parasympathetic nervous systems. When the Fire Element is not in balance there is a lack of joy and warmth, difficulty in intimate relationships, depression, confusion and doubt, low energy, digestive problems such as irritable bowel syndrome, insomnia, cardiac disease and tinnitus.
The season for the Earth Element is Late Summer. This is harvest time when food is plentiful and the warmth and golden light of the Late Summer days create a sense of relaxation and contentment. The organ systems of Earth are the stomach, spleen, pancreas and all digestive processes. In the individual, Earth corresponds to nourishment, contentment, harvesting what is needed for self and others, stability, security, empathy and caring. Earth corresponds to the biological mother, as well Mother Earth. When the Earth Element is not in balance we see a person who can be obsessive, self centered, opinionated, insecure and uncaring. The physical symptoms include eating disorders, upper and lower gastrointestinal disease including peptic ulcer disease and inflammatory bowel disease, sinusitis, frontal headaches and all gynecological disorders.
The season of the Metal Element is Autumn. This is a time of decreasing light, increasing cold and shorter days. Trees lose their leaves as they withdraw their energy internally. In the individual, the Metal Element represents internal resolve and strength, self worth, self esteem, vitality and endurance, as well as the ability to let go of emotional upsets and grudges. The organ systems are the lung, skin and colon. Metal represents the biological and spiritual Father. When the Metal Element is out of balance there can be depression and sadness, an inability to recover from loss, lack of inspiration, rigidity, poor self esteem, excessive materialism and emotional withdrawal. The physical symptoms include asthma, rhinitis, eczema and other skin disorders, constipation and lower bowel disorders.
The Water Element is correlated with Winter. This is the darkest and coldest time of the year, when activity in the plant kingdom occurs only deep in the roots. In the individual, the Water Element represents energetic reserves, the will to survive, courage, our ability to procreate, movement and flow, self actualization, willpower, trust and faith. The organ systems are the bladder, kidney, bones and endocrine system. When out of balance, the Water Element corresponds to fear and a struggle for survival, a lack of reserves and deep fatigue, reduced sexuality, timidity and a lack of trust in life and in other people. The physical symptoms include fatigue and exhaustion, all disorders of the urinary tract, infertility, hypertension, all endocrine disorders, lumbar syndromes, ankylosing spondylitis and dental pathology.
OFFICIALS, FUNCTIONS AND LAWS
In Five Element acupuncture the function of the organs and meridians are described by the term Officials. Porkert (12) describes the Official (Orbs) as "defined not by physical properties, but by its specific roles in the processing, storage and distribution of vital energy and thus the maintenance of life." In the case of the Wood Element, the two Officials are the "Official of Decision Making and Wise Judgment" (the Gall Bladder) and the "Controller of Planning" (the Liver).
The Gall Bladder is "responsible for what is exact and just." Determination and decision stem from it. The Liver "holds the office of general... assessment of circumstances and conception of plans stems from it."(13) When these officials are poorly functioning, the effect might be indecisiveness, lack of initiative, anger and frustration, or hypochondria with constantly changing symptoms. Decisions relating to career or relationships might be repeatedly flawed and lead to stress and agitation. The ability to make appropriate plans is affected and disturbance in the 'blueprint' for functioning on a cellular level (i.e. diabetes), or a global level (i.e. drug addiction) might be the outcome. This might be more significant than the physical manifestation such as headaches, dizziness, myalgias, chest pain, or eye disorders which are often attributed to Gall Bladder and Liver.
The Officials give us the ability to use a ëwide angle lens’ to look at the life style that a person has created as a reflection of the functioning of the Elements. Understanding the behavioral manifestation of the Official often provides insight into the dynamics behind chronic illness. In the Wood Element, repeatedly making decisions which undermine an individual’s well being reflects poor functioning of this Official. This information is critical in Five Element diagnosis. Figure 4 has a list of the Officials and the corresponding Element and organ. (14)
Understanding the functioning of the Officials and Elements and the acupuncture laws provides the organization of symptoms and signs needed to provide effective treatment. The laws which govern the movement of energy within the person are reflective of the physical laws of nature. The Law of Five Elements (Wu-Hsing) (Figure 1) describes the Elements as energetic capacities that create transformation and change, observable in Nature as well as in the person. There is a set relationship between these Elements which is repeatable and observable in nature. The movement through these Elements reflects the nature of human experience from birth to death.
The energy of the Five Elements move through a creative cycle and a controlling cycle. (Figure 6) The creative cycle (also called engendering, productive, Sheng) is best understood using the macrocosmic Images of the Elements. The Sheng cycle can be seen in this traditional description: Water produces plants/trees, that is Wood; Wood brings forth Fire; Fire produces ashes, that is soil (Earth); soil brings forth Metal; when heated Metals produce steam, that is Water. The controlling cycle (Ke) is illustrated as follows: Water overcomes fire through inhibition; Fire activates Metal; Metal structures Wood; Wood penetrates Earth; Earth absorbs water.
These two sequences form the basis for health and when not in balance provides the understanding of the development of disease. A clinical example is a patient who has a history of low back pain with sciatica who has not responded to acupuncture or other treatments directed at the back pain itself. Her history revealed that she had eczema and asthma as a child and the onset of the back pain occurred after a series of deaths in her family from which she has never recovered emotionally. She also had a history of depression as a child as well as a critical and demanding father.
The Elements involved in this case are initially the Metal (asthma, eczema, depression, abnormal grieving and her relationship with her father are all correspondences for Metal) and then Water (low back pain and sciatica). The Sheng cycle movement of energy from the Metal to the Water describes the chronology of events and dictates that treatment address the Metal for the Water symptoms to improve. This is described as the Law of Mother Child, where the preceding Element (Mother) when imbalanced, will not provide the normal energetic support (Sheng cycle) to maintain the health of the following Element (Child) and symptoms will occur in both the Mother and Child Elements.
BODY MIND AND SPIRIT
A major emphasis of Five Element acupuncture as currently practiced is on the concept of spirit and the assessment of the person from a body, mind and spirit orientation. In Chinese philosophy there is no separation of body, mind and spirit. Life is the organization of the vital life force Qi, manifesting in body, mind and spirit through the Laws of Five Elements. Death is the dispersion of this organization.
Joan was 58 years old when she first consulted me for chronic fatigue syndrome. She had the onset of the chronic fatigue 12 years earlier after an episode of severe sciatica led to bedrest and multiple medications. The sciatica had continued to be a problem, as well as the incapacitating fatigue. She also had symptoms of fibromyalgia, cognitive dysfunction and recurrent fevers. Joan had not responded to previous medical and complementary therapies and admitted to feeling hopeless, overwhelmed and depressed.
The Five Element system provided a diagnostic structure to identify the Element and the energetic basis of the complex symptoms presented by Joan. Through the treatment of the appropriate Element and acupuncture points addressing the spirit level of illness, she responded with dramatic improvement in her energy and cessation of the sciatica. Most important for her was the restoration of her spirit and a new found enthusiasm, aliveness and optimism.
Spirit in this context is the inner sense of aliveness that gives us our purpose and direction in life. In a person with a strong spirit there is vibrancy and strength reflected in the eyes. A healthy spirit brings ease to the individual, allows you to deeply connect with them, and brings them into alignment with their will and higher purpose.
A further understanding of the concept of spirit is through the Law of Five Elements. The manifestation of spirit in the Fire Element (Heart) is shen, which is considered a fundamental substance of the body and is the basis of consciousness, joy, aliveness and happiness. The Earth Element is Yi, which is translated as memories and nourishment and provides understanding, empathy and concern for self and others. The Metal Element is P’o, the ëCorporeal soul," which provides the instincts to know the truth and live in the material world. The Water Element is Zhi, self actualization and manifestation. Wood Element is Hun or transformation and the ëHeavenly soul.’
Spirit level problems do not always manifest as major medical disease, but can also be seen in people with minor physical ailments. Individuals with spirit level problems find it difficult to make significant changes and often do not respond to intervention with long lasting improvement. They appear to lack purpose, joy, enthusiasm, commitment and direction, feel unfulfilled, empty inside themselves and seem to be constantly desiring or striving.
As Worsley points out illness is often not isolated to one level: "If the body is sick, the mind worries and the spirit grieves; if the mind is sick, the body and spirit will suffer from its confusion; if the spirit is sick, there will be no will to care for the body or mind." (15) The ability to directly effect the whole person, body mind and spirit, is one of the greatest gifts of this system of healing.
ASSESSING THE WHOLE PERSON: CORRESPONDENCES AND DIAGNOSIS
Jack was 52 years old when he presented with recurrent tension, ocular headaches and chronic irritable bowel syndrome. The headaches occurred when he felt anxious or under pressure, as well as when in bright sunlight. The irritable bowel symptoms would also worsen when he was under more stress. During the examination he was nervous, unable to sit still, and spoke with a halting though rapid pattern. The findings in the Five Element examination showed a green facial color, shouting voice and a pattern of suppressed anger.
His Five Element diagnosis was Wood (Gall Bladder) causative factor. The color, sound, emotion, headaches, eye involvement, nervousness, constant moving and speech pattern are all correspondences for the Wood Element. Most important for the diagnosis was his pattern of being disorganized and responding to stress with irritability and difficulty in seeing solutions.
If we look at the historical correlates regarding the Wood Element and how this patient demonstrates the correspondences of the Wood Element, we can see the rationale for his Five Element diagnosis. The Nei Ching discusses the Wood Element as providing the ability to "discover the Tao, the Right Way," which allows for healthy decision making, planning and a balanced and well coordinated life style. The emotion attributed to the Wood Element is anger. (Figure 5) This is generated by the frustration of being blocked in setting out in new directions. Anger in this situation also stems from loss of a sense of control over life’s events and often manifests as aggressive behavior
The correspondences allows an organization of essentially all symptoms as well as emotional and behavioral styles. One of the advantages of the Five Element system is that the language used to describe and classify information is familiar. In Five Element diagnosis the establishment of rapport with the patient is critical in allowing a clearer vision of the underlying Elements. The traditional diagnosis calls for the examiner to be an active participant in the experience. This involves testing the five emotions, voice qualities, odors and colors in an interactive way. Through this deep connection with the patient, the practitioner can access the key diagnostic aspects of the examination and act as a guide and teacher as well. (16) Another important part of the examination is the traditional pulse diagnosis with emphasis on the individuation of the Twelve Officials.
When an imbalance occurs in a significant way within an Element and Official, the history will often reflect this in a chronological order. Illness occurs when the Officials are unable to overcome either internal (excess emotions), external (injuries, surgery, climactic conditions) or inherited perverse energies. The events or experiences that initiate the imbalance in an Element often occur at an early age and can be related to early childhood experiences or traumas. The disease process is often triggered later in life by an inability to adapt to additional challenges and stress.
What appears to a physician as the "onset of the present illness" is often the culmination of a long sequence of energetic disturbances in the Officials and the Elements. The laws of acupuncture will determine what the configuration of the patient’s symptoms will be. These laws include: Creation (Sheng cycle), Control (Ke cycle), Midday-Midnight and Mother-Child. The most important of these laws are the Sheng and Ke cycles (see Figure 6). In the example of the Wood Element an imbalance could create symptoms in Wood, Fire (Sheng cycle) and Earth (Ke cycle) through the abnormal movement of qi through these different cycles. The correspondences of these Elements will clarify the specific sequence of events.
TREATMENT IN FIVE ELEMENTS: ENGAGING THE ESSENCE
Jack, the patient described above with the Wood causative factor, also had a spirit level imbalance. The treatment involved using points that effect the spirit as well as a variety of points on the Liver and Gall Bladder meridians. His response to treatment was, in his words, "I am more focused, resilient, balanced, centered, stable, less irritable, and more self aware physically and emotionally." His headaches and irritable bowel symptoms also reduced significantly.
When Five Element acupuncture treatments are effective the changes seen embrace the body mind and spirit of the person. In Jack’s case the effect of balancing the energy of the Wood Officials was to reestablish the ability to plan, organize, be flexible and make healthy decisions which reflects the function of the Officials of the Gall Bladder and Liver.
In my practice the use of the Five Element system has been a catalyst for change with many of my patients. The treatment is organized by the diagnosis of which Element and Officials are the root factors, the level of illness and the relative excess or deficiency of energy noted on pulse diagnosis. The recognition of major ëblocks’ in the balance of the energy is critical for effective treatment as well. These blocks include aggressive energy (perverse qi), husband wife imbalance (yin-yang imbalance), possession (losing control of one’s spirit from either disease or perverse outside influences) and entry exit.
The goal of treatment in Five Element acupuncture is to reach the level of the constitutional imbalance or causative factor and not focus on treating a symptom or syndrome. The symptoms are interpreted as signs of an imbalance in an Official and, if not corrected, will lead to chronic problems. Treatment aimed to clear present symptoms will mask the underlying effect on the causative factor and delay deeper healing effects.
For example, a patient I recently treated had the following symptoms: chronic and severe back pain, fatigue, a lack of initiative, unhappiness and a history of breast cancer. If I were to focus on treating the back pain primarily the points along the bladder meridian would have been the logical choice (Tai Yang). The Five Element diagnosis in this case, however, showed the Earth Element and the Spleen Official to be the causative factor. With treatment of the Earth Officials, including aggressive energy and spirit level points, she reported an immediate shift in her desire to engage in life more fully, started new projects, sought out friends, felt excitement about life, had improved energy, as well as clearing of the back pain. This demonstrates the impact of treating on the correct Official and level with this system.
The organization of the treatment course in Five Element acupuncture is to first clear ëperverse qi’ (Xie Qi) (Aggressive Energy, Possession and Husband-Wife) if present and then balance deficiency or excess of normal qi through the use of transfers of energy. The transfer of energy from one Element and Official to a deficient Element is organized through the Sheng and Ke cycle relationships. (Figure 5)
The effects of the points chosen are related to their Element function and include Tonification and Sedation points, Junction (luo) points, Alarm (mo) points, Associated Effect (back shu) points and Entry and Exit points. The way these points are used in the normalization of qi is unique to Five Element acupuncture.
The needling technique used is a powerful stimulant to release the effect of the specific point chosen and often involves tonification and immediate removal of the needle. Very few points are used at each session. Direct moxibustion (heating a point by burning a cone of mugwort on the skin) is frequently employed. The points are selected through several criteria: 1) they are on the meridian of the Causative Factor; 2) they have certain classical functions i.e. tonification, sedation etc.; and 3) they bring to the body, mind and spirit of the person the desired effect as encoded in the name and the function of the point. Pulse diagnosis is used to verify the effect of the point immediately after each point is stimulated bilaterally. Points are generally chosen individually and not by groups, as the treatment is aimed at a precise effect. Each treatment is specific for that patient at that time and is not based on a symptomatic formulation.
In my practice I have found that involving the patient in their care through the use of homework to be invaluable. This includes exercise, diet changes, meditation and specific mental exercises related to the Element which is being treated. I use the positive qualities that are represented in the correspondences of the Element to create a healthier environment for the energetic movement to occur. The suggestions given to the patient work on areas such as forgiveness for the Wood Element or trust for the Water and support the positive aspects of each Element. THE ORIGINAL INTEGRATIVE HEALTH CARE Five Element acupuncture has frequently been the catalyst that allows patients to make the appropriate health enhancing life style changes. In the case of Jack, he developed improved judgment and healthier decision making ability. There was less hostility, less need for control and a clearer vision of future needs. He was able to follow through on suggestions for a healthier diet, use of meditation and an exercise program which further reinforced the effect of the acupuncture treatments.
The complex patient with a multi-faceted problem presents a challenge in organizing information in a context that can lead to effective treatment. It is in this aspect that the Five Element approach is most effective. The modern ideas of psychoneuroimmunology are seen within the Five Element concepts of causative factor, Officials and level of illness. The system of correspondences aids in the understanding of the diverse information gathered from the patient. Both physical and emotional symptoms can be placed within this diagnostic framework. The most significant aspect of Five Element acupuncture is that it allows for treatment of the whole person, body mind and spirit with the goal of addressing the root of the disease process.
The Five Element system lends itself to application in other ways than acupuncture itself. Understanding the positive qualities and correspondences of the Elements can help an individual support change and effectively deal with many of the issues that can challenge us on a daily basis. For example, when the Wood Element is the causative factor, dietary practices such as eliminating caffeine, alcohol and high fat foods are particularly important. Behaviorally it is important to reduce demands and develop a plan for the near and long term. Emotionally, adopting an attitude of forgiveness can help to reduce some of the frustration, anger and hostility seen with imbalance in the Wood Element.
The information from the Five Elements does not only apply to illness and dysfunction. In traditional Taoist thought the Five Elements are a guide to living a healthy, happy and integrated life. Understanding the connection to the laws of nature allows a person to be more self aware and become a more compassionate member of the greater whole, Tao.
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