Because the body is frequently affected by dysfunction of the mind or spirit, it is essential to discover how a patient’s physical problems arose. The more obvious the physical or environmental cause, the more likely it is that a symptom is a genuinely physical problem. A sports injury, sunstroke, being caught in a snow storm and suffering from cold, food poisoning, living in a damp area and having stiff joints are all predominantly physical problems because their origin appears to be physical. At the same time, however, a person may also have underlying deficiencies, which have resulted from problems at a deeper level and these must still be taken into account.

Practitioners can make a further check by discovering what affects the symptom, for example, whether further activity makes the injury worse, whether exposure to the sun is debilitating or whether wearing wet clothes after a rain storm makes the joints even stiffer. Physical symptoms can, however, also be radically affected by the state of the patient’s mind or spirit. For example, a patient’s pain in the neck may get worse when she or he is anxious or frustrated but the cause is still physical.

People’s ability to think is a reflection of their mental level. Practitioners can therefore evaluate the mental level by assessing a patient’s mental clarity, memory and by noticing their ability to solve problems. For example, when people’s minds are clear they can solve problems by:

While taking a case history the practitioner can observe how well the patient’s mind has worked when dealing with past problems. It also provides opportunities to ask patients how they will deal with current situations.

Another common sign of a mental level problem is an unrealistic attitude to what causes events to occur. People have widely differing notions of what makes things happen, so it is useful for the practitioner to explore this area generally when using it to make an assessment of the patient’s mental level. If a patient says that in order to get a larger house, they are going to buy more lottery tickets, the practitioner may wonder if the patient’s imbalance is primarily at this level.

Because the spirit is more subtle than the mind and body, it can be more difficult to diagnose. In order to diagnose this level accurately, it is often important for practitioners to be aware of the context of the patient’s life situation. For example, some patients may seem to be very healthy until a difficulty arises. The fragility of their spirit then manifests as they crumble under the strain of what appears to others to be a relatively minor problem. In contrast, even a very healthy person may have difficulty coping with an emotional shock if it is severe enough.

The health of the spirit manifests in various ways. Listed below are some areas that the practitioner can observe:

It can help practitioners to deepen their understanding of their patients’ spirits if they focus on the inner capacity of each Element. For example, looking at each Element, people should have the ability to:

Practitioners can use their knowledge of the Five Elements to consider which of these aspects are healthy, which are deficient and where the patient’s potential is not yet manifested. The practitioner can focus on any aspect from the above list and make an assessment. For example, the practitioner may decide that a patient has an imbalance in the area of caring and nourishing. When practitioners are planning future treatment they can consider including spirit level points that have an effect on this function. This area of diagnosis will usually dovetail with that of the CF.

The practitioner could also go further by gently questioning whether the patient is happy with that area of their life and whether they have hopes or wishes for being better cared for and to care better for others. It is important for practitioners to be sensitive at this stage as they may be entering an area where a difficulty in the spirit will manifest. The response may be unpredictable. These aspects of a person’s spirit are often highly defended and full of ambivalence, awkwardness and pain. Three things are essential: high-quality rapport, complete acceptance of the patient whatever they say, and accessing the appropriate inner state.

Box 27.1 outlines a way of developing the ability to assess patients’ spirits from their eyes.

Colours, sounds, emotions and odours are traditional Five Element resonances that are laid down in the Nei Jing. Non-traditional resonances have never been written down in the Chinese classics. Instead they have been developed recently by practitioners and have been drawn from the observation of thousands of patients. Using their understanding of the Element and the associated Officials, the practitioner decides that certain behaviour or attitudes are resonant with a particular Element. Much of the material for this form of diagnosis is set out in chapters associated with each CF.

Golden keys are usually significant moments that strike a practitioner as odd, quirky or unusual. They are often expressed via the patient’s words or behaviours and they often carry a sense of being an unhealthy rather than healthy expression of the patient.

To begin with practitioners might notice something unusual about the patient and their curiosity is aroused, but at the same time they may not associate golden keys with any particular Element. The practitioner may wonder what could cause the patient to behave or think in this way and she or he strives to understand the underlying cause of this particular behaviour. It is this cause, rather than the behaviour itself, that informs the diagnosis. For example, noticing that a person has withdrawn from others does not help the diagnosis. Realising what has driven them to withdraw, however, could be the key to a correct diagnosis.

A patient, Mr Green, was a secondary school teacher. He was threatened by a possible thrombosis in his leg and wondered whether acupuncture could help. Throughout the case history, Mr Green mentioned several accidents that had occurred to him. The first was when he was 6 and he lost an eye when he and a friend were going fishing and climbed over a farm gate. His friend’s fishing rod entered his left eye, with the result that his sight was severely impaired. He said that this accident happened on 5 August 1931 in the early morning. There were another five such ‘accidents’ and for each the date and time were given, without prompting. By the third account, the practitioner was thinking, ‘This is odd. So many severe accidents and such precise times and places.’

The incident immediately preceding the threatened thrombosis was not presented as one of these incidents, but it had a similar flavour. A student in Mr Green’s school had mischievously set off the fire alarm knowing that, because of regulations, the whole school would be required to assemble in the playground with all students being accounted for. Classes were severely disrupted. Mr Green thought he knew the culprit and was inwardly furious. The weather in the playground was very windy, which Mr Green commented upon, and said he found annoying. The swelling of his leg occurred that evening.

What are the golden keys? There were several accidents and the patient knew the date and time of each one. They all seemed to be accidents, but after one or two the practitioner became suspicious. Yet no one deliberately arranges for his or her eye to be poked. The practitioner might ask, ‘What might tie all these incidents together?’

At this point, those who are new to the Five Elements may be puzzled, but most experienced practitioners, whatever style they practise, would probably have the Element or the Organ in mind, especially as there are some helpful associated clues – the anger and the wind.

Assuming that the golden key represents a more generalised pattern and truly is a pathological manifestation of the patient’s underlying imbalance, the method of diagnosis is as follows:

By now it is probably easy to guess that Mr Green is a Wood CF. The Gall Bladder is the Organ responsible for judgement and the Liver is responsible for planning. His pattern was to both put himself in places of danger, evidencing poor judgement, and to also remember and communicate vast amounts of detail, implying over-planning. Both of these behaviours are significant golden keys and should be used to support the use of colour, sound, emotion and odour but not to replace it.

When processing golden keys, other resonances, such as wind and anger, may also come up and these should also support the diagnosis. The use of colour, sound, emotion and odour alongside the golden keys confirms the power of the Five Element approach when assessing the overall pattern.

The method for using golden keys that is written down in the above section is rarely carried out in its entirety. Under normal circumstances practitioners are struck by the behaviour or information and attribute it to an Organ or Element.

By treating patients, establishing their CFs and seeing them change as a result of treatment, practitioners build up a repertoire of patterns or ‘resonances’ that are non-traditional, but are nevertheless based on clinical experience. The greater the practitioner’s experience, the more solid and reliable is their repertoire of unconscious patterns. Intuition builds faster when it is encouraged. New practitioners who consciously ask the three questions listed below will be more inclined to develop intuition and discover more ‘golden keys’.

Over time, some of these golden keys become part of the practitioner’s diagnostic framework and the practitioner begins to notice that certain behaviours correlate with certain CFs. These are written about in greater depth in the chapters on the patterns of behaviour of the CF.

It is important for practitioners not to rely solely on golden keys when identifying a patient’s CF. To prevent incorrect generalisations and explanations from being made they must always then be checked against colour, sound, emotion and odour and subsequently against the results of treatment. An ongoing verification process is essential as only then can valid generalisations be made.