Some practitioners try to label colour before they have seen it properly. In this case they have left out the first step. They need to learn to see colour first. This can be an important part of the training when learning Five Element Constitutional Acupuncture. More is written about this below.

Other practitioners see a distinct colour but then do not know what to call it. Some people have a wider range of labels for colour than others. For example, a person who mixes colour for a paint manufacturer or a person who paints landscapes is likely to have more labels for different colours than solicitors or linguists who use their visual acuity less. It can be helpful if practitioners take the time to observe a wide range of colours, especially those seen in nature, in order to increase their colour ‘vocabulary’. Being able to label colour is essential as it links what practitioners observe with their Five Element diagnosis.

Comparing colour increases sensory acuity. For example, looking at two faces simultaneously (or at least quickly moving back and forth) heightens practitioners’ visual awareness. Acupuncturists who are working on their own, looking at only one patient, can easily cross the habituation threshold. To focus their minds on the sensory input it can be useful for them to compare different areas of the patient’s face. This gives them several colours to observe. To help them to do this they can ask themselves a question, such as, ‘How do the colours on either side of the face compare?’ or ‘Which colour is paler?’ The landscape painter does this naturally as his or her eye travels back and forth from field to canvas and back again.

In a group, when people are learning to see colour, it can be useful to line up two to five people to compare their different colours.

Natural light is important when observing colour, so practitioners may sometimes need to ask patients to step outside or over to the window of the treatment room in order to find the best light. It is often useful to ask patients to face the light and to then turn their heads slowly from one side to the other. This will enable the practitioner to observe the facial colour on all areas of the face.

Observing in different lights can be useful as this helps the practitioner to understand the benefits of good light. Mid-winter in Britain is not a good time for natural light. The skies are greyer and the days are shorter. Many treatment rooms have little natural light and artificial light subtly distorts the true colour. Making comparisons between artificial and natural light, one side of the room and another, bright sunlight and soft northern exposure, enables a practitioner to get used to the effects of different lights. A change in colour will easily convince the practitioner that bringing the patient to the best source of light is a good idea.

Light is reflected off walls, blankets and clothes. A patient with a green shirt or pink blanket may appear different when wearing a brown shirt or using a blue blanket. It is useful for the practitioner to experiment and notice any differences caused by different lights.

It can also be useful to remember that make-up distorts colours and the practitioner may need to ask some patients not to wear make-up on the day of treatment. Figure 25.1 describes an exercise to help develop the practitioner’s awareness of facial colour.

Hard eyes limit the range of our vision and make it difficult to see colour. The more we relax and soften the eyes the wider our vision and the better we can see the patient’s colour (Box 25.1).

As with colour, smelling more keenly is an essential stage to go through before learning to apply the correct odour labels. After taking a case history, a common complaint from practitioners is that they didn’t smell an odour. The reason for this is simple. Most people do not need to be able to smell to get through their day. Apart from smelling smoke (indicating a fire), a gas leak or perhaps food to determine whether it has gone off, most people do not regularly use their ability to smell. Compared to a cat or dog, both of which will constantly be checking their environment for odour information, humans barely use their sense of smell. Thus to use odour regularly with patients requires some development.

When practitioners learn to hone their sense of smell, they still have the problem of identifying the smells correctly. The labels for the odours listed above are not particularly helpful, as many people do not have clear ideas about, for example, the smell of rotten as opposed to the smell of rancid.

One problem when smelling odour as opposed to looking at colour is that a colour is more constant and objective. If practitioners look at the colour by the eye, then look away again, they expect to look back and see the same colour again. This is especially true if they do it quickly and they or the patient do not change position or alter the light. This is less true with odour because people habituate to smells very quickly. This habituation is similar to what happens if we repeat a word endlessly and it seems to lose its usual meaning. We may initially smell something strongly, but then the smell quickly fades. The fragile nature of an odour is a matter of degree, but it is less constant and substantial than colour. Box 25.2 describes an exercise to help develop the ability to smell odours.

Because people habituate quickly, it becomes important to ‘catch’ odours by surprise. One of the best times for practitioners to smell a patient’s odour is when they have just entered the treatment room. If a patient has removed some clothing, the odour seems to fill a room and build up, especially if the patient has been in the room for several minutes. The practitioner can smell the hallway and then smell the room, in a matter of one to two seconds. In this way they can use contrast and comparison to accentuate the odour. After the practitioner has been in the room for more than a minute or two, the chances of detecting the odour become considerably less.

If a patient is lying under a blanket in a warm room this may also provide the practitioner with an opportunity to smell the odour. When the blanket is lifted in order to check the temperature of the three jiao or to carry out abdominal diagnosis a smell may be detected.

It can also be useful for practitioners to notice the odour in the area between a patient’s shoulder blades. The odour is often more distinct here as this is a difficult area for people to clean.

The more the practitioner is relaxed the easier it is to smell the odour. ‘Trying hard’ to smell is especially ineffective. Sometimes the odour becomes stronger and clearer when it is least expected. When a practitioner is deeply relaxed, for example, when taking pulses, the odour may suddenly become more apparent.

It is important for practitioners not to obviously sniff or show that they looking for an odour or rapport can easily be lost. The patient may wrongly conclude that the practitioner thinks she or he has an offensive smell!

Another point the practitioner needs to remember is that patients are often wearing a number of artificial and acquired smells that cover up the underlying odour. These range from perfumes, hairsprays, what the patient last ate, deodorants, toothpaste, whatever is clinging to clothes (freshly dry cleaned or not) to flatulence. It is often appropriate for the practitioner to ask patients not to wear perfumes and other artificial smells on the day they come for treatment.

Most practitioners’ ‘smell vocabulary’ is less developed than their colour vocabulary. The vocabulary they do have often includes many judgmental words like ‘awful’, ‘yucky’ or ‘gorgeous’. These do not help a person to improve their ability to label odours. In Table 25.1 an attempt is made to describe the various odours.

As with colour, one way practitioners can enhance their ability to recognise odours is to make a diagnosis using the other three key methods of diagnosis and then link the odour to that Element. Some practitioners are naturally gifted in the ability to smell odours, but for many it is their least developed sense. The challenge for them is to develop their ability to use it effectively. Box 25.3 suggests a practical way to improve the ability to distinguish smells.

The ‘laughing’ sound is not an actual laugh, but is more like a pre-laugh. It is as if a person is being given a little tickle and might break into real laughter. The sound itself tends to move upward in the body.

Some people have a voice tone that is lacking in laughter. This voice tone has no sparkle or animation to it. It can easily be mistaken for a groaning voice. A distinguishing feature is that it often has a croaky quality, as though it comes from deep in the person’s throat or chest.

The ‘singing’ voice is used by a mother when she is soothing her upset child. It can also be compared to the voice of a rider calming an agitated horse. It is the voice tone often used by someone being ingratiating. The sing, as compared with other voices, has more frequent and more extreme variations in pitch.

The weeping voice is not actually weeping, but more as if the person is about to weep. It often tails off in volume near the end of sentences, as if the lungs are too weak to sustain their power for a whole sentence. It is often a bit thin, quavers or sounds fragile. To use a photographic analogy, the density of the weeping voice often has a lower resolution and fewer pixels. The underlying grief can create a ‘catch’ or slight choke in the voice.

A groaning voice lacks the variations in pitch of a singing voice and is often recognised for being flat or expressionless. It is as if a normal voice has a flat upper and lower governor that squashes any upward and downward variation in pitch. It is easy to imagine its connection with fear. If a person is in a dangerous situation, say, in a room where there is reported to be a poisonous snake, then in order not to create panic or frighten the snake, she or he might easily put a clamp on variations in pitch, keeping the voice level and constant. The voice can often ‘drag’ towards the end of the sentence.

‘Shouting’ usually implies an increase in loudness and, while often true, loudness is not the essential quality of this voice tone. Another way of describing this sound is that it contains an ‘emphasis’. Emphasis means that one syllable, for example, of a three-syllable word, is louder. For instance, if a person says the word ‘exactly’ and emphasises the middle syllable – exactly. Another description of this sound is that it is clipped, implying an abruptness or sharpness. Such a voice can be quiet but assertive.

Some people have a voice tone that lacks any strength to it. This voice is unnaturally quiet or becomes so when the person is challenged or uncertain. It does not have the power or force that would be expected from that particular person. The practitioner often needs to strain slightly to catch what is being said. It is as though the voice cannot be projected sufficiently to easily travel across the intervening distance between the two people.

Box 25.5 suggests an exercise to develop the ability to discriminate sounds.

There are three important stages to recognising the inappropriate voice tone.

The first stage to remember is that the practitioner is aiming to identify the Element that is most out of balance. If the sound that resonates with Wood is the least appropriate voice tone, then this is evidence for the Wood Element being the CF.

The second stage is to learn to identify the sounds normally associated with anger, joy, sympathy, grief and fear and to be able to sort them out from other sounds and characteristics of the voice. When learning Five Element Constitutional Acupuncture people start with different talents. Some can only make some rough distinctions at first while others immediately have a much more conscious appreciation of the different voice tones and can imitate and recognise them with ease. It is useful for beginners to practise, perhaps using the exercises suggested above.

The third stage is to monitor three things simultaneously:

While monitoring these three areas, the practitioner needs to pick out which sound is most out of balance. This may sound easy, but it is a bit like patting the head, drawing circles on the stomach and making circles with the elbows, all at the same time. It requires practice to do each part separately before they can be successfully combined.

Of the four key diagnostic criteria used by Five Element Constitutional Acupuncturists, emotion is the most complex and any judgements about normality or appropriateness can have important moral and cultural implications. At the same time the inappropriate emotion provides one of the most accurate keys to a patient’s CF. By observing a patient’s least fluent emotion, practitioners can also increase their understanding of how this same emotional pattern appears in many other aspects of a patient’s life.

The English language distinguishes at least three descriptions of different types of emotions. These are an ‘incident’, a ‘mood’ and the ‘feeling capacity of a temperament’.

An incident creates a one-off emotion. For example, a person becomes very angry when insulted.

In contrast, a mood goes on for some time. For example, a patient may say they have been depressed on and off for several weeks. The statement about mood does not mean that the person has been having the emotion continuously. It suggests that the feeling comes and goes or surfaces from the background and becomes more foreground.

In further contrast, a temperament may predispose someone to incidents of emotion that are typical of that temperament. For example a person may describe her or himself by saying ‘I am a fairly happy person. I generally feel happy and always have been’ or ‘I tend to be an anxious person. I get frightened over the smallest things.’ A temperament is like a mood but one that is more entrenched in the person’s character.

The Element–emotion association is one of temperament. A person who has a particular CF is prone to experiencing certain emotions because the qi of that Element is constitutionally weaker. When the qi of an Element is healthy this permits the emotions associated with that Element to be expressed in a balanced way. When the qi of an Element is out of balance it means that the emotions resonating with that Element become less resourceful.

Because the CF is constitutional, people’s personalities, at least in part, develop around the imbalanced emotion. A Fire CF, for example, will have less resourceful emotions around joy, a Water CF around fear, and so on. Thus assessing emotions is really observing the qi of an Element.

When people’s most inappropriate emotion is on the surface it can easily be observed. For example, when people seem frightened about almost everything, they may be judged to have excessive fear that might, therefore, be used to support a diagnosis of Water.

Emotional expression is conveyed by observing different aspects of a person, for example, eyes, facial expression generally, the words a person uses, the tone of voice, the body posture and specific gestures. Sometimes the label for a person’s emotion may be obvious. At other times, it is less clear and different observers may disagree about what they observe. (See Ekman, 2007, Chapter 1, for the scientific case that the emotional expression of the face exists across cultures.)

Often patients will exhibit some of their emotions to the practitioner and there is no need to deliberately ‘test’ them. When practitioners just observe, however, they may not get information about all of the Elements. People are often happy to reveal some emotions, but not others. Also, a patient who is shy and withdrawn may avoid being expressive. The practitioner may have no idea that a particular emotion is so inappropriate or intense unless she or he evokes it. Emotion testing attempts to overcome these problems.

In contrast to observing a patient, a practitioner may ‘test’ a patient’s emotional response. ‘Emotion testing’ involves the practitioner consciously attempting to evoke emotions in the patient (see Box 25.6). The practitioner then observes the response. Does the patient respond at all? Does she or he respond more intensely than seems appropriate to the context? Does the voice, facial expression or body language change, and does this change indicate disharmony in the patient’s qi? The practitioner assesses whether the emotions resonant with each Element are in balance or out of balance. ²

At the crucial moment of testing the emotion, practitioners must be able to access the emotion inside themselves. No patient will respond to sympathy, joy, grief or any of the emotions if the practitioner is not authentic in its expression. Saying sympathetic words to someone will not touch them if it does not come from the heart. This is why practitioners must be able to access each of the emotions in themselves and why this is one of the most important goals in the inner development of the practitioner of Five Element Constitutional Acupuncture.

The limitations of the practitioner in the skill of emotion testing form one of the greatest obstacles to becoming an excellent diagnostician. It is the cause of many mistaken diagnoses. The practitioner tries to induce an emotion in a patient but because the feeling was not truly present, the patient does not respond as they would if the feeling had been authentic. In the example of testing grief given in Box 25.6, the patient will respond totally differently to two different practitioners. An acupuncturist who has good rapport and genuinely accesses grief about the death of the pet, will receive a different response from another practitioner who really thought grieving about a pet a bit pathetic. The ability to test grief, and all the other emotions, effectively depends upon such differences.

Emotion testing is like talking with a friend and from the outside it should be indistinguishable. The patient will be unaware that the practitioner is doing anything other than taking a case history and making rapport. An emotion test that is overt or is obvious to an observer has not been skilfully carried out.

Conversing with a friend does not require a high level of concentration. Emotion testing, however, does require focused awareness and while carrying out a test practitioners also need to:

The phrase ‘emotion testing’ is not an ideal one, particularly because the word ‘test’ is used in conjunction with emotions. It does, however, accurately describe what practitioners do. The ‘test’ evokes an emotional response resonant with an Element. The emotion is a movement of qi and this gives the practitioner a chance to observe the movement of qi resonant with a particular Element. There is no better way of prompting an Element to reveal its nature to the practitioner.

It is important for practitioners to be aware of the range of emotional responses of people from different cultures. (See Kaptchuk, 2000, footnote 16 on pp. 168–169, for a discussion about how people in one culture speak differently about their emotions from those in another culture.) It is much easier to have a sense of the appropriateness of emotional response if the patient is from a similar culture to the practitioner. It would be very hard, for example, for a practitioner born and brought up in the Midwest of the USA to have a great understanding of the emotional responses of an Australian Aborigine. Even among people from the same country there can be significant differences in emotional expression dependent upon age, gender, ethnic background, social class, subculture, etc. For example, grieving processes vary in different cultures. Different cultures tolerate very different levels of aggression amongst members. Men tend to accept sympathy from male practitioners less readily than from female practitioners. The practitioner must have a broad vision of these factors and make appropriate allowances.

A good level of rapport is essential when testing emotions. The degree to which a patient will reveal her or himself to the practitioner is in direct proportion to the level of rapport achieved. Patients are being asked to respond genuinely from the inside and to do this it is essential that they trust the practitioner. Without this trust patients will not normally show themselves, especially any of their painful emotions.

Sometimes opportunities present themselves. At other times practitioners need to generate them. For example, in order to determine if a patient has reasonably balanced anger, it is useful to be discussing some event where the patient was frustrated. Frustration tests the ability of a person’s Wood Element to make new plans when previous ones have been thwarted. For each emotion, there are some events that can easily lead to a ‘test’ situation. These are referred to in Table 25.2, Table 25.3, Table 25.4, Table 25.5, Table 25.6, Table 25.7 and Table 25.8, listing the testing process for each Element under the heading ‘Opportunity’.

At first, students think that opportunities to test occur only rarely and are difficult to create. With experience and by establishing a deep level of rapport with patients, they realise that more opportunities arise than they thought. They also realise that an opportunity to test grief may also be an opportunity to test sympathy, anger or another emotion. They can use the same event and simply nudge it in one direction or another, in order to elicit the emotion they feel they need to understand more. Once students understand what constitutes an opportunity, they can begin to create them (see Box 25.7).

Practitioners are frequently presented with a situation in which more than one emotion could be tested. For example, a complaint by the patient may generate a choice of testing either anger or sympathy. After this has become apparent, there is a moment when the practitioner has to make a choice. The practitioner will then need to decide if all of the criteria for the test are in place. These are referred to in Table 25.2, Table 25.3, Table 25.4, Table 25.5, Table 25.6, Table 25.7 and Table 25.8 under the heading ‘Criteria for a workable test’.

Once the practitioner has chosen an emotion, she or he needs to ensure that certain factors are present so that the patient can naturally experience the emotion. These are referred to in Table 25.2, Table 25.3, Table 25.4, Table 25.5, Table 25.6, Table 25.7 and Table 25.8 under the heading ‘When to test’.

This is the verbal or non-verbal ‘request’ to experience the emotion, to get angry, feel respected, etc. In order to understand another person’s emotions it is important for practitioners to understand their own emotions and be able to access them. The delivery of the test requires that the practitioner carrying out the test expresses genuine and congruent emotion. The delivery must be short and then stop. Examples of how such requests might be made are given in Table 25.2, Table 25.3, Table 25.4, Table 25.5, Table 25.6, Table 25.7 and Table 25.8 under the heading ‘How to test’.

Practitioners are evaluating the patient’s response (especially non-verbal) in the first few seconds after the ‘request’. Hence alertness and concentration are essential. Making the judgement accurately requires a level of experience and wisdom about how people respond in different situations.

In order to have a balanced viewpoint it is also necessary for practitioners to be aware of their own emotions and which situations evoke intense or inappropriate emotions in themselves. This will allow them to judge whether the patient’s response is ‘normal’, ‘inappropriate’ or, as is sometimes the case, hiding another emotion which is close to the surface, but not easy to observe.

The aspects to observe during an emotion test are the fluency and the intensity of the change evoked when the emotion is felt. Examples of how these observations are made are in Table 25.2, Table 25.3, Table 25.4, Table 25.5, Table 25.6, Table 25.7 and Table 25.8 under the heading ‘Evaluation’.

As testing is carried out several times, it is important that the practitioner has a quick way to notate the type of test and the judgement about the patient’s response. Stopping at that moment to write for thirty seconds will appear odd to the patient and rapport can be lost.

One way to notate the emotion tests is for the practitioner to use abbreviations for the emotions, for example, ‘J’ for joy. If the patient seemed unable to express anger about a noisy neighbour, even when it was obviously appropriate, then the practitioner might record ‘A → no A’. Ideally the practitioner will add a few words which remind the practitioner of the incident, for instance, writing ‘noisy neighbour’ might be a sufficient reminder.

The overall judgement about a test can be complex. The practitioner is looking for which of the patient’s responses to the emotion tests are the least fluent and most disturbed. Most patients have one emotion that is markedly more imbalanced than the others. In others several emotions are inappropriately intense or frequently expressed and it can be hard to decide which one indicates the CF. These judgements require the practitioner to review several of the patient’s responses and compare them to what is a normal response. The practitioner also needs to compare the ‘lack of fluency’ from one Element to another. Good recording helps to develop the practitioner’s ability to make this judgement. These judgements are usually made intuitively and in milliseconds, so when the practitioner is learning, it is useful to carry out the process consciously and slowly.