The most common reason why a patient doesn’t immediately respond to treatment is because the practitioner has not yet discovered the patient’s CF. Below are the most common reason why CFs can be confused.

Some Wood CFs cover up their anger with sociability and laughter. If this is the case they are more likely to stay ‘up’ and laughing for a prolonged period of time. The laughter is likely to be more loud and raucous than that of the Fire CF. Some Wood CFs also love poking fun at others as their humour often has an aggressive edge.

When Wood CFs are depressed they can also descend into deep gloom. This could be mistaken for a lack of joy. The depression of a Wood CF is caused by internalised anger that is unexpressed. Because of this Wood CFs often feel somewhat better when the source of frustration has been removed whilst a Fire CF is more likely to brighten up when given warmth or a compliment by someone else.

When Earth CFs want sympathy but feel that no one is giving it to them they may feel angry. This can give a practitioner the impression that they are Wood CFs. However, when Earth CFs are then given the support and consideration that they want, they change and feel better (see Shifrin, Chapter 15, p. 169, in MacPherson and Kaptchuk, 1997).

When Earth CFs tend to reject sympathy they may appear to be hard and angry and can also be mistaken for Wood CFs. This is because they find the sympathy difficult to deal with and harden themselves in order to keep it away.

The qi of many Wood CFs naturally travels outwards. As a result they may be very giving and benevolent by nature. This may make it easy to mistake them for sympathetic Earth CFs. The object of their sympathy is frequently a cause they are supporting and their motivation is seeking justice. It is important to assess their colour, sound, emotion and odour to ascertain whether their behaviour is pathological or not.

Wood CFs and Metal CFs may both have a slightly impenetrable exterior and pretend that they don’t care about what others think of them. They may both also have a strong sense of their boundaries. Metal CFs have strong boundaries because they feel fragile and wish to protect themselves from ‘attack’. They can have a cutting anger, especially when they feel that their boundaries have been invaded or they have not been treated respectfully. In this case they could be mistaken for an angry Wood CF. Many Wood CFs hold back on fully expressing their anger. Instead they express it indirectly, causing them to make cutting remarks. In this case they resemble a critical Metal CF.

Both Wood and Metal CFs may also have quiet voices – the Wood CF’s voice may be lacking in a shout and the Metal CF may have a weak voice because their lungs and throat are not strong.

Water CFs’ fear may cause them to become threatening. Rather than being intimidated they may react to these ‘threats’ by intimidating others and ‘getting their retaliation in first’. In this situation it is common for them to be mistaken for a Wood CF. In this case if Wood, the ‘child’ Element, is treated it may be effective for a short time but the treatment will ‘run out’. This may indicate that the practitioner should then test the mother, Water, as the CF.

A Wood CF who is lacking in anger can also be mistaken for a Water CF. The person is likely to be timid and this is often mistaken for the fear of a Water CF. Colour, sound, emotion and odour are obviously crucial but, in terms of behaviour, it is the lack of assertion that is mistaken for fearfulness and suggests Water.

Earth and Fire CFs are both often ‘people persons’. Both can be upbeat and can put a lot of their energy into others. Both are often hungry for more contact with people. It is important to observe exactly what they are trying to obtain from others as Fire CFs’ need to give or receive love and warmth can be mistaken for Earth CFs’ need to give or receive emotional support. This is a very common mistake (especially in patients who, in the viewpoint of TCM, suffer from Spleen qi xu and Heart Blood xu; the key is to discern which syndrome is primary).

Worry can also be mistaken for anxiety. The worry from the Stomach and Spleen may be centred around the abdomen whilst the anxiety from the Heart will usually be felt in the chest.

Confusing Fire and Metal CFs is a common mistake made by many practitioners. The white facial colour can be mistaken for ‘lack of red’ and at the same time the unhappiness of the Fire CF is often confused with the grief of the Metal CF.

Sadness (bei) affects both the Fire and Metal Elements and grief (you) is also held in the chest area. It is important to assess the emotions carefully. Fire CFs are more likely to become joyful then drop into sadness. Metal CFs are less likely to go up and down but will have difficulty taking in respect. In general, Metal CFs are less volatile and more brittle. They are also less inclined to be driven to make intimate contact with the practitioner.

Water CFs can easily be mistaken for Fire CFs because a common way for them to cover up their fear is by smiling and laughing. Laughter is a person’s most sociable emotion so it is often used to hide fear and give the appearance of ease and comfort. These are qualities many Water CFs would love to project. The practitioner may notice that the patient never goes into a state of lack of joy. They may then wonder what other emotion lies behind the joy and may see that the joy covers up fear. Often the laughter of a Water CF is more of a nervous laugh or titter or a phoney raucous laugh. It probably fails to elicit joy in others.

Fire CFs can also be mistaken for Water CFs if they are extremely anxious. Shock or fright affects both the Heart and the Kidneys. For many people who have had rather traumatic lives both these Organs can be extremely imbalanced. If the shen is disturbed, it can cause the person to feel panicky or have difficulty sleeping. If the Fire and Water are out of harmony, it can make the diagnosis more confusing and it can be difficult to tell which Element of the two is the primary imbalance. Colour, sound, emotion and odour, as ever, are essential in finding the primary imbalance.

Earth CFs may cut themselves off from others in order to push away sympathy. In this case they may appear distanced and hard and may be mistaken for Metal CFs who are cut off for other reasons. Earth CFs may also be desperately unhappy and this can be confused with the sadness evident in many Metal CFs.

Earth is the mother of Metal and when the Earth Element is the underlying cause of a person’s problem signs and symptoms may initially appear to be coming from the Metal Element. If the Metal Element is treated it may have some effect but treatments will tend not to hold until the underlying cause, which is in the Earth Element, is treated.

Earth CFs can become very agitated and fearful if they feel that their security is under threat. This is especially true for Earth CFs who lack strong feelings of internal security. This may give the appearance that they are Water CFs. The Earth CFs need support, however, and sympathy and support will tend to settle their agitation.

In comparison, Water CFs who don’t get reassured can keep asking for more and more reassurance. The need for reassurance can be mistaken for the need for sympathy. In this case it is the opposite way around. No amount of empathy and support will appease them. Worry, anxiety and fear are words that are used interchangeably by some people, and these two emotions can easily be mistaken for each other.

Commonly both Metal and Water CFs have more internal and yin emotions. They show their feelings less than Wood, Earth and Fire CFs whose emotions are more yang. Metal and Water CFs may therefore be more difficult to understand. They are often more hidden and enigmatic. This can cause these two CFs to become confused.