4. The Constitutional Factor
Chapter contents
The concept of the constitutional imbalance in Chinese medicine18
What do we mean by the Constitutional Factor?18
How does a practitioner diagnose the CF?19
Elements within Elements21
How does our Constitutional Factor affect us?22
Treating the CF23
The concept of the constitutional imbalance in Chinese medicine
The notion that people have a particular constitutional imbalance is very old and widespread in Chinese medicine. Ling Shu Chapter 64 is devoted to an exploration of Five Element constitutional types, based mainly on physical shape and aspects of a person’s character. Another system given in Ling Shu Chapter 72 outlines a four-fold yin/yang system that divides people into taiyang, shaoyang, taiyin and shaoyin types (see Flaws and Lake, 2000, p. 27). In Japan there is a strong tradition of treating people according to constitutional type. For example, there is a style based upon the six-fold system outlined in the late Han dynasty classic, the Shanghan Lun. Using somewhat different criteria it divides people into six types, taiyang, shaoyang, taiyin, shaoyin, yangmimg and jueyin (Schmidt, 1990). Master practitioners such as Fukushima and Honma (Eckman, 1996) have also developed styles that diagnose and treat constitutional types. In Korea, Kuon Dowon teaches yet another constitutional style (see Eckman, 1996, p. 209).
The phrase that is currently used in Chinese medicine today to describe a person’s constitution is chang ti, which means ‘bodily type’. This is an appropriate phrase to describe diagnosis that is primarily based upon the physical shape of the person’s body (see Maciocia, 2005, pp. 292–298, or Requena, 1989, pp. 81–93, for discussion of these systems). J. R. Worsley, however, developed his style based upon completely different diagnostic criteria, which are set out in the Nei Jing and Nan Jing. The practitioner’s focus is on certain signs that arise as a patient’s qi goes out of balance.
What do we mean by the Constitutional Factor?
The Constitutional Factor, known as the CF, is one of the most important concepts in Five Element Constitutional Acupuncture. J. R. Worsley used the phrase ‘Causative Factor’ because, as it is the primary imbalance, it ‘causes’ other Elements to become imbalanced. Although this is true there are also other causes. Along with many other practitioners of this style we prefer, for clarity, the term ‘Constitutional Factor’. The word factor is used, partly because it is the word used by J. R. Worsley and partly because it is commonly used in Chinese medicine, as in ‘pathogenic factor’. It is the main focus of the practitioner’s diagnosis and much of the patient’s treatment is centred on it. Because it is the patient’s most underlying imbalance it creates much of the imbalance that can be detected in other Elements. For this reason, as it returns to a better state of health through treatment, it in turn enables many other imbalances to respond and improve. Many of the most dramatic and profound changes that patients can experience from acupuncture treatment are achieved by focusing treatment on it.
The word constitution is defined in the Oxford English Dictionary as: ‘The character of the body as regards health, strength, vitality, etc. Condition of mind; disposition; temperament.’ The concept of a person’s constitution covers both the physical body and the mind and temperament. The word gives a sense of a person’s constitution having lifelong characteristics that may manifest in their physical health or psychological make-up.
There is some debate amongst practitioners of Five Element Constitutional Acupuncture about whether the CF is always inherited or whether it can be acquired in early childhood. Examining the occurrence of the same CF in several members of different generations in a family suggests that many constitutional imbalances are carried in the genes. The person’s responses to subsequent traumatic life situations further imbalance that Element. Other Elements are also affected over time but the CF is the person’s Achilles heel and is the most vulnerable.
Just as people can inherit diseases or weaknesses in particular Organs, people can also inherit imbalances in their temperament or disposition depending on the balance of the Five Elements. The ‘nature versus nurture’ debate is probably irresolvable and will continue wherever people study humanity, whether they are psychologists, educationalists, acupuncturists or anyone interested in the formation of character. The key task of the acupuncture practitioner is to diagnose the pattern of the person’s imbalances and to assist them to achieve a better state of health.
According to Chinese medicine theory the jing is the main vehicle by which imbalances are handed down from generation to generation. Jing is governed by the Kidneys and determines people’s constitutional strength or weakness. This is different from the CF. It is obvious that not all congenital imbalances are found in people’s Kidneys. Just as, for example, heart problems or skin problems can be inherited, so also are imbalances in any of the Elements or Organs.
How does a practitioner diagnose the CF?
The four diagnostic signs
The four diagnostic signs are:
• the emotion that has the most inappropriate expression in the person
• the colour can be observed on the face, particularly on the lower temples beside the eye
• the odour that is emitted by the body
• the sound present in the voice, particularly a tone that is not congruent with the emotion being expressed.
As well as focusing on these four signs, a practitioner also concentrates on assessing the nature of the person’s character in the light of the Five Elements and twelve Officials (see Chapters 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22, this volume, for a discussion of the Elements). The idea that imbalance of an Organ or Element produces these energetic signs comes from both the Nei Jing and the Nan Jing.Chapter 34 of the Nan Jing, Su WenChapters 4 and 5 and Ling Shu Chapter 49, amongst others, outline the emotion, colour, sound and odour that ‘resonate’ with each Organ. The odour, colour, season and climate are also given in the Huainanzi, a non-medical Han dynasty text.
Chapter 16 of the Nan Jing says that when a person’s Organ becomes distressed the emotion and colour associated with that Element will manifest themselves. The Ling Shu laid down the basic idea by stating, ‘Examine the external resonances of the body to know the body’s inner viscera’ (Wu, 1993, Chapter 47). These four signs enable practitioners to use their senses and intuition to discern which Elements have become dysfunctional.
The importance of diagnosing by signs
This emphasis on diagnosing purely by signs is a distinctive feature of this style. (The use of pulse diagnosis and palpation of the body to reveal signs is discussed in Chapter 28, this volume.) Chronic physical symptoms are usually regarded as merely a manifestation (biao) of the primary underlying imbalance (ben), and should not distract the practitioner. Even if a patient has obvious signs or symptoms of a congenital or constitutional imbalance in a particular Organ, for example, a heart abnormality or being born with only one kidney, this offers no clue to the person’s CF. Diagnosis by signs always takes precedence over physical symptoms when diagnosing the CF. In practice, a significant physical dysfunction is often in the CF Element, but it cannot be relied on diagnostically.
Su Wen Chapter 54 and Ling ShuChapter 3 both stress that the practitioner should not rely only on symptoms for making a diagnosis. In fact, hoping to reach a diagnosis of the person’s CF by questioning patients about their physical symptoms or even their own perception of their emotional tendencies is regarded as missing the point. As it says in Nan Jing Chapter 61:
To be able to make a diagnosis by observation alone is to possess divine power. To be able to make a diagnosis by hearing alone is to be a sage. To be able to make a diagnosis by questioning alone is to be skilled physician.
(Lu, 1972)
That said, there is no doubt that basing nearly all of the diagnosis on signs and virtually none on symptoms is an extremely difficult path to follow. Practitioners who practise Five Element Constitutional Acupuncture without integrating it with another style pay little attention to the information that can be gained from questioning the patient. This places huge demands on the practitioner. Depending on their inclination, this style suits some practitioners more than others.
Practitioners of Five Element Constitutional Acupuncture need to hone their senses in order to become adept at diagnosis using only signs. Liu I Ming writes of the ‘encrustation of the senses’ (Cleary, 2001, p. 66). It is this numbing of our sensory perception that has to be transcended. Much of an acupuncturist’s training, both while a student and throughout their career as a practitioner, is devoted to refining sensory and intuitive faculties.
Diagnosis by assessing the emotion
Of the four diagnostic signs the emotion is probably the most reliable indicator of the CF. The ability to use the intuition (zhiguan) to gain insight into the patient’s emotional life is therefore one of the most important skills that the practitioner needs to develop. As the Huainanzi stated, ‘The external is manifest, the internal is concealed’ (Major, 1993, Chapter 7).
Practitioners need to develop the ability to understand the balance of the qi of the Five Elements. To do this they interact with the emotions of the patient. As emotions arise, they create movements in the patient’s qi (see Chapter 5, this volume). Patients will often attempt to hide their emotions, especially when they are intense or painful. In Britain, for example, mastery of the ‘stiff upper lip’ is much admired. The art of the practitioner lies in discerning these movements of qi, however well the person tries to hide them. The movements that arise in the qi inevitably also produce subtle changes in the person’s voice tone, eyes, face and body language (see also Chapter 26, this volume). This enables the practitioner to decide which emotions are producing the greatest disturbance in the person’s qi and how appropriately or inappropriately these emotions are being expressed.
The concept of ‘inappropriate’ emotions
The sage is joyous because according to the nature of things before him he should be joyous, and he is angry because according to the nature of things before him he should be angry.
(Ch’eng Hao; quoted in Chan, 1963, p. 526)
When a loving relationship is abruptly ended, the practitioner expects a patient to feel sad and hurt. It is ‘inappropriate’ if another emotion, such as anger, the need for sympathy or fear is the most powerful or prolonged emotion exhibited. It probably means that either:
1 The person finds it difficult to experience feelings of hurt and rejection and finds it easier to express another emotion instead. It is, for example, sometimes less painful for people to express their anger than to fully experience their profound sense of abandonment. This means that the person’s Fire Element is not healthy and may be the CF.
or
2 Fire is not the CF and the inappropriate emotion gives a valuable diagnostic clue to the CF.
In this situation, it is relatively straightforward for the practitioner to determine the range of emotional response a person might exhibit. In many situations, it is far less clear and there may be a range of emotions that must be regarded as appropriate. Being aware of the ‘structure’ of emotions makes it easier for the practitioner to assess the appropriateness of an emotion (see Chapter 25, this volume, for further details). There are no easy objective criteria in this form of diagnosis, however.
It is essential that the practitioner respects the individuality of the patient at the same time as drawing conclusions concerning which emotions are being inappropriately expressed. Which emotions weaken the person and which help them to express themselves in the world? For one person, getting irritable and impatient one more time is another step away from good health. For another, becoming able to assert and stand up for her or himself against a tyrannical boss or partner strengthens the person significantly. Are the tears the patient is shedding a mark of strength or weakness? Does the expression of an emotion enhance or diminish the person’s vitality and life?
The answer also partly lies in the practitioner evolving an idea of how a person would be if they returned to a state closer to their ‘true nature’. Many people, for example, fearful of the consequences of their fiery temper in childhood, repress their anger to such an extent that they become diminished and excessively inhibited in themselves. Much as being more hot-tempered might make their life difficult in many ways, it is only by returning to something closer to their ‘true nature’ that they can hope to recover their inner vibrancy and strength.
Diagnosing only by signs is not always difficult, however. Once a practitioner, or even a student, becomes familiar with the key resonances, it is possible to diagnose some people almost immediately. Some patients wear their CFs on their sleeves. When they have voices that laugh, and they easily bring joy and warmth to a room, their CF is very likely to be in the Fire Element. For practitioners to be sure of their diagnosis they also need to ascertain the odour and the colour, but having two of the four diagnostic criteria is sufficient to make a tentative diagnosis.
Confirming the diagnosis of the CF
A practitioner of Five Element Constitutional Acupuncture confirms the diagnosis through treatment. This is done in two main ways:
• by observing improvement in the patient’s signs
• by an improvement occurring in the patient’s overall health and well-being.
Improvement in the patient’s signs
During the course of treatment emphasis is placed on detecting changes in the patient’s signs. For example, the practitioner looks for a lessening in intensity in the patient’s colour, sound, emotion and odour during the treatment session. If this occurs it is an excellent indication that the treatment is on the CF. Over the course of treatment the practitioner constantly monitors these key signs. Pulse changes are also extremely important and overall improvement in the quality of the person’s pulses is an indication that the Element treated is probably the CF.
Improvement in the patient’s overall health and well-being
Over the course of treatment amelioration of symptoms is obviously vital. When confirming the CF it is especially significant when the symptoms are linked with Organs not associated with the CF. For example, initiating improvement in the Lungs while treating the patient on the Fire Element.
A positive change in how patients feel ‘in themselves’ may manifest as improved vitality, greater joie de vivre, feeling more relaxed, more tolerant, more self-assured, more emotionally resilient or in other ways that are difficult to describe, but are none the less very real for the patient. Changes in how people feel in themselves are often crucial to their ability to heal their chronic symptoms. Emotions primarily affect the spirit. Illnesses produced by stress and unresolved emotions cannot be cured without a change in the person at this level (see Chapter 5 for a discussion of the causes of disease).
A positive change in a person’s sense of well-being is therefore not just a bonus on top of the alleviation of symptoms, but an essential part of their return to a long-term better state of health.
Elements within Elements
Once the patient’s CF has been diagnosed, practitioners may attempt to refine their diagnosis so that they can more accurately discern the nature of the imbalance. One way of doing this is by diagnosing the Element within the Element. The Ling Shu Chapter 64 also sets out the idea that each Element is represented within each Element. Qi Bo says:
First establish the five appearances of Metal, Wood, Water, Fire and Earth. Separate them into the five colours. Differentiate them into the five body types of man, and then the twenty-five types of men as a whole.
(Lu, 1972)
This is reflected in the attribution of a point on each channel that corresponds to each Element. The Earth point on the Heart channel, for example, is shen men or Heart 7; the Water point is shao hai or Heart 3, etc.
An Earth CF, for example, may be deficient in Water within the Earth. This could lead to the body fluids drying up and a more agitated and insecure personality. Patients can also have excess Water within Earth. In this case they might exhibit an excess of body fluids and perhaps a stodgy mind and character. This diagnosis can only be made by perceiving, for example, that the yellow on the face is a bluish kind of yellow, that the singing tone of voice is a groaning kind of singing, that the odour is a putrid kind of fragrant and a fearful craving for sympathy. This is obviously a very hard diagnosis to make. It is extremely difficult to differentiate between someone whose CF is Earth and whose Water within the Earth is also imbalanced compared with someone whose CF is Earth, but the Water Element itself is imbalanced. 1
The diagnosis and treatment of patients at this level requires considerable experience and aptitude and is necessarily beyond the scope of this book. However we give a brief introduction in Appendix H.
This difficulty in diagnosing and treating the Element within the Element was even noted by Po-Kao when talking to the Yellow Emperor.
Yellow Emperor ‘….I wish to hear about the physical shapes of the twenty-five categories of people, how their qi and blood are governed, how to distinguish them from their appearances, how to infer their internal conditions from their external outlooks; could you tell me about such things?’
Po-Kao replied, ‘That is indeed a complete question. But it is the secret of the ancient teachers, and even I am unable to understand it.’
(Ling Shu, Chapter 64; Lu, 1972)
How does our Constitutional Factor affect us?
The effect of the CF on the emotions
The CF inevitably shapes a patient’s responses to the circumstances of their life. It may affect their physical shape or function, the way their mind works and the nature of their character. By definition the emotion that resonates with the Element of the CF is also out of balance.
Situations are bound to arise that provoke emotional responses. How these manifest are affected by a person’s CF. Certain situations are obviously inclined to provoke certain emotions. For example, if somebody one loves dies, it is normal to experience grief. Metal CFs are likely to have more dysfunctional reactions to this particular situation than other people. They may be flooded with feelings of loss to such an extent that their spirit never fully recovers. They may generate physical symptoms and they may be unable to return to their previous state of relative balance. Some Metal CFs go to the other extreme and are unable to fully access the feelings of loss. This may also have a lasting impact on the state of health of the person’s Metal Element. As Proust said: ‘We are healed of our suffering only by experiencing it to the full’ (A la Recherche du Temps Perdu).
A profound grief can obviously seriously affect people who are not Metal CFs. How much their Metal Element is affected depends on the state of their Metal Element and the state of their qi in general. Metal CFs, however, are particularly inclined to find grief difficult to deal with.
It is also often the case that a particular situation evokes a complex mixture of emotions in a person. For example, very different emotions may be felt when people lose their jobs. Anger directed towards the company, a sense of loss, anxiety about the future, a need for support and sympathy or a sense of emotional flatness may all be felt. Which feelings predominate is partially determined by the specific nature of the situation, but most crucially they are shaped by the temperament of the person. For example, a Wood CF whose tendency is to be excessively angry will be inclined to struggle most with the feelings of anger that arise from the redundancy. A Water CF who is inclined to be fearful may well be most affected by the anxiety inherent in the situation. The person’s CF, as well as the state of the qi of the other Elements, accounts for why different people respond differently to the same event.
Positive characteristics arising from the CF
Practitioners understandably usually concentrate on how the CF makes it difficult for patients to lead spontaneous, happy and fulfilled lives. People’s CFs also give them strengths, however. Practitioners may diagnose the excess joy in a Fire CF as a pathological sign. This excess joy may, however, also mean that the person has an extraordinary ability to bring joy into other people’s lives. The ‘tears of the clown’ may be excruciating to the clown, but he or she comes to life once the band strikes up and the spotlight picks out the figure. Only certain people have this ability to bring joy to a crowd of people (the strengths that the different CFs can manifest are discussed in more detail in Chapters 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22, this volume).
Treating the CF
Nourishing the root (yangben)
One of the strengths of Chinese medicine is its understanding of how imbalances in a person’s qi manifest in signs, such as the pulse, the colour on the face, voice tone, odour, etc. This enables the practitioner to concentrate treatment on the Elements emanating such signs, sometimes before symptoms have arisen. This initiates change at the root of the patient’s disharmony. Su Wen Chapter 77 outlined the emphasis many great practitioners of antiquity placed on tracing illnesses back to their origin: ‘The sages…, knew the root and the beginning of the illness’ (Su Wen, Chapter 77; Unschuld, 1992).
The following quotation also recognises this:
The foundation for the treatment of illness is that one must seek out the root … if one does not know how to seek out its root, then one’s treatments are as vague as if one was gazing at the wide sea and would not know how to ask for water.
(Yu Chang)
Each Element is in relationship with the other Elements through the sheng and ke cycles. This is crucial to the practitioner’s understanding that change is created in any Element by treating the CF. As discussed in Chapter 2, the Elements are not discrete entities but phases in a cycle. Any change in the condition of an Element inevitably has an effect on the other Elements to some degree. One of the key aspects of treatment focused on the CF, the weakest link in the chain, is the extent of changes evoked in other Elements. The pulses normally become more balanced and stronger.
When a patient is in a life-endangering situation, concentrating treatment exclusively on the root is not appropriate. There are also some situations when a practitioner might find that treating the underlying constitution is inappropriate, for example, when treating some musculo-skeletal disorders or acute infections.
Chronic diseases, however, form a large percentage of conditions presented to practitioners in the West. It is these chronic conditions that respond so well to treatment on the CF.
The importance of minimum intervention
One of the advantages of focusing treatment on the CF is that the practitioner needs to use only a small number of points when treating. Some patients require treatment on several different channels in order to respond satisfactorily. Many patients, however, even those with severe and complex conditions, improve hugely with the use of only a few points.
The ethos of minimum intervention has been much prized by many acupuncture practitioners over the course of history. The great physician Hua To (+110 to +207), for example, was admired for only using one or two points in his treatments.
As for moxa, he applied it to no more than two places and not more than seven or eight times in one place. In needling two places were sufficient and often only one.
(Li Chan: Soulié de Morant, 1994, p. 10)
A thirteenth century ode, describing some of the great practitioners of the past, asserted:
What these doctors (who used what is known as spiritual healing) in all sincerity thought most highly of was a single needle inserted into a hole, the disease responding to the hand and it lifting. In recent times, this class of doctors has nearly broken from tradition.
(Da Cheng; Bertschinger, 1991, p. 17)
This kind of ‘spiritual healing’ is only possible because changes in the qi of one Element affect the qi of other Elements through the complex relationships of the sheng and ke cycles. Practitioners who do not give these processes a chance to operate lose the chance to discover whether the patient can get better by nourishing just the root.
Preventive treatment
Practitioners of Five Element Constitutional Acupuncture place a high value on preventive treatment. Once the Five Elements have returned to a state of greater balance between themselves, patients can expect to enjoy better physical and psychological health. They may then wish to continue treatment in order to stay healthy. The idea of the physician using treatment in order to help patients to avoid illness is often referred to in the classics of Chinese medicine. However, the story that in antiquity patients paid their physician when they were well and not when they were ill, touching tale that it is, appears to have no basis in fact.
When medicinal therapy is initiated only after someone has fallen ill, when there is an attempt to restore order only after unrest has broken out, it is as though someone has waited to dig a well until he is already weak from thirst, or as if someone begins to forge a spear when the battle is already underway. Is this not too late?
(Su Wen,Chapter 1; Unschuld, 1992, p. 283)
The really excellent physician controls disease before any illness has declared itself, the man of middling art practises acupuncture before the disease has come to a crisis, and the inferior practitioner does it when the patient is declining and dying.
(Nan Jing, Chapter 61; quoted in Yang and Chace, 1994)
Focusing treatment on symptoms does not ultimately prevent disease from occurring. This is because preventing disease involves harmonising the underlying imbalance that occurred before symptoms arose. The emphasis on diagnosis using signs enables the practitioner to diagnose before symptoms develop. Treatment focused on the CF, or root, lessens patients’ predisposition to suffer future problems. This concept of the ‘Achilles heel’, which may lead to physical and/or psychological illness, is fundamental to the concept of the CF.
In +500, T’ao Hung-Ching wrote in the herbal classic Shen Nong Ben Cao:
Who, except a brilliant physician, can recognise a disease which is not yet a disease by listening to the tones of the patient’s voice, examining the colours of the face, or feeling the pulse?
(Chung, 1982)
Fulfilling our potential
Some people may think that the goal of diagnosis is to fit people into one of five boxes, but this is to seriously misunderstand the approach of practitioners of this style of acupuncture. Everybody is unique. The responsibility of the practitioner is to honour that uniqueness. One of the goals of treatment is to assist people to fulfil their potential, to achieve their ‘contract with heaven’, or their destiny. 2 It is not that practitioners desire patients to be ‘balanced’ in a way that robs them of their individuality. On the contrary, it is disharmony of qi (sometimes in the body, but more commonly in the mind and spirit) that holds people back from achieving their potential. The spirit of writers, artists or musicians often shines through more fully in the creativity of their work if they are strengthened through effective acupuncture treatment. (The authors have treated a number of artists and writers who have attributed the end of a fallow period to acupuncture treatment.) To see people change because the depth of their spirit has been touched by treatment, is one of the greatest joys of practice.
2See Jarret (1998), for example, pp. 28–32, for discussion of the Chinese concept of each person having a ‘contract with heaven’ ming, an individual obligation to achieve one’s own destiny. Confucians were inclined to see this as being achieved by fulfilling one’s duty to society and the family and cultivating the classic Confucian virtues. Daoists typically were inclined to have a much less structured and more mystical vision of how best to ‘nourish their destiny’.
Harmonising our qi
In the Han dynasty the goal of acupuncture treatment was to harmonise the patient’s qi with that of Heaven and Earth: ‘Unite these two to make a whole person. When they are in harmony there is vitality. When they are not in harmony there is no vitality’ (Nei Yeh; Roth, 1986, p. 619).
Practitioners of Five Element Constitutional Acupuncture also strive for this and the method for doing this is to concentrate on enhancing and harmonising the Five Elements. This is largely achieved through treatment of the CF. As the patient’s Five Elements become more balanced the mind and spirit become more settled and the emotions become less inappropriate. Patients frequently report feeling as well as they did earlier in their lives. The goal is balanced Elements and therefore appropriate emotions. The Han dynasty text, the Zhong Yang, describes this as: ‘The state when the emotions are aroused and relaxed, each attaining its appropriate measure, limit and articulation, is called harmony’ (Davis, 1996).
Confucius described it in another way:
Before the feelings of pleasure, anger, sorrow and joy are aroused it is called equilibrium (chung). When these feelings are aroused and each and all attain due measure and degree, it is called harmony. Equilibrium is the great foundation of the world, and harmony its universal path. When equilibrium and harmony are realised to the highest degree, heaven and earth will attain their proper order and all things will flourish.
(Chan, 1963, p. 98)
Summary
1 The Constitutional Factor (CF) is the primary imbalance in the person’s qi. It is usually present at birth, certainly by the end of infancy, and remains constant throughout a person’s life.
2 Diagnosis is mainly by signs rather than symptoms. These are predominantly the inappropriate emotion, the colour on the face, the sound of the voice and the odour.
3 Emphasis is placed on improvement in the signs and the person’s feeling of well-being rather than on the alleviation of symptoms.
4 The CF has a profound effect on how people respond, either positively or negatively, to different life situations.
5 A high value is placed on the practitioner needling as few points as possible.
6 Using acupuncture to treat patients preventively in order to enhance their state of health and reduce the likelihood of future illness is regarded as important.
