Chinese medicine and acupuncture have made considerable progress in the West and seem to be becoming more acceptable as complementary and alternative therapies. Without care and caution it is conceivable that these might be absorbed into western medical approaches and styles of thinking with the attendant danger of losing sight of what was important about the ancient Chinese philosophy that produced them in the first place. These kinds of issues mark the way for acupuncture in the West in the 21st century and are briefly explored here in relation to a range of conceptual frameworks drawn from the philosophy of science, psychology and social studies of science which highlight where and how these issues might arise.
Key words: acupuncture, qi, Chinese medicine, paradigms, thinking styles, experiential, rational-analytic, East and West, worldviews
That all thinking is grounded in analogization shows up especially clearly when we try to come to grips with the thought of another civilization. The concepts which it assumes as self-evident, until persistent failure to solve a problem calls attention to them, appear to an outsider as strange metaphorical structures to be examined as he learns his way around the conceptual scheme. Graham (1992, p.59)
Generally, acupuncture practitioners in the UK may have been trained in traditional Chinese medicine (TCM), Five Elements acupuncture, or a combination of the two. Following their basic training, acupuncturists may have ventured into other Asian approaches to acupuncture such as Japanese or Korean traditions and they may also have started to develop their own idiosyncratic perspectives on conducting treatments. Practising acupuncture involves a long journey with many possible diversions and the further people progress along these routes the more difficult it may seem to reconcile the differences between the different traditions and forms of practice. It is not difficult to notice the tensions that arise between proponents of these different expressions of acupuncture. As examples of these, see for instance, the debate between Peter Deadman and Lonny Jarrett in 2004-2005 over whether Chinese medicine can treat the spirit or mind. Notice also, the recurrent discussions of specialisms with cases being put forward by proponents who think it is a natural progression of Chinese medicine practice and counter-advocates arguing that this practice risks severing acupuncture from its classical roots. Different views of what Chinese medicine and acupuncture can do are influenced by our thinking styles and the ‘worldviews’ we embody. Acceptance of acupuncture in the West, the way it is practised, and what we expect of it is influenced by these factors, so it is worth exploring these to understand more fully the current practice and presentation of acupuncture in the West.
Acupuncture in context The practice of acupuncture is very old, some would say it originated more than ten thousand years ago in China’s Neolithic age (Zhen, 1984). Reasonably blunt instruments were probably used to induce pressure more than puncture (and combined with moxibustion), or sharp stones were used to incise abscesses to remove pus. Linking acupuncture with the development of recognisable metal needles puts acupuncture in the first century bce (Bai & Baron, 2008). The difficulties in identifying the original approaches which lie in the far past are at least made up for by the conservatism of Chinese society which meant that methods and records are at least available for more than 2000 years with texts like the Huang Di Nei Jing Su Wen Ling Shu. It seems that acupuncture may also have existed over 5000 years ago in the West as evidenced by the strategic placing of tattoos on acupuncture points found on the preserved body of the Tyrolian Iceman (Dorfer, Moser, Bahr, Spindler, Egarter-Vigl, Giullën, Dohr, & Kenner, 1999). Whether acupuncture stretches back further and travelled from China to the West earlier than we think, or whether it existed more widely in the old world than we might have expected we will probably never know. Whatever the starting date for acupuncture, it seems clear that the originators had a very different view of the body, illness and health than we do today.
Prior to the modern period, Chinese medicine was practised differently in different regions (Unschuld, 1985) and was propagated through ‘schools’, kinship or family traditions (Scheid, 2002). More recently, acupuncture has seen an overhaul with the invention of traditional Chinese medicine in the medical schools of China since the Cultural Revolution (Scheid, 2002; Hsu, 1999). This seems to have involved the construction of a modernised and westernised version of Chinese medicine which omitted many concepts with spiritual connotations and instead borrowed modern western medical concepts. Today, we often hear that western and Chinese medical services exist side by side in Chinese hospitals in a display of eastern pragmatism and professional cooperation.
Already, in this very brief history, we have a view of acupuncture having developed historically to the modern position where it might be seen as compatible with western medicine, if it was not for the thorny concepts of qi. Acupuncture is all about qi. In fact it is very difficult to escape qi in any sense when thinking from an eastern perspective. Qi is fundamental to ancient Chinese thinking and underpins many fields of endeavour (Zhang and Rose, 2001). Qi has been translated as ‘vital energy’, although many are unsure that this term adequately conveys what qi is, especially where this has been adopted alongside and influenced by western definitions of energy by some, (eg, Soulie de Morant, 1994). It has been translated as ‘configurational energy’ or ‘configuration’ in Porkert’s Sino-arteriology, which tried to establish a Latinised terminology which might be more palatable to western medicine (Porkert, 1974). It has been imagined in Chinese thinking as something that flows like water (Allan, 1997) but which is relatively intangible and it is used in modern Chinese as a term to describe a multitude of things, from the air in a tyre to the bad feeling in a room (Zhang and Rose, 2001). The nearest we in the West can approximate to qi is the ancient Greek idea of pneuma which translates conveniently, like qi, as air or breath with vitalising characteristics. Since everything is ultimately qi in Chinese philosophy (Hayashi, 1995), some Sinologists such as Graham (1989) have explicitly avoided attempts at translation. The translation of qi and other concepts of Chinese medicine require some awareness of the way that we think about the world we encounter and what processes are involved in conceptualising it.
Eastern and western thinking One of the main hindrances to understanding Chinese medicine in the West is that it developed in a philosophical context quite different to modern western disciplines such as biomedicine. It is notable that thinking in Chinese medicine is portrayed as holistic, while its western counterpart is analytic. How did these two perspectives develop? And why do they characterise eastern and western thinking? It seems if we go far enough back in history we see both styles of thinking represented in the eastern and western context. Although most western thinking was analytic, the pre-Socratic philosopher Heraclitus (5th century BCE) could have easily been taken for a Daoist. So much so, that one wonders when the stories tell of Lao Zi leaving for the West whether he decided to choose a nice Greek name once he arrived!
Everything flows and nothing abides; everything gives way and nothing stays fixed. (Heraclitus in Wheelwright, 1959, p.29)
Conversely, while most thinkers in the East adopted more holistic styles of thinking, Mo Zi and his followers in 5th century bce China were concerned with logic, geometry, mechanics and economics (Graham, 1989). So it seems that East and West had both these general philosophical orientations available to them but took diverging paths in the expression of formal thinking about 2500 years ago. In academic circles Heraclitus’ thinking eventually lost out to Aristotelian thought in the West and Mo Zi held less influence in the East compared to Lao Zi, Zhuang Zi and Confucius. This is a strange idea to be faced with, that perhaps the different thinking styles exhibited in Orientals and Caucasians even today were adopted or already employed as predominant orientations over two thousand years ago. The East generally used holistic and the West analytic thinking. These two types of thinking have been identified by a number of psychological theorists but I will just use Epstein’s (1994) nomenclature to discuss them briefly. ‘Experiential’ modes of cognition are holistic, rapid, largely unconscious, more concrete in representation and relate to affect. ‘Rational-analytic’ modes of cognition are analytic, slower, more conscious, abstract in representation and relate to logic. Over 2000 years ago the East primarily preferred an experiential style of thinking and the West primarily emphasised a rational-analytic style of thinking. Of course, we all as individuals operate both styles of thinking but people will have preferences which style of thinking they employ most. Western scientific thinking, is of course, rational-analytic in form, classical Chinese medicine is much more experiential. It is interesting to note in relation to this, that learning and practising Oriental medicine seems to inculcate holistic thinking in students (Koo & Choi, 2005). Here it can be seen that crosstalk from one style of thinking to the other is unlikely to be easy because they each partition or categorise the world in different ways. Extreme rational-analytic thinking can lead to the dismissal of more holistic concepts as fuzzy, and highly holistic thinking might characterise details as being unimportant. Both styles are necessary and they each provide windows on aspects of the world that cannot be acquired by one viewpoint alone.
These differences in thinking styles may also be traced to personality traits and social influences. Western psychologists assume a universal structure of personality (based perhaps on western thinking styles) but this view has been challenged by Chinese psychologists who argue that certain oriental characteristics (such as social harmony) are omitted from these models of personality (eg, Cheung, Leung, Zhang, Sun, Gan, Song, and Xie, 2001). Richard Nisbett, an American professor of psychology, was made aware of this when he asked his Japanese PhD student what he thought of the American football game he had taken him to and was surprised at his response (Nisbett, 2003). The student expressed his shock that when the game got exciting many of the spectators would stand up from their seats shouting and cheering. In raising this, he said that in Japan people have ‘eyes in the back of their heads’, meaning they look out for each other and wouldn’t think of standing up and obscuring other people’s views of the spectacle. This led Nisbett to experimentally explore the differences in thinking styles between easterners and westerners with fascinating results. He found that easterners were better at perceiving the whole in the tasks they were asked to undertake, while westerners tended to focus on the details more immediately. When they were shown an animation of a fish tank the westerners focused on the main fish in the foreground saying ‘I see a fish’; while the initial comments of easterners referred to the setting, saying ‘this looks like a pond’. In the East, at least traditionally, the whole comes first (of course things are changing as the East becomes westernised and Nisbett notes that Asians who speak English start to think in a more western way, indicating that the language may be part of this influence on the style of thinking adopted). This is demonstrated even in something as mundane as addressing a letter. In China, the first line of a home address would be ‘China’ and the last line would be the specific location such as the road and house. In the West, of course, the specific location comes first (we focus on the detail) and the address line by line becomes more general until we mention the country.
Following this brief review of different thinking styles it comes as no surprise then that combining Chinese medicine with western medicine is likely to be somewhat problematic. Being aware of these thinking styles and the frameworks in which we approach knowledge can help to make sense of this process of accommodation to, or absorption of foreign knowledge. Thomas Kuhn (1970) in his book The Structure of Scientific Revolutions put forward the view that science is not a cumulative exercise where we continually add to a pile of truths. Instead, scientists implicitly take positions, adopt perspectives or worldviews, which dictate what is acceptable to theory and practice (so-called paradigms). When we are in one paradigm we cannot easily make sense of another and the findings that constitute that other paradigm look anomalous at best and absurd at worst. Kuhn called this concept ‘incommensurability’. The philosophies that underpin Chinese medicine are essentially Daoist with contributions from Confucianism, Mohist thought and the yin yang school (Lin, 1995) and generally require quite a different sense of reality than that which informs western science. Seeing one paradigm through the perspective of another means that concepts, if not rejected outright, are appropriated to the privileged paradigm and inevitably undergo some distortion in the process. It is documented that the absorption of one cultural phenomenon into another (foreign) culture inevitably leads to the transformation of its practices in ways which permit it to fit into the absorbing culture (see Adams, 2002; Fadlon, 2004; Scheid, 2006).
When participants in these perspectives are faced with the necessity to communicate between paradigms, there can be translation problems (Kuhn, 1962) or ‘frame conflicts’ (Schon, 1993). We can understand this by looking at the models and metaphors we use to structure our experiences and in which we root our scientific theories (Pepper, 1942). As an example, we can see that in the English language, argument is structured metaphorically like war. Argument involves ‘attacks’, ‘defences’, and ‘retreats’. In eastern cultures the metaphors were much more oblique so that argument and even war itself, were structured ideally in terms of a less confrontational or oblique stance (see Jullien, 2000). War metaphors are quite common in western medicine too, bacteria are said to ‘invade’ and it has been said that we are under ‘siege’ by diseases such as cancer (Sontag, 2001) and we ‘wage war’ on these illnesses using high technology such as radiotherapy and chemotherapy which may incur ‘collateral damage’. Although there are also possible connotations of war in Chinese medicine (see definitions of wei (defensive) qi and invading xie (evil or pathogenic) qi), the more aggressive treatments in western medicine are of a different order from the soft, subtle, almost intangible influence of acupuncture where qi is ‘gathered’, ‘moved’ or ‘tonified’. This view fits more with the older Chinese view that the illness was seen to be due to a ‘guest’ rather than an ‘invader’ (Wu, 1993). The host’s behaviour to the guest becomes important from this perspective and would have different consequences from someone seeing the illness as an invasion where their role would be more passive. Another frame in ancient accounts of Chinese medicine which places responsibility for keeping well on the person themselves is the retention of a state of balance and harmony (see Williams, 2008) which offsets illness. These frames arguably stem from the lived experience in Chinese society where social harmony and cooperation is a fundamental concept. Western concepts stem from an emphasis on the competitive and heroic individual as the ultimate constituent of society. These are very different views on the phenomena of illness and cannot easily be reconciled.
Thinking about acupuncture in the 21st century western clinic it is easy to miss these nuances because the western clinical context borrows so much from western biomedical practice, which in turn is set within the context of the natural sciences and their mechanistic metaphors. But it is, I think, clear that acupuncture can start to change as a consequence of western ways of seeing. Some changes may be seen as useful, others possibly detrimental. Some further examples of this are set out below.
The modern situation Acupuncture is an ancient medical therapy in a modern setting. Cut off from its past in classical Chinese medicine it makes little sense, or at least changes its sense (see Fruehauf, 2002a, 2002b). As we have seen it is an expression of its time and place and of the eastern mind which tends traditionally to emphasise holistic and relational processes, compared to western thinking which tends to call on analytic and reductionistic strategies. Absorbed completely into a western medical framework acupuncture can for instance become simply a pain reduction technique (eg, Carlsson, 2002) – in this context, it can be taught to western medical practitioners in a short period because it is seen simply as a local treatment for musculoskeletal problems. Those with a background in western medicine (which largely relies on a mechanistic and quantitative perspective), will tend to see mechanisms in Chinese medical practices which would traditionally be more relational and qualitative, with a central role for the practitioner who should hold the right kind of intention. Intention, like qi, is a concept that does not fit with western accounts and therefore becomes unnecessary or an example of superstitious thinking.
As another example of how western thinking influences our perceptions of Chinese medicine, it is interesting to note that in texts produced by western-trained writers Chinese medical concepts all too easily find their western correspondences. Looking through our western science lenses these tendencies happen without our realising; unless we exercise a critical sense, we assume that these concepts easily map onto western concepts. Kendall (2002), who comes from an engineering background, tellingly restricts concepts like qi to only two references in the index. From a very mechanistic frame, qi is almost an embarrassing concept and is certainly not worth exploring in itself. When he does discuss qi he complains that English writers of Chinese medicine books ‘...have expanded the meaning of qi to include everything in the physical world, elevating it to a cosmic level.’ (Kendall 2002, p.7). Chinese philosophy of course, assumes exactly that; Zhuang Zi for instance, assumes qi is the ultimate constituent of the ancient Chinese world. More at home in his paradigm or perspective using western analytic thinking, Kendall prefers mechanistic terms to explain the action of needles. De qi is explained in terms of functions of pain sensory (nociceptive) neurons and neural reflexes (Kendall, 2002, p.139). Dealing with some of the fundamental constituents, the modern equivalent of yuan qi (original qi) is defined as the ‘spark of life and genetic disposition’ and zhen qi (true qi) as ‘energy production and use at cellular or mitochondrial level, adenosine triphosphate (ATP).’ (Kendall, 2002, p.140). Even in visual presentation, Kendall unwittingly tidies up drawings expressed in ancient Chinese style with a limited concern for true likeness, turning them into something much more akin to western drawings of exact anatomy, assuming that representations of the body that do not refer to anatomy are somehow inaccurate. Kendall undertakes an interesting attempt to make sense of Chinese medicine from a western perspective but treats its context in Chinese philosophy and history as an unnecessary encumbrance. This approach speaks volumes about notions of truth, it is implied by these transformations that western science and medicine are nearer the truth than their Chinese counterparts.
There are other attempts to understand aspects of Chinese medical physiology that are perhaps more sensitive to the Chinese concepts. Langevin and Yandow (2002) for instance, suggest that the qi channels might have a subtly physical counterpart in the interstitial connective tissue. There may be new ways of understanding qi and Chinese medicine through these kinds of concepts but they require some accommodation of western frameworks, rather than just absorption into mechanistic frameworks which is obvious in Kendall’s approach.
Stepping cautiously In spite of what seem to be real benefits in the everyday world of treating people, and increasing reports of efficacy in the medical literature, Chinese medicine from the perspective presented here obviously requires some scholarship in assessing how we understand and implement it. The modern Chinese clinical texts have already been influenced by western materialistic philosophies and biomedicine. Those texts arising from English speaking authors, while providing a curriculum for acupuncture colleges, have provided little philosophical background to the difficulties of translation of ideas and worldviews. All too easily do they find uneasy correspondences for Chinese concepts in western thinking.
As western science and medicine is more privileged in the West (and also in the East for the past century or so), we often look to ensure that the final word is the western one. In my own training in acupuncture I have heard Chinese medicine tutors (you know who you are!) make this amusingly clear when they make the slip that if they had a headache they would visit a western medical doctor and get a ‘real’ diagnosis! On the basis of what we have discussed already we can begin to see how Chinese medicine can play an equally important role as modern western medicine. We have seen that western medicine and science are analytic and reductionistic and depend on a quantitative form of assessment while Chinese medicine (following eastern thinking styles) is more focused on holistic relationships and qualitative assessment. Western medical explanations focus on the small and individual, seeing pathology in specific entities such as vital organs and molecular biological processes; Chinese medicine emphasises the patterns of relationships, looking at the whole and assessing a diversity of factors rather than focusing down. Chinese medical explanations assume a more subjective or phenomenological position in talking of symptoms; they appear as they are felt by humans, so heat is red, blistering and rises up. Western medical explanations are mechanistic and rely more and more on the extreme ‘objectivity’ and detachment afforded by physiological measurement by machines so that the personal feelings of heat will be given less attention than detailed temperature data. The current obsession with fMRI as an almost photographic examination of the brain is a good example of where the onus of proof resides in a mechanistic approach to modern western scientific thinking (for a critique of the way fMRI is conceptualised and misrepresented see Joyce, 2005 and see Pickering, 1995 for further theories about machine-led epistemology).
Chinese medicine can be seen to offer westerners a more experiential view of health, something we have lost to a significant degree and perhaps is responsible for increasing health problems. Lin (1995) uses the expression ‘qi yun sheng dong’ (the metre of the inner life), commonly seen in the context of Chinese painting, to convey the fundamental nature of qi in Chinese thinking. It also perhaps points to a very useful way of thinking about qi if we adopt Lin’s translation of this phrase. Qi is a way of experiencing, communicating, registering, measuring and acknowledging the movement, change and expression of life. It provides us with a proprioceptive process, akin to the Buddhist concept of ‘mindfulness’ (and those processes explored in self-cultivation by Yuasa, 1993), but since qi is part energetic, part material this would need to be expanded to include a ‘bodyfulness’ as well. This is something that is generally lacking in the modern western context. We are reminded by NHS advertising and supermarket food packaging to eat five portions of fruit and vegetables a day and overeating is frequently treated through mechanical restriction of the stomach where a patient cannot exert the will to stop eating. The idea of qi as proprioception could bring about quite dramatic changes in how people relate to themselves and their world. Lin (1995, p.123) emphasizes this when quoting Lao Zi: ‘...if a man loves the world as much as he loves his own body, we can commit the world to his care.’
Where western medicine operates reductionistically, it naturally means that specialisation is a natural progression. To some extent each organ, or mechanism can be examined in isolation and this offers the opportunity of becoming an expert on that particular system. Chinese medicine, as we have seen, is classically focused on the whole, or adopts a systems approach and so is less likely to specialise. Current debates over specialisms in Chinese medicine owe a debt to a modern western context, and drawing on the conceptual differences between eastern and western thinking, it seems unlikely that this approach would naturally complement Chinese medicine. This focus on details is particularly western as we have already seen. It may also be seen as a more masculine rather than feminine approach. Lin (1995) assumes that ancient Chinese thinking was not only different from western European thinking but might be considered a more feminine style of thinking.
Chinese traditional thinking falls under the yin category. In my opinion, traditional Chinese ways of thinking have shown no difference with basic tendencies of female thinking. We can thus reasonably say that traditional Chinese ways of thinking have feminine traits… Lin (1995, p.135)
Included in these traits are: ‘the central idea of wholeness’, ‘paying attention to function and relation, not substance’, ‘skill at thinking in images, but not so much skill in logical thinking’. Hanawa (1995) in the same volume reports similar tendencies in Japanese thinking styles. These are interesting because they are the same kinds of attributes we might assign to experiential thinking already mentioned above. It is likely that modern thinking is expressed in more rational-analytic terms while older styles of thinking which prevailed for longer in the East employ more experiential terms. Older approaches in western medicine which predate the modern period tended to employ more experiential thinking along similar lines as Chinese medicine (see Dutton, 2008). Ultimately western medicine’s highly logical, analytic and reductionistic approach needs Chinese medicine’s concern for wholeness and relational thinking. In addition, the incursion of Chinese medicine into the West in the modern period has meant that Chinese medicine has had to explicitly adopt more analytical approaches. A balance needs to be struck.
Conclusions Chinese medicine and acupuncture in the West in the 21st century have a challenge of accepting change but not losing the original informing spirit. Changes that are informed by a different thinking style, paradigm or worldview may dilute or erase the original impetuses and understandings. Good scholarship, critical awareness of these issues and tendencies will help to maintain the lifeblood of Chinese medicine and acupuncture, perhaps allowing western thinking, science and medicine to learn something about themselves as well.
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Note on the Author Carl Williams PhD is a senior lecturer in psychology at Liverpool Hope University. He has research interests in conceptual frameworks and metaphors and how these structure approaches to scientific theory and applications, especially in the area of oriental medicine.