It’s not working

‘It’s not working’

Locked down in a Lake District winter wonderland, John Hamwee decided to investigate why the practitioner-patient relationship can sometimes suddenly turn icy

John Hamwee

Member: Cumbria

Over the years many patients have decided to stop having treatment and they have given me a variety of different reasons for doing so. Although I have chosen to have regular treatment myself, I usually understand their reasons and I am perfectly comfortable with their decisions. Perhaps the symptoms cleared up completely; or maybe, after a reasonable number of treatments, nothing much seemed to have changed; or possibly there was as much improvement in a chronic condition as we both could have expected.

However, sometimes a patient will say that he or she is stopping treatment because it isn’t working, even though I think it is. Assuming I am not the only practitioner who has had this experience I thought it worth investigating.

Looking through my notes, a few categories start to emerge. The most obvious one is that the treatment is working alright but I have made a mistake, or a series of mistakes, which undermine the patient’s trust and belief in me. I’m not thinking of mistakes in diagnosis or needling which, for me, are an inescapable part of normal practice, but times when I have failed a patient in some way. It can be apparently trivial. I used to treat two sisters who had a close relationship, albeit with some deep-seated resentments and jealousies between them. One day, by mistake, and not once but twice, I called one sister by the name of the other. A week later I got an email cancelling her next appointment as ‘treatment wasn’t working’.

So my first category is of patients who say this because they don’t want to tell me that I have hurt or upset them – and that is why they don’t want to come back.

The next category is where patients say it isn’t working because, although treatment worked well for a while, the symptoms then start to recur or even get worse. I usually think that it is a temporary dip and say so; sometimes I think there is a perfectly plausible reason why it has happened, and I explain that too. In other words, I think it is worth persisting with treatment but the patients don’t.

It makes me sad, of course. It also leaves me with some uncomfortable questions. Am I overconfident? And if so, is it overconfidence in my own abilities, in acupuncture itself, or indeed in both?

A fifty-year-old man came to me with what he described as chronic fatigue syndrome following a viral infection three years earlier. After two months of treatment he said that he had had a particularly busy week but had coped

well; after three he had been to a film for the first time since he had been ill; and after four he had walked for five miles and felt none of the expected after-effects. After six months he reported that his energy had suddenly dropped to a new low and he felt he had gone backwards.

I said that we knew acupuncture could work for him so I was pretty sure he would recover from this temporary dip. He agreed, though without much conviction. And at his next treatment he told me it still wasn’t working so he was going back to his GP for more tests and then do whatever the GP suggested. I asked him a number of times to explain his change of mind, but in the end I was convinced that he really did believe treatment wasn’t working and that was the only reason he had chosen to stop.

I thought about why he might have come to this decision. It seemed to me that at the start of treatment he was willing to give acupuncture a go, however strange or implausible it seemed. As he got better he started to believe in it as a system of medicine. But then, when there was a reversal, he jumped to the conclusion that the previous improvement must have been a coincidence, or some kind of placebo effect which had now worn off. Along with the loss of faith came a kind of disillusionment with me, as if I had duped or at least misled him, with my optimism.

He is not unusual. Other patients have made the same kind of decision and, I think, for the same sort of reason. So what is to be done? First, I tell my patients many times that regaining health is not a steady or consistent process; that each day, each week, will not necessarily be better than the last; that what matters is an underlying pattern of fewer bad days, which are less bad than before, and more good ones.

Next I also make a point of changing the treatment. Even if I am fairly confident of my diagnosis, and even if the patient has done well with the kind of points and the kind of techniques I have used, I still change them. For one thing, the patient’s whole attitude to treatment has changed and that amounts to a significant energetic shift, so to carry on as before would be to ignore that reality. But to some extent I am trying to rekindle the patient’s original interest and hope. If it was the sheer novelty of acupuncture that amplified the effect of treatment last time, well then I can do something new again, and hope for a similar boost.

Finally I take a long hard look at my own expectations and how I have communicated them to the patient. I am passionate about acupuncture so it is easy to slip into thinking it can achieve miracles routinely. We all know of successful treatments for back pain or headaches, for example, but what about my patient’s chronic fatigue, or many of the other ills that people bring to us? Here are a few recent examples: severe acid reflux; violent itching only in the early morning; diabetes; putting on weight – ‘the less I eat the more I gain’; a mystery pain in one buttock; frozen jaw; and depression due to a sudden loss of faith in God. What is the line to tread between Tigger and Eeyore, between being bouncily overconfident on the one hand and gloomily defeatist on the other? Not an easy question to answer.

My final category is where I can see significant change for the better through treatment, but the patient wasn’t looking for that kind of change or doesn’t value it when it happens. Here are two brief examples.

A young woman tells me that when she gets ill she struggles to recover – spots on her face can last for months, a cold for six weeks and a headache for ten days. After three treatments, each a week apart, I notice that she looks very much better, with clearer skin and more shen in her eyes, and she says that for the first time she has managed to set some boundaries with her boyfriend. However, she adds that she has had an unusually bad headache for the past week so she is going to stop coming as treatment isn’t working

A successful businesswoman tells me that she is ‘hopelessly lethargic’, has put on twenty pounds in the last two years, can’t go for a run like she used to and has eczema under her big toes. I discover that she has two teenage children, no partner and works a twelve-hour day. After six treatments, during which we get on well, she says she has cut her working day to nine hours, spends more time with her children, is sleeping better and is generally less stressed. However, she still can’t go for a run and the eczema is unchanged. She is adamant that acupuncture hasn’t worked.

I don’t think it’s just a matter of persuading these patients to stick with treatment or with me; I think the issue goes to the core of much of our work. Many patients live with all kinds of stress, of pain and dysfunction, of agonising anxiety and emotional turmoil and so on, and it never occurs to them that change is possible; sometimes I don’t even know about something really important until the patient mentions, quite casually, that it is much better. Although I always explain that acupuncture works on what is often called body mind and spirit, and all together, I think that many patients hear the words but don’t really absorb the reality of it. So it is hard for them to accept that something like starting to set boundaries with a partner or working more sensible hours can be a result of treatment.

At a deeper level some patients may not even want to change. The young woman with the persistent headache was worried that setting boundaries might have jeopardised her relationship; even though, to my way of thinking, the relationship would never make her happy unless she did so. And the businesswoman told me, at her last session, that now she seemed to have more time she was thinking of opening a new factory – so back to twelve-hour days, presumably. It is not for us to judge, nor even to think we know what is best for a patient, but this kind of thing can be frustrating. I suppose there will always be a gap between what we believe to be possible and the changes any particular patient is willing to undertake; a thought which leads me to my last reflection. With most of my patients, I get interested in, and excited about, the enormous potential that acupuncture can have for them and their lives. But if patients don’t grasp that potential, or choose not to do so, then I can imagine that it makes them feel obscurely uncomfortable with me. They may sense that I am disappointed in them in some way; that they have failed some test they didn’t know they were taking, or that I want them to be someone they are not. So their response is to say, ‘it isn’t working’.

The first rule of a genuinely therapeutic relationship is to accept patients as they are and for who they are. So when a patient surprises me by telling me that acupuncture isn’t working, I now think this may be because I haven’t done just that.