On the couch

Steve Wheeler

Member: West Wales

Sigmund Freud, accompanied by his wife Martha and his daughter Anna, arrived at Victoria Station in London on 6 June 1938, having fled the growing Nazi menace in Anschluss Vienna for exile in England. Freud himself would survive illness for only another year, but his ideas, which had preceded his arrival by decades, would continue to exert a powerful influence on British life and culture for years to come. As WH Auden said in his memorial poem, ‘to us he is no more a person / now but a whole climate of opinion’.

Initially, Freud’s ideas had not been universally popular in Britain. Early reviews of his work had turned their nose up at the ‘impropriety’ of their sexual focus, and one anonymous article in the Lancet in 1921 suggested that ‘few medical men past middle age can swallow the new psychology whole without some symptoms of indigestion, culminating in… spiritual, if not physical nausea’. Even when Isaiah Berlin, like so many of London’s intellectual class, paid the customary honorary visit to Freud in his last year of life, the psychoanalyst’s response to learning that Berlin taught philosophy – ‘then you must think me a great charlatan’ – was not, Berlin would later admit, entirely untrue.

Nevertheless, through the course of the first half of the 20th century, Freudian ideas percolated their way through the whole of anglophone society, appearing as much in popular magazines, bestsellers like Spock’s Baby and Child Care and movies like Hitchcock’s Marnie as in the learned journals of academics and psychiatrists. By the post-war era, references to the ‘ego’, the ‘id’, to ‘complexes’ and ‘neurosis’ were ubiquitous throughout culture.

It was into this milieu that acupuncture was first introduced in the UK. Just as psychoanalysis was in the process of developing into the many schools and flavours of psychotherapy, so there was a profoundly eclectic interest in any and all exotic otherness as part of the search for ‘self-actualisation’. As China began to open up to the world and the west became increasingly enamoured with eastern culture, religion, and martial arts, some of the early pioneers – such as JD van Buren, Jack Worsley, and Sidney Rose-Neil

Steve – established their own schools, setting the template for acupuncture in the Wheeler country for the generations that followed Member: West Wales afterwards. And while there were many factors involved in the reception and reinterpretation of acupuncture in the west, one aspect that is often overlooked is the relationship between the newly introduced eastern medical paradigm and the psychoanalytic model so dominant in the culture of the time.

Psyche and soma

Traditional East Asian Medicine (TEAM)’s role in western culture was always going to be different than in the east. Whereas, until modern times, TEAM was the primary medicine for all illnesses – mental or physical – in East Asia, in the west it was entering a medical ‘marketplace’ already occupied by western medicine. What was simply practical healthcare in the east was ‘alternative’ in the west. Perhaps it was inevitable, then, that in preference to competing directly with the more established modalities of physical and pharmaceutical medicine, TEAM would come to share the kind of quasi-medical space occupied by psychoanalysis; matters of the mind and emotions being less easily defined and circumscribed, they can form a kind of refuge for alternative practices that might otherwise not survive the twin blizzards of xenophobic disdain and mechanistic reductionism. Certainly, the acupuncture that came to be practised in the west tended to focus more on matters of psycho-emotional wellbeing than was ever the case in East Asia – though this tendency is perhaps particularly marked in the Worsleylineage five element traditions, and was stronger before the establishment of more TCM-aligned courses in the 1990s and 2000s. Before considering the way in which the psychoanalytic ‘climate of opinion’ might have had a direct

influence on western acupuncture, it is worth considering some of the ways in which the differing cultural paradigm as a whole was likely to change the way it was received:

The Cartesian split: The western conception of being is structured by a clear schism between mind and body. Though many trace this all the way back to the JudeoChristian roots of the culture, René Descartes has long served (somewhat unfairly) as a symbol of the pivotal cultural moment when bodily consciousness began to be suppressed in favour of the abstract mind.

While, for many, the attraction of acupuncture and East Asian medicine has been precisely its potential to bridge this divide, the legacy of the Cartesian paradigm is not so easily abandoned and it is possible that some of the early emphasis on psycho-emotional treatment stemmed from a subliminal sense that ‘energetic’ medicine must necessarily have more to do with the ethereal realm of the mind than with the material mechanisms of the physical.

Consider the opening words of Leon Hammer’s Dragon Rises, Red Bird Flies, for example: ‘Psychology and Chinese Medicine are congenial therapeutic partners. They are closer in concept and practice to each other than either is to the principles of Western science and medicine’. The sense that there is more ‘headroom’ for TEAM to expand into the realm of psycho-emotional treatment than down into the more physical realm is perhaps a commercial truth in the west, but is also pushing at an open ideological door, where a ‘holistic’ approach is intuitively seen as having more to do with the health of the soul than of the body. So long as the mind is seen as the ‘seat of the self’ in the west, the most humanly meaningful medicine will be seen as that which prioritises the psyche. In other cultures, where the self is seen as centred at a more energetic, feeling or physical plane, this presumption would not hold.

Individualism: As has often been observed, the western concern with the individual consciousness contrasts with the East Asian emphasis on the relational network of society as a whole. It’s tempting to say that western individualism has simply given us an exaggerated sense of the importance of our own internal experience, and that the best thing for us would be to get out of our own heads and do some work (preferably physical and practical) to help other people.

Even today, psychotherapy is looked upon in much of East Asia with the same scepticism that TEAM suffers in the west. UK-based psychotherapist Yuko Nippoda has suggested that psychotherapy is seen in Japan as being fundamentally based in western cultural values, and the focus on the individual’s inner being is considered almost self-indulgent or narcissistic in a culture rooted in more collective and relational values.

By way of anecdote: on the BAcC cultural exchange trip to Harbin in 2018, we were shown the

‘psychotherapy’ department in one of the city’s major

TCM hospitals – a small cupboard-like room occupied by a single, amusingly acerbic female doctor. On a hunch that pays testament to my immense powers of cultural observation, I asked her what the status of psychotherapy was in the hospital there. Her response was simply an arch look of irony, gesturing to the room around her and asking the question: ‘What do you think?!’

But it may also be the case that, in a kind of selffulfilling prophecy, the western focus on the individual actually led to the development of more complex and problematic internal dynamics. At the same time, and accelerating the trend by doing so, the vocabulary and conceptual architecture to define and discuss that complexity in great detail was developed; in the form of western theology, then philosophy, and finally psychoanalytic theory.

Some practitioners have explicitly identified their modifications of TEAM as being a way of taking account of this complexity – in his 1990 work Pulses and Impulses, for example, Graham Townsend states that the more complex pulse system he is proposing is designed to match the greater psychological complexity of patients in the modern west.

Reductionism: Modern medical technology has produced many undeniable marvels of treatment and repair. As the techno-scientific world has conquered new realms of biological understanding, however, the culture of biomedical research has emphasised ever more stringent standards of experimental design, cohort size and reductionist scepticism, and the space in which alternative medical paradigms can thrive has been steadily eroded. Even psychoanalysis itself has been progressively supplanted since the 1980s by the rise of the neuropharmacological approach to mental health.

Throughout recent decades, of course, noble attempts have been made to establish a convincing evidence base for the more physical benefits of acupuncture, and if they have failed to convert the mainstream scientific institutions this has perhaps more to do with the intransigence of those institutions and their ever-receding goalposts of ‘sufficient evidence’ than with any weakness in the argument. There is much to decry about this trend, but its direction and dominance are undeniable; and it provides one more element of ‘nudge’ for our medicine away from the physical and towards the psycho-emotional.

Tabling the agenda

While this deep cultural background explains much of the parallels between psychoanalysis and acupuncture in the 1960s and ‘70s, I believe that the psychoanalytic tradition had some more specific, and deeply formative impacts on the development of acupuncture in the UK. If, when acupuncture was introduced into the anglophone west, and particularly into the UK, it modelled itself on the dominant quasi-medical modality, psychoanalysis, it did

so both as a result of the deep cultural paradigmatic trends we have discussed above, and for reasons of expediency – to present something new and difficult to understand as something more familiar – and status – psychoanalysis being seen as an elevated pursuit whose practitioners were respected professionals more akin to academics than mechanics (thereby invoking a whole nexus of western presumptions around the superiority of the mental over the material, the theoretical over the practical). The results of this decision have been various and far-reaching, and continue to shape and influence our practice and community today.

Some of the pointers in this direction are necessarily speculative, and perhaps better answered by those Elders of our community who were present in the early days: Is the reason ‘standard’ acupuncture sessions are one hour long, and one week apart, simply because that matched the pre-existing model of psychoanalytic therapy? Certainly, there does not seem to be any precedent for this approach in East Asia, where you might get treated every day, or a few days apart, and would usually be lucky to receive a whole hour of individual treatment – or, where practitioners do practise in that way, treatment might last as long as two or three hours. Indeed, is our very use of the term ‘treatment couch’ in the UK – which so confuses our ‘table’-using American brethren on shared training courses – derived from the psychoanalytic ‘couch’?

If true, what might this imply for how we think of our treatments? Do we think of our treatments as analogous to talking therapy? Do we think of ourselves as primarily ‘therapists’ rather than ‘medical practitioners’? (If you doubt the continued influence of psychotherapy in our culture, consider how, despite the existence of physical, occupational and speech therapists, to name but a few, the abbreviated form ‘therapist’ means ‘psychotherapist’ to most people – just try introducing yourself at your next cocktail party as a ‘therapist’ and see how quickly the misunderstandings occur!)

Many a slip

Is there a While some of the implications of all this tendency are merely culturally interesting, others are in western more serious: Is there a tendency in acupuncture western acupuncture to emphasise to emphasise the therapeutic relationship – the the therapeutic bedside manner, the opportunity to talk relationship? through problems during case history, the feeling of being attended to and ‘held’ for an hour – over the actual practical effects of needling? The world of psychotherapy has been recently rocked by various studies that suggest that it is the relationship itself, rather than any particular theory or method, that produces positive results in psychotherapy – perhaps by providing a space to replicate the broken attachment experiences of early childhood. Do we rely a little on the provision of a warm, caring, receptive space, making use of this same mechanism? Is there a danger that, by failing to focus on the practical functionality of our medicine, we might inadvertently prove our critics right by turning it into a ‘theatrical placebo’?

Similarly, might there be a tendency to allow our patients to pick up an ‘acupuncture habit’, coming back week after week for years as part of ‘self-care’, just as analysands spend years in talking therapy waiting for a breakthrough, rather than holding ourselves to the kind of limited run of treatments we would expect of a more physical medical modality? Are we sometimes insufficiently motivated to ensure universal provision of our medicine because we compare ourselves to psychotherapists rather than physiotherapists – thinking of ourselves more as enabling an optional add-on of

‘self-actualisation’ and ‘optimal wellness’ rather than as physicians equipped to treat serious physical illness, whose medicine should therefore be available to all?

Or again: is it possible that, in seeing TEAM as similar to psychoanalysis, we might be adopting a particularly cerebral version of the medicine, losing ourselves in theoretical cogitations rather than attending to the practical grind of

needling practice, as is more common in the East Asian traditions? Is there a possibility that our model of acupuncture education would thereby emphasise abstruse and abstract learning over the practical skills needed in clinic?

And if we feel ourselves lacking in those skills, are we more likely to seek additional training in them, or to ‘addon’ something else to our treatments – NLP, shamanic journeying, mindfulness coaching – that looks a little bit like psychotherapy?

One other anomaly in western acupuncture that might also owe its origin to the psychoanalytic legacy is the current focus on supervision; while informal mentoring has always been an aspect of TEAM, the formal institutionalisation of supervision as an aspect of practice seems directly modelled on the psychotherapeutic standard. In psychotherapy, however, the justification for the practice is that the medicine consists of working directly, personality-to-personality, with someone else’s mind – and so the therapist themself should also be in therapy or analysis to ensure they do not project their own psychological issues onto their patients. The direct analogy with acupuncture would be that every acupuncturist should be receiving acupuncture.

Of course, every profession could benefit – time and money allowing – from a system where practitioners have a space to talk about their concerns, and if the majority of your practice consists of working with psycho-emotional issues, such supervision may well prove psychologically indispensable. But it is just another example of the strange in-between space that acupuncture occupies in the west – part-medicine, part-therapy; part-physical, partpsychological – that ‘supervision’ has become a common element of practice amongst acupuncturists where it is not for any comparable profession.

Off the bench

The prevalence of all these elements in western acupuncture could be easily exaggerated, of course. Almost all TEAM practitioners in the west are treating at least some physical ailments, are fascinated by the practicality and effectiveness of the medicine, and are continually seeking to heal the body-mind split by grounding their patients’ psyches in their bodies. On the other side, it has always been the case that TEAM has also treated ailments of the shen, even if not with such particular focus as in the west. If the trends I’ve identified are real, they are subtle and largely born of deep, invisible cultural currents. But such currents are also powerful; they are ever-present, and over long periods of time can shape the geology of our practice. As such, I think they are worth considering and, where we detect their problematic influence, should be compensated for and countered.

We might also look to the relationship between psychoanalysis and acupuncture for positive guidance, though. Like acupuncture, as we have seen, psychoanalysis was the subject of scorn, opposition and innuendo in its early days of adoption in the UK. But, within 50 years, it was the dominant paradigm for understanding the human experience. The tide of its influence has been receding for some time now, of course, and it is possible that the conditions for that kind of widespread, unified influence on the cultural conversation are no longer extant. But it shows how important it is to hold true to your understanding, and to belief in the usefulness of your medical paradigm, in the face of ridicule and obtuseness.

We might also look at the relationship between psychoanalysis and acupuncture in the west as one of positive dialectic. There has never been a single ‘East Asian medicine’, and its evolution on arrival in the west was both inevitable and necessary. If the medicine has come to address the psyche more in the modern, industrialised, individualist west than it did in classical China, perhaps that is an appropriate adaptation to the conditions it has found here.

So let’s continue to look critically at our own presumptions, and continue to strive to make our medicine as effective and useful to our patients as we can, while working towards its ever-greater acceptance in the west. After all, as Sigmund himself said, ‘One day, in retrospect, the years of struggle will strike you as the most beautiful.’

Steve Wheeler Member: West Wales