JR Worsley's Legacy to the Practice of Acupuncture
by Peter Mole
JR Worsley’s death on June 2nd, 2003 has inspired several obituaries and tributes in the pages of EJOM and elsewhere. He was an inspiring teacher and a remarkable practitioner, but what did he teach? And how does the style he taught fit into Chinese medicine theory? This article attempts to give a brief outline of his approach for those who were not taught by him. This interpretation of his teaching is solely that of the author and should in no way be construed as any form of authorised synopsis of his teachings. Any misunderstandings or omissions are purely the responsibility of the author.
In the 1960's when JR Worsley was learning acupuncture, it was not possible to visit China. In the absence of teachers from China, he learnt from practitioners from Europe, as well as Japan, Korea and Taiwan. He visited the Far East several times. In Japan the Five Elements has been the dominant underlying principle in oriental medicine and the Nan Jing (first or second century AD), which is largely based on Five Element theory, has always been the main classic. Taiwan (where JR Worsley visited the teacher Wu Wei-ping) had been ruled by Japan for most of the twentieth century. Its practice of acupuncture was heavily influenced by Japanese-inspired Five Element thinking. Peter Eckman's In the Footsteps of the Yellow Emperor is an extraordinary piece of detective work into JR Worsley's different teachers and the history of acupuncture in the UK in the 1960's.
Although there are a couple of significant innovations, Five Element Constitutional Acupuncture (1) is a very classical style, firmly rooted in the Han dynasty (202 BC - 220 AD) classics of Chinese medicine. In fact it is the acupuncture style that in some ways most closely adheres to the values and priorities expressed in the Nei Jing and other classics.
It is hard to say how many practitioners now practice acupuncture based upon what they learnt from him or his students teaching the style. A survey carried out in 1995 of members of the British Acupuncture Council showed that 38% of practitioners were using the style regularly compared to 66% using TCM2 and 8% using Japanese Meridian therapy (3). In many ways Five Element Constitutional Acupuncture is radically different from both these styles.
The Main Characteristics of the Style:
The observation and experience of nature is regarded as being a major path to understanding people and illness
The qualitative nature of the Five Elements can be best understood by the observation and experience of nature. The differing qualities of qi expressed in the cycle of the seasons serve as a model for understanding how the Five Elements manifest in a person. The melancholic nature of autumn, for example, resonates with the emotion associated with the metal element, grief. The dynamic thrusting qi of the spring is reflected in the creative assertive nature of the wood element. Worsley strongly urged his students to deepen their understanding of how humanity is an integral part of nature and how the Five Elements are represented within the person. This attitude was expressed in the Han dynasty Daoist classic, the Huainanzi;
“I have gazed upwards to study Heaven and examined the Earth below me and about me, and sought understanding of the principles of humanity’ (4).
Emphasis is placed on nourishing the most underlying imbalance via treatment of the CF (‘Causative Factor’) or constitutional imbalance:
The diagnosis and treatment of a primary constitutional imbalance lies at the heart of the style. Chapter 64 of the Ling Shu set out the concept of the Five Element types, including the concept of each element having each of the Five Elements represented within it. It is therefore possible to diagnose twenty five constitutional types. Most practitioners, however, concentrate on diagnosing and treating the primary element, or CF, as it is known. Very little, if any, treatment is carried out specifically focused upon a particular physical symptom.
CF stands for 'Causative Factor', a term borrowed from homoeopathy. J.R. Worsley's assertion that 'all' imbalances result from the Causative Factor is a simplification that fails to take into account the pernicious effects on a person's health of diet, climate, drugs, etc. For this reason the term is unclear and many practitioners prefer the term Constitutional Factor. What is striking is how treatment focused on the CF has the ability to initiate extraordinary changes in a person's health and sense of well-being. As the CF is the primary imbalance, change is commonly initiated in other organs and elements not treated directly. This is due to the relationships between the elements expressed in the sheng and ke cycles.
Diagnosis Is Based Entirely On ‘Signs’ As Opposed To Symptoms:
Most styles of Chinese medicine base their diagnosis on a mixture of signs, such as pulse and tongue, and the nature of the patient's symptoms. Worsley taught that physical symptoms are not to be relied upon for diagnosis of the underlying imbalances in the person's qi. The colour on the face, the sound of the voice, the odour and the predominant inappropriate emotion are the primary indicators of the CF.(5) Diagnosis is therefore dependent on the sensory acuity of the practitioner, rather than the answers to any questions the practitioner might ask.
In an innovation, he attributed an inappropriate need for sympathy, to feel cared for, as being indicative of imbalance in the earth element. Sympathy largely replaces si, over-thinking or worry, which is not a true emotion. According to Su Wen, Chapter 39, si 'knots' the qi, which is not a movement of qi as implied in the word emotion. The traditional associations outlined in Su Wen chapter 5 - anger for wood, joy for fire, grief for metal and fear for water - provided diagnostic indicators for the condition of each of the other elements.
The nature of each element is also revealing diagnostically. An extreme expression of an element's characteristics reveals imbalance. For example, as it says in the Shu Jing, wood 'permits of curved surfaces or straight edges' (6). A tendency towards excessive rigidity or inappropriate flexibility in the mind and spirit can often be seen in people whose wood element is imbalanced. Metal CFs tend to be somewhat inert emotionally compared to Fire CFs who are usually more volatile. These kinds of characteristics can reveal much about the balance of the Five Elements.
The patient's underlying health is enhanced to alleviate the patient's physical and psychological complaints. Subsequently emphasis is placed on preventive treatment
Focusing treatment on the root or underlying imbalance leads to an overall improvement in the patient's health. This is usually reflected in the person 'feeling better in her or himself'. A key goal of treatment, therefore, is an improvement in the patient's feelings of well-being and vitality.
As diagnosis is based on signs rather than symptoms it is relatively easy for the practitioner to make a diagnosis of dysfunction before symptoms arise. Preventive treatment based upon 'nourishing the root' (yangben) is emphasised. This is in keeping with the recommendation in both the Nei Jing and the Emphasis is placed on 'balancing' the Five Elements
One of the key goals of treatment is to bring about greater harmony in the Five Elements. Pulse diagnosis is used to assess the accuracy of the CF diagnosis. Treatment focused on the CF generates more harmonious pulses. This can be better quantitative and/or qualitative balance. Change must be seen to take place on organs/elements not treated directly.
Treatment protocols can be employed to transfer qi, for example using tonification and sedation points, to lessen the imbalances detected between the elements. A practitioner will usually only end a particular treatment when the pulses have shown a significant change and achieved a reasonably harmonious state.
'The principles of needling dictate that needling should stop as soon as qi is brought into harmony.' Ling Shu, Chapter 9.
Pulse diagnosis is used extensively to discern the balance of the elements and to monitor the patient's response to treatment. The 28 classical qualities are not used, as the strength of the pulse is regarded as the most important factor (8). The relative strength and quality of each pulse compared to each of the others is assessed.
Taking the pulses throughout the treatment helps the practitioner decide whether to treat further or not. Over a course of treatments, the pulses are used to ascertain which elements are responding to treatment on the CF element and which are not.
Emphasis on Treating the Patient's Mind and Spirit:
The practitioner observes and experiences the patient's spirit, especially focusing on how the emotions have affected it. Worsley did not teach specifically about the shen, hun, po, yi and zhi. Worsley preferred to look into a patient's eyes and heart to see which emotions were causing suffering in the patient's spirit.
The spirit is also assessed in regard to the description of the organs given in Su Wen, chapter 8. In this chapter they are described as being like officials in a court, each with its own role. For example, 'The Liver is the general who works out the plans' and the 'The Gall-Bladder is responsible for what is just and exact. Determination and decision stem from it.(9) Along with colour, sound, emotion and odour, dysfunction of the 'officials' is used to diagnose the CF.
Treatment is largely focused on enhancing the health of the person's spirit. This is in keeping with many references in the classics of Chinese medicine. For example 'When one applies medical treatment, one must keep in mind first of all, the patient's spirit (10) Ling Shu, Chapter 8. Treatment on the CF may be ineffective if the practitioner is unable to affect the patient’s spirit.
‘In order to make all acupuncture thorough and effective one must first cure the spirit'. Su Wen, Chapter 25.
Emphasis on the internal/emotional causes over and above the external/climatic and miscellaneous causes:
The emotions are both powerful causes of imbalance in the Five Elements and crucial diagnostic indicators of the health of an element. As the Su Wen says, 'The emotions of joy and anger are injurious to the spirit (shen). Cold and heat are injurious to the body’’ (11). Diagnosis of the CF is partly made by deciding on the effect created by the patient's experience of the five emotions of anger, joy, the need for sympathy, grief and fear. Realising that a patient is perhaps consumed by resentment, beset by anxieties, unable to fully grieve or to really experience joy is to make an essential diagnostic discovery. Describing the effects of intense emotions on a person's qi, Su Wen, Chapter 76, states; 'A physician cannot be regarded as a good one unless he can detect such things in his diagnosis (12).
The Importance of Rapport:
JR Worsley taught that there is infinitely more to the practice of medicine than just making a correct diagnosis and carrying out appropriate treatment. Few patients reveal the suffering in their spirits caused by painful emotions unless a high degree of rapport is achieved. Grief, anxiety, heartbreak, anger and other emotions are commonly hidden from sight. Rapport is the catalyst that enables patients to reveal something of their inner world to the practitioner. The appropriateness of the emotions can therefore be assessed more accurately when there is trust and intimacy.
Rapport and Assessing The Emotions Is Emphasised When Questioning A Patient. The dialogue with the patient is largely used as a vehicle for 'testing' the patient's emotions. 'How' a patient describes a situation can reveal their emotional predispositions. The practitioner may encourage the expression of emotions in order to gain insight into the nature of the patient's Five Elements. Dialogue also gives the opportunity to diagnose whether the sound of the voice is predominantly shouting, laughing, singing, weeping or groaning.
'If a man is brusque in his movements, others will not co-operate. If he is agitated in his words, they awaken no echo in others. If he asks for something without having first established relations, it will not be given to him.'
The Importance of Intention:
The intention of the practitioner is crucial to the efficacy of the treatment. Acupuncture is a subtle form of medicine and is greatly helped by a harmonious and, in some ways, intimate relationship between patient and practitioner. At the moment of needling the practitioner needs to focus her or his intention in order to bring about a change in the patient's qi and spirit. As Sun Si-Miao wrote nearly 1500 years ago, Medicine is intention (yi). Those who are proficient at using intention are good doctors (13).
The emotions are both powerful causes of imbalance in the Five Elements and crucial diagnostic indicators of the health of an element. As the Su Wen says, 'The emotions of joy and anger are injurious to the spirit (shen). Cold and heat are injurious to the body (11). Diagnosis of the CF is partly made by deciding on the effect created by the patient's experience of the five emotions of anger, joy, the need for sympathy, grief and fear. Realising that a patient is perhaps consumed by resentment, beset by anxieties, unable to fully grieve or to really experience joy is to make an essential diagnostic discovery. Describing the effects of intense emotions on a person's qi, Su Wen, Chapter 76, states; 'A physician cannot be regarded as a good one unless he can detect such things in his diagnosis (12).
JR Worsley stressed the desirability of effecting the maximum change in the person's qi through using as few needles as possible. The great physician Hua To, for example, was admired for his ability to treat patients effectively by using only one or two needles (14). Diagnosing and treating the CF, the person's primary and constitutional imbalance, is the key to this principle. A Chinese herbalist will often write a prescription which has herbs for several different patterns. A practitioner of Five Element Constitutional Acupuncture, however, is inclined to initiate change in the primary imbalance and observe what change this produces in other elements.
This emphasis on the inter-relationship between the elements and organs is characteristic of many schools of Five Element acupuncture. Pulse diagnosis is used throughout the treatment to this end. This is made easier through the use of the Japanese needling technique of tonifying without retention. This allows for monitoring of the effect of each point by pulse diagnosis.
Emphasis on Treating Chronic Conditions:
In general J.R. Worsley did not advocate making significant change to treatment protocols if the patient came in with an acute condition, such as an infection. He believed that strengthening the person's CF, and perhaps other organs, thus assisting their ability to throw off the illness, was usually the best treatment. Although this can be true, many practitioners trained in TCM see this as a significant weakness in his style.
For the treatment of chronic conditions, however, especially for those that largely stem from weaknesses in the patient's constitution or from emotional causes, it can be extraordinarily effective.
Four Blocks to Treatment:
JR Worsley taught that there are four important ways that a patient's qi can become pathological. If any of these 'blocks' are diagnosed then they should be cleared before the CF is treated (15)
'Aggressive Energy'. This method of diagnosing the presence and clearing xie qi (more usually translated as 'perverse' or 'evil' qi) probably derives from an oral Taiwanese tradition (16). Worsley taught that patients should have the back shu points of the yin organs very superficially needled in order to clear any 'Aggressive Energy' present. If present in an organ it can affect the yin organ across the ke cycle in a destructive way. ‘Aggressive Energy’ can cause severe problems, physically and/or psychologically.
Husband/wife Imbalance. This imbalance is regarded as extremely serious and potentially life-threatening. It can also be the cause of severely disturbed psychological states, especially deep resignation and/or extreme anxiety. It is diagnosed from the pulses and the condition of the person. The pulses of the left hand (husband side) should be slightly stronger and qualitatively superior to those on the right hand (wife side). Transfers of qi are carried out between the organs diagnosed on the pulses of the right hand to those on the left until the left hand pulses are fuller (17).
Possession. Two treatment protocols can be used when the patient's spirit is no longer fully under their control. Obsessive thoughts, 'psychic disturbance', the feeling that 'the lights are on but nobody is at home', or a deadness or glazed expression in the eyes can all be indications of 'possession'. Psychological trauma or extremely intense emotions are the usual causes. Either the '7 Internal Dragons' (points on the front of the body) or the '7 External Dragons' (on the back of the body) are treated to clear the 'possession'.
Entry-Exit Blocks. In Ling Shu, Chapter 16, a circuit of qi is described that starts in the lung channel, flows through the 12 organ channels and finishes in the liver channel. Blocks can arise between channels or, less commonly, in a channel. The point of entry and/or the point of exit is treated in order to clear the block, which if present, can lead to a significant improvement in the patient's health (18).
Emphasis on the 'Spirit Of The Points" and the Name of the Point, Along with Command Points:
Points Are Used In Three Main Ways In Five Element Constitutional Acupuncture:
According to the type of point. These uses were first laid down in the early classics, especially the Nei Jing. For example, different types of points are back-shu points; yuan-source points, element points, tonification points etc. These points form the basis of much of the treatment. The Five Element associations of the points are of particular significance as they allow 'transfers' of qi between organs. They also allow the practitioner to influence the elements within the element, for example reducing the fire in the liver by using Liv 2 xing jian.
According to the qualities implied by the names given to them in antiquity. For example, points such as Ht 7 shen men, Spirit Gate, or Ki 25 shen cang, Spirit Storehouse, can be used to treat a person at the level of the spirit. The great physician Sun Si Miao wrote 'The names of the points are not nominal; each has a profound meaning' (19). The use of points based upon the name of the point became a major aspect of the point selection of many Daoist practitioners and is described in the Yellow Court Classic (+ second century), a component of the Daoist Canon or Dao Zang.20. There are still Daoist practitioners (21) who have maintained the tradition of using point names extensively in their treatments.
Using a combination of points. Some points are used together to create a specific effect. For example using a point just below Ren 15 jiu wei ren, St 25 tian shu, St 32 fu tu and St 41 jie xi to clear possession or exit and entry points, such as Liv 14 qi men and Lu 1 zhong fu , to clear a block.
These are the key areas that mark out J.R. Worsley’s style of acupuncture. There are many other aspects that are distinctive to the style. For example, some Japanese diagnostic protocols were taught, such as abdominal diagnosis and the Akabane test. The 'Chinese clock' is used diagnostically and the horary points are used at particular times of day. The Korean Four Needle technique is sometimes used to transfer qi.
If the reader has followed this far then it should be apparent that Five Element Constitutional Acupuncture is based upon quite different presuppositions and values to TCM, Japanese Meridian Therapy or any other style of acupuncture currently being taught. Through the observation of the cycles that occur in nature, the Five Elements in a human being can be understood. Based entirely on signs, rather than symptoms, a diagnosis is made of which element is the person's primary constitutional imbalance. Treatment is then focused on nourishing the root to promote health in the person’s body, mind and spirit. The health of the spirit is often regarded as the main priority. Minimum intervention is prized, as is preventive treatment. The classics of Chinese medicine support all these principles.
The Ming dynasty physician Xu Dachun wrote 'Illnesses may be identical but the people who have them are different' (22). In some ways this phrase appears to sum up the difference between Five Element Constitutional Acupuncture and other styles of acupuncture that concentrate more upon the nature of the person's illnesses. Practitioners of TCM, for example, focus much of their diagnosis on understanding the energetic disharmonies that manifest in a particular symptom. Five-Element Constitutional Acupuncture, however, focuses upon diagnosing and treating the energetic disharmonies of the different people who have the illnesses.
But the statement implies a duality between the person and the illness, as though they were disconnected from each other. The good practice of medicine, of whatever lineage, has always been concerned with the person, the illness and the relationship between them. This is expressed in Chinese medicine by the concepts of ben and biao, root and manifestation. The concept of the CF and the practitioner's focus on generating change in the person's spirit make Five Element Constitutional Acupuncture a style almost exclusively focused on nourishing the root (ben). Other styles of acupuncture are often more focused on treating the manifestation (biao) and if consistent treatment on the root is ineffective this is what is required. As it says in Su Wen, Chapter 62 'One should first treat the root, then later treat the symptoms (23).
What is undeniable is that the style that JR Worsley taught has been hugely influential in the growth of acupuncture in the UK, USA and to a lesser extent in other countries such as Holland, Norway, Canada and Germany. His greatest gift to the acupuncture community was in his understanding and teaching of how to use acupuncture to treat people rather than illnesses. For this reason alone, Five Element Constitutional Acupuncture offers a tremendous amount to practitioners trained in other styles of acupuncture. Added to good quality TCM or one of the different Japanese styles it gives the practitioner a diagnostic and therapeutic practice that can enhance patients' health to an extraordinary degree. Many tens of thousands of patients have already benefited and many more will in the future. That is a great and extraordinary legacy for any person to leave behind.
1. The style of acupuncture taught by JR Worsley came to be known in recent years as Classical Five-Element Acupunture. In this article I shall use the term Five Element Constitutional Acupuncture.
2. The acronym TCM is used to describe that style of Chinese medicine currently taught and practised in China.
3. Dale J. (1996). Diversity amidst Unity?: Responses to a Survey of Acupuncture Practitioners. European Journal of Oriental Medicine, Vol 2. No 1.
4. De Bary W.T., Watson, B., Chan, W.T. (1960). Sources of Chinese Tradition, New York, Columbia University Press
5. The idea that imbalance of an organ or element produces these energetic signs comes from the Nei Jing and Nan Jing. Chapter 34 of the Nan Jing, Su Wen chapters 4 and 5 and Ling Shu chapter 49 amongst others, outline the emotion, colour, sound and odour that 'resonate' with each organ.
6. Quoted in Needham J. (1956). Science and Civilisation in China, Vol 2, Cambridge, Cambridge University Press, p 243.
7. Su Wen, Chapter 1 and Nan Jing, Chapter 61.
8. That is not to say that qualities are not detected by the practitioner. 'Thin' for example would be registered as a form of weakness. 'Wiry' would often be seen as a form of fullness.
9. Larre C, Rochat de Valle E. (1992). The Secret Treatise of the Spiritual Orchid, Cambridge, Monkey Press, pages 53 and 67.
10. Sunu,Ki. (1985). The Canon of Acupuncture, Los Angeles, Yuin University Press, page 108.
11. Veith I. (1949). The Yellow Emperor's Classic of Internal Medicine, Berkeley and Los Angeles, University of California Press.
12. Lu, H. (1973). The Yellow Emperor's Book of Acupuncture, Vancouver, Academy of Oriental Heritage.
13. Scheid V, Bensky D. (1998). Medicine as signification - moving towards healing power in the Chinese medical tradition. European Journal of Oriental Medicine, Vol 2 No 6.
14. Da Cheng quoted in Soulie De Morant G. (1994). Chinese Acupuncture, Brookline Massachusetts, Paradigm Publications, page 10.
15. Bob Flaws wrote an interesting article in November 1989 edition of the Traditional Acupuncture Society Journal (sadly now hard to find), entitled Four LA Blocks to Treatment. (LA stood for Leamington Acupuncture, as it originated in Leamington Spa, Warwickshire where JR Worsley taught). He gives his understanding of the place the 'four blocks' in the body of Chinese medicine.
16. Eckman P. (1996). In the Footsteps of the Yellow Emperor, San Francisco, Cypress Book Company, page 201.
17. J.R. Worsley’s knowledge of the Law of Husband/wife probably derived from the French teacher Soulie de Morant who learnt acupuncture in China during the 1920's and 1930's. See Eckman P. (1996). In the Footsteps of the Yellow Emperor, San Francisco, Cypress Book Company, page 203.
18. P. Eckman notes that this protocol was being taught in the Shanghai Military Medical College in the 1960’s but is not to be found in Chinese textbooks since that time. See Eckman P. (1996). In the Footsteps of the Yellow Emperor, San Francisco, Cypress Book Company, page 203.
19. Ellis A, Wiseman N, Boss K. (1989). Grasping the Wind, Brookline MA Paradigm Publications.
20 Eckman P. (1996). In the Footsteps of the Yellow Emperor, San Francisco, Cypress Book Company, page 213.
21. Such as Jeffrey Yuen in New York.
22. Unschuld P. (1990). Forgotten Traditions of Ancient Chinese Medicine, Brookline Massachusetts, Paradigm Publications, page 17.
23, Lu, H. (1973). The Yellow Emperor's Book of Acupuncture, Vancouver, Academy of Oriental Heritage
Peter Mole has been a practitioner of Five Element Constitutional Acupuncture since 1978. He studied with JR Worsley for many years and received his Master of Acupuncture qualification from him in 1984. He has been a teacher of this style for over twenty years, first at the College of Traditional Acupuncture in Leamington Spa and latterly at the College of Integrated Chinese Medicine in Reading, where he is the Dean. His book for the general public, Acupuncture, Energy Balancing for Body, Mind and Spirit, has a Five Element emphasis. He has just completed co-writing, with John and Angela Hicks, a text book called Five Element Constitutional Acupuncture, Nourishing the Root, which will be published in 2004. firstname.lastname@example.org.
Copyright Peter Mole 2002