A question that I often get asked in the clinic is “what is qi? For many people, the word “Qi” is either little more than some sort of mysterious hippy concept or that annoyingly convenient word that allows your scrabble partner to make use of the letter “Q” on the board giving them the triple word score and a cheeky 33 point word out of two letters!! It will often be described as life force, vital energy, circulating life force, cosmic energy or other equally non-descript terms. Even as an acupuncturist I shy away from giving a quick sound-bite of an answer to this question because there really isn’t one out there that does it justice. Although there are many interesting and insightful parallels that can be compared to aspects of qi, such as electromagnetic fields, piezoelectricity or the seemingly magical properties of fascia and cranio-sacral therapy, these explanations can never really explain the many different applications of the word. In a Chinese dictionary, the character for “Qi”, is usually used with other characters to describe the sense in which it was meant to be used. For example, the Qi that pertains to air is called “KongQi” or “air/space qi”, weather is defined as “TianQi” or heaven qi, the slow moving exercise that is known as “Qigong” literally means Qi work/ skill/ cultivation. Just to clear up another matter, the martial art form known as “tai chi” does not actually refer to the word “qi” or “chi” in its title. Tai chi which comes from Taijiquan, translates as “Supreme/Grand Ultimate Fist” and is named after the Taiji symbol, otherwise known as the yin yang symbol. In fact there are over 400 definitions for uses of the word “Qi” in an abridged Chinese dictionary, translating into a vast and obscure range of things, from a hovercraft to courageousness and even a tracheotomy. Qi can only really be understood with a recognition of the tradition, age and culture from which it has come from and that takes a period of time for it to mature from an abstract concept to something with more functional relevance. However all of the usages of the word centre around a process of change and transformation. To stimulate the qi within the body, whether through needle, hands or other, is to stimulate some form of transformation process. The desired change felt in the body of the patient by a skilful practitioner is due to the manipulation and transformation of qi.
Another common misconception around “Qi” that is often heard around complementary health practitioners including some acupuncturists is that Qi is an exclusive and precious substance that can only be accessed and influenced by an acupuncturist or another style of “Qi” related practitioner such as a Shiatsu practitioner in some sort of esoteric dance with the spirit world. In Chinese medicine, emotions move qi in different ways. For example, anger is said to raise qi whereas fear is said to drop or descend qi. It is common to say that people can “boil up with anger” or “blow their lid”. This raising of anger can sometimes give people a headache as the blood visibly rushes up to the head. It is also well known that extreme fear can make people lose control of their bladder or even sometimes their bowels as well. This would be a good example of fear causing the sudden dropping of Qi. As Andrew Nugent Head of the Association of Traditional studies explains in an article published in the Journal of Chinese Medicine, “just look at the stands of a British football match and you’ll see the supporters undergoing intense emotional experiences of sadness, anger, happiness and euphoria. I can’t reproduce that level of qi movement in a patient with a needle! Needling is about moving qi - but life moves qi, sadness moves qi, cheering your football team moves qi … it's not something different”. Another more refined example of a syndrome recognised in Chinese medicine is called “plum pit qi” (meihe qi). This describes the feeling of having a lump in your throat (like a stuck plum stone) brought about by emotional distress, often felt when we are about to cry.
The use of clever poetic language that Chinese Medicine uses to illustrate and most importantly, guide treatment, into often complex manifestations of illness and health is actually testament to how functional and pragmatic this medicine really is. Through careful observation and meticulous enquiry into the unfolding of nature within its myriad forms, comes a practical language through which we can navigate life for the better. Qi is not a wishy-washy ethereal substance that stops flowing when you drink non-organic milk, it is life happening in all of its forms. Concepts and metaphors in Chinese Medicine such as Qi and the Taiji (yin-yang) are the building blocks of a profound philosophy that provides us with the tools that help us to stay upright on the great tightrope of life.
Awareness is half the battle done.
Where is the pain?
Pain is felt in the body, by the brain. Acute pain is a sensory signal coming from the damaged or stimulated area of the body. The signal travels through the spinal cord and to the brain which interprets how much pain you should be, and consequently will be, feeling. So, your brain makes an educated guess which is based on all the relative information, including prior experience, visual input and emotional factors as well as actual tissue damage. In basic terms,
the level of pain perceived is largely based on the level of threat perceived.
We have all experienced a situation where we have not been in pain until we visually see that we have damaged ourselves. This reminds me of one time that I was cycling home on a dark winter night when my front wheel slipped on ice causing me to face-plant into the gravelly pavement and skid for a few feet. I was certainly aware of how uncomfortable this experience had been but it wasn't until I got home and looked in the mirror to see my swollen lip and grazed face that I realised how much pain I ought to be in. Here we have a pain stimulus that once backed up by info from our visual cortex is perceived to be a high enough level of threat to warrant a sudden upwards surge in pain level. This is all the more important to hold in mind in an era where just about anybody can search their symptoms up on google and catastrophise about a hundred and one horror stories related to “a sore back”. Owch!!
If I have bulging discs will I have pain?
More than 50% of people with MRI-detected abnormalities (such as bulging discs and disc protrusion) in their lumbar spine report no pain.
(Jensen et al 1994).
There is a heap of studies that demonstrate this MRI scan phenomenon. In fact, many people who develop acute back muscle spasm and are diagnosed primarily on the basis of MRI scan findings may have unnecessary surgery that doesn't alleviate their symptoms.
In another study Dr James Andrews performed MRI scans of 31 healthy pain-free baseball players shoulders and found that 90 percent of them had abnormal cartilage and 87 percent had abnormal rotator cuff tendons. One theory as to how this may happen is that if the joint degeneration develops over a long period of time then the brain will fail to register it as enough of a threat to the system to perceive it as pain. An acute knee cartilage tear on the football pitch would however be much more likely to flag up as pain.
Interestingly, you can determine the presence of chronic pain pathology by changes found within regions of the brain… For example, if a limb is in chronic pain then it will show marking within that specific region of the somato-sensory cortex.
“The most consistent biomarker for chronic pain involves changes in the function and structure of cortical areas of the brain – whatever the diagnoses”
(Apkarian et al 2009).
What is the difference between acute and chronic pain?
As we worked out earlier, pain is extremely subjective. There are many different types of sensory nerve receptors and fibres attuned to different stimuli. We can make a significant distinction by considering the differences in the biological processes of acute and chronic pain:
The first 48 hours after an injury is considered the acute phase. This acute pain is the sort of pain that results from an acute stimulus such as a pin-prick or tissue damage from an injury like a sudden twist of the neck as you turn to face your beloved but bothersome offspring throw their dinner on the floor. Following an incident such as this there will be an inflammatory reaction which will cause a relatively sharp pain that carries along larger and faster nerves called type A myelinated nerve fibres.
Sometimes however, even after the tissue-healing period, or just after any of the multitude of pain contributing factors have become loud enough for you to perceive them, you will experience chronic pain.
Chronic Pain is pain that has been around for some time. A number of physiological changes will have been made by the nervous system during the period taken in order for it to become a chronic pain. Chronic pain is usually travelling down slower, smaller nerves called type C fibres. These nerve fibres give a more dull, achey or throbbing sensation. Whereas most sensory nerve receptors will stop being registered by the brain after a period of time, (including type A nerve fibres), type C fibres can be constantly firing. Superficial sensory nerve receptors in our skin allow us to feel the sensation of fabric on our skin when we put our clothes on in the morning, but we don't carry on feeling them all day long. The constant type-C pain signals, however, become a persistent irritant to our autonomic nervous system. This, over time may push our body into a more sympathethic fight or flight nervous system state.
Sensitisation in chronic pain
What is interesting about chronic pain is that the connection between the level of tissue damage sustained and the pain perceived may have moved even further away from each other. This is basically due to the neural activity (in this case pain) being activated so much that the brain becomes more and more sensitive to it. We can see this type of neural priming with all sorts of everyday activities, from roller skating to long division, we gradually learn to become more specialised to deal with what we are most exposed to, which in this instance, is pain. So this process is called long term potentiation, and is present to some extent in all long-term chronic pain problems.
"It now seems as if pain carves a path through us in the same way that water creates a route down the side of a mountain. It flows where it must. Chronic pain is the result of flooding on that pathway until it erodes a deeper channel, or creates new ones... The longer and deeper pain flows the more it lays down a sensitised trail for future pain"
In some cases chronic pain sensitisation can lead to a hypersensitivity to multiple sorts of stimulus. This is called central sensitisation. This involves an increased sensitivity to mechanical pressure, temperature, bright lights, noise or even medication. This pattern is often associated with other triggers such as emotional distress, lack of sleep, excess medication, tissue-irritating dental fillings, unsuitable diets or irregular eating patterns. One must not forget that being in chronic pain leads us to a chronically over-active sympathetic nervous system leading to a sustained arousal of fight or flight body state. This state sharpens our senses, causes our eyes to dilate, increases muscle tone, prevents proper restful sleep, decreases our ability to digest food properly, and speeds up our breathing and heartbeat amongst many more physically and mentally distressing symptoms. Being in chronic pain is downright exhausting, we should appreciate the self perpetuating nature of pain if we want to have a better grip on managing it.
Pain ►Fight or flight nervous system state ► Less restful sleep + emotional stress + increased muscle tension ► increased sensitivity to pain and stress ► more and more pain....
Phantom limb and internal body maps
An interesting phenomenon that demonstrates how pain isn't always related to tissue damage is called "phantom limb syndrome". This is where someone who has lost a limb, or other body part, through amputation or an accident still registers sensation where that limb used to be. This sensation is in 70% of cases sensed as pain, however, it can also be a contraction or altered spatial perception. This rather distressing syndrome tells us so much about how the brain works. It really highlights the distortion between our cognitive perception of the body and our sub-conscious neural perception of the body. We all have a sub-conscious body map. Just as in the case of a phantom limb patient physically feeling a body part that isn't there, in many chronic pain cases we may be sensing a pain that has already healed. Much of my bodywork is about bridging this gap between objective tissue changes and perceived neural input. It's like a kind of re-tuning of our somatic nervous system.
The hierarchical sensory world
This "body map" is an amalgamation of all the neural input. So if we look at all the internal neural input we can see that there are many different contributions from different types of nerve receptors. We can broadly categorise them into terms of nociceptive, which are associated with pain, proprioceptive which is kinaesthetic or sense of bodily orientation, interoceptive or internal perception such as that of the viscera. We also know that pain works in a somewhat hierarchical fashion. All of these different types of sensation are all signals and they compete for recognition into our conscious neural feed. When we fall and hit our knee we instinctually hold and rub it. The sensation of holding and rubbing, which feeds into our mechanoceptors and somewhat reduces the nociceptive pain signals from reaching their target.
It is a bit like who shouts the loudest and for the longest duration will get the most attention from the brain. As we know from before type C chronic pain nerve fibres can consistently be firing. This means that after a period of time people in chronic pain don't just become better at feeling pain but they now lose a significant portion of other types of sensory input. Pain begins to rule the show!
If we want to understand pain we have to account for the emotional contributions. We may learn to associate physical feelings with emotional pain. To borrow the second part of the quote (borrowed from Cranial Intelligence by Ged Summers and Steve Haines) that I started earlier;
"The longer and deeper pain flows the more it lays down a sensitised trail for future pain. And this can become a conduit for other kinds of pain - divorce angst will head straight for that channel, until body pain and life pain become indistinguishable... Pain creates a language for wordless events like loss. Sometimes I think pain is just the body thinking out loud"
To complicate the matter further we may associate negative past emotional experience with physically felt sensation that re-emerges as a kind of emotional somatic memory from the time of the initial trauma. A feeling of grief that surfaces as we sink with our listening elbows into a sore shoulder that started at the time we lost a loved one or even the gutting feeling of past rejection that re-emerges when we release the diaphragm with a myofascial release technique. Sensory signals offer us a narrative to our emotional existence, a way of associating the experience of the things around us with the feelings within. Even on a sub-conscious level we are responding and acting upon internal feelings all the time. Our gut feelings or butterflies in our stomach are examples of language that we use to explain the physical sensations that can alter and shape our behaviour.
Some practical tips on how to better regulate pain.
A person in chronic pain is like a loaded donkey. The more loads the donkey has to carry the closer it will get to collapsing. Equally, the more factors we have contributing to the pain, the harder it will be to overcome. The best way to start is to take off some weight. It may be wise however, not to do it too quickly. It will not help you to be seeing five different types of therapists simultaneously whilst fasting on a smoothie diet and seeing a personal trainer. Each load you take off will be a change that your system will have to deal with. Make considered interventions individually so you can see how your body is responding.
. Awareness is half the battle. Educate yourself in pain science and use it to manage your pain instead of fighting it.
. Don't catastrophise. Internal neural input is modified by structures such as our frontal lobe, the visual and auditory cortex. Reading scary internet blogs about illness can be a slippery slope.
. Calm down the nervous system. An overactive sympathetic nervous system makes it very difficult to make any progress. Bodywork such as taichi and yoga that train breathing and body awareness are excellent ways of reducing sympathetic overdrive, amongst many other benefits.
. Overcoming pain isn't just about eradicating the bad signals as if it is an enemy. Introduce other signals that can add to your available menu of sensory input. Acupuncture, yoga, massage are potentially all sophisticated ways of talking to the nervous system and introducing more harmonious connections with the bodies we inhabit.
. Do nice things and take good rest. Nourish yourself
"Neurons that fire together, wire together"
A common and largely misunderstood phenomena in bodywork is the idea of the emotional release. We are probably familiar with expressions such as "butterflies in your stomach" or "a broken heart" but what does that really mean to hold emotional pain and how do we let it go? Part of the problem in understanding this phenomenen lies within our understanding of the mind and brain as being distinct and separate entities. Increasingly however, more and more clinicians, both working in mental health and with physical ailments such as pain and musculoskeletal dysfunction, are utilising a more Eastern perspective of the mind and body being both one and the same in the search to find more efficient ways of creating meaningful change in peoples lives. So what is the thread that links the two?
Neurons that fire together, wire together
Interoception and how we feel inside
Interoception is basically the sense of what we feel is going on inside our bodies. The cravings for food and the urge to relieve our bowels are interoceptive messages that come from neural pathways within our body that are processed by our brains and inform necessary behaviour. Importantly though, we can also relate to internal sensations triggered by emotional stimuli. "Butterflies in our bellies" or being "scared stiff" are internally felt and perceived responses to things that threaten our inner sense of wellbeing. The importance of this connection to what we feel inside is being proven to be an incredibly useful resource in the management of stress, anxiety, bulimia, and many other forms of psychological distress that were once exclusively seen within the domain of cognitive based approaches such as counselling or CBT. Interoceptive practice is actually embedded within many systems of bodywork, as well as spiritual and meditative traditions, particularly found in the East. Yoga and taichi are brilliant ways of training interoception and proprioception (kinaesthethic awareness) through sustained awareness of breath and bodily sensations alongside dynamic to more subtle alterations of bodily movement.
"One of the clearest lessons from contemporary neuroscience is that our sense of ourselves is anchored in a vital connection with our bodies. We do not truly know ourselves unless we can feel and interpret our physical sensations; we need to register and act on these sensations to navigate safely through life. While numbing (or compensatory sensation seeking) may make life tolerable, the price you pay is that you lose awareness of what is going on inside your body and, with that, the sense of being fully, sensually alive."
Bessel Van Der Kolk
A brief understanding of trauma and Porges hierarchical survival response
When we face a threat to our safety our body makes a snap decision as to whether we can use our skills of verbal and bodily communication to get away from trouble. This first response is called our Social engagement system. A sign of a healthy social engagement system is being able to synchronise and engage smoothly with others body language, voice tone and verbal cues. When people are scared and this system is challenged you can observe a change in voice tone, posture and often see an increase in the speed and volume of their talking. However, if this fails to work or we have already bypassed this step, then we instinctually employ the physiological survival mechanisms that are hardwired into the most primitive parts of our neural circuitry. When we activate our primal survival resources, it feeds straight into the limbic system and the brain stem. This is why trauma will often effect the most basic bodily functions such as eating, sleeping, defocating and breathing. Interventions focussing on the frontal lobe and cognitive processing are at best limited in these cases.
The first system to occur after the social engagement system is the fight or flight system governed by sympathetic activation (SNS) of the autonomic nervous system (ANS). This causes a surge of adrenalin and then cortisol into the system which increases our heart rate and speeds up breathing whilst our pupils dilate to spot danger and our digestive processes slow down. It is very common to see people who are running on chronic SNS activation. A lot of my clinic time involves bringing people back into their bodies and calming this system in order to work at a deeper and more therapeutic level.
Perhaps though, we may experience a scary and overwhelming experience that we can't fight or run away from. This, "freeze" or feign death" response", is another primal survival mechanism that you can see in many animals that become trapped and unable to escape the danger. This survival response can be seen when a cat catches a mouse. Often the mouse will instinctually play dead which fools the cat into losing interest in it's dinner and leaving the motionless mouse alone. Once the danger has passed the mouse will spring back into life and make a speedy getaway. The freeze response will also often cause people to suddenly lose control of their bowels, hence the commonly heard phrase of "being scared shitless".
What the trauma researchers have recently shown us is that these trauma states can become chronically activated, thus hijacking our ability to operate smoothly at neo-cortical levels that are crucial to building successful, loving and trusting relationships to others and, indeed, to ourselves. When we are activated into these survival states, the inability to inhibit activation into more primitive neural networks means that we may not be able to give a very detailed account of what might have happened to us. What we do find though is that we will still have ingrained implicit memories of the sensory experience. This means that we may powerfully recall the odours, sounds and sensations of the trauma without being able to deliver a coherent sense of the timing and order of the events. These lucid, sensory memories may re-activate the horrors of the experience at a later date when we experience similar sensory experiences. This is called state dependent recall in PTSD. An ex soldier becoming going into a sweat and having a sudden sense of a panic attack at a firework display that triggers an implicit traumatic memory of being in a warzone would be an example of this. Trauma can also be through physical injury as well as emotional overwhelm.
"Trauma can be defined as anything that overwhelms our resources"
Somatic emotional triggers
The clinical name for a complete lack of interoceptive ability is alexilthymia. People with a complete lack of interoceptive ability are evidently impaired in their ability to recognise emotions accurately. A very common experience found within bodywork is that people can lose connection with certain parts of their bodies. Sometimes this can be seen through an inability to accurately sense or feel what is going on within their bodies when palpated, asked verbally to track sensations or perform specific movements. It can also be picked up by the skilled practitioner as an observable and palpable area of relative inactivity, or local stagnation of fluid, blood etc. It is almost like the area of the body has been erased from the internal body map. I personally share the opinion, amongst many other practitioners, that this block of awareness is a coping strategy, put in place so we are not continually subjected to the potentially unpleasant or distressing bodily sensations that may have arised during a personally traumatic experience or overwhelming time in someones life. This sensation may form a kind of somatic trigger, that when activated through touch, movement, related external sensory input or internal awareness practice, releases the same neuro-endocrine response and consequent felt sense of emotion that was generated at that time of increased stress or single traumatic incident. If this was the case then we could begin to understand how the subconscious avoidance of somatic triggers to unpleasant guarded emotional arousal, could lead to habitual postures and movement patterns developed in clinical states such as depression and anxiety. When was the last time you saw a truly depressed person with an upright and engaged posture? This initial sensation of something more ethereal has undergone the transition to a chronically held physical state of tension or, equally possible, lack of tension.
Exposure therapy and cathartic emotional release practices
We know from studies into the de-sensitisation or exposure approach to PTSD treatment that when the patients recall their experiences through verbal triggers or even through computer generated scenes of battlefield action, for example, that their biological responses are the same as if they were experiencing the trauma at that present time. In other words, they are being re-traumatised again and again in order to numb their arousal response to the effects of their trauma. Unsuprisingly, these interventions have an extremely high dropout rate and in some cases cause patients to spiral out of control and lead to irrational and dangerous behaviour. So in this case we are initiating the same emotional and neuro-endocrine response, but this time it is through our external senses or mental processing and it is without the awareness and connection to the body.
Exposure therapy and other highly charged and emotionally challenging techniques seem to be too direct an approach to safely allow an integration between a safe and contained sense of self in the present moment with the turbulent nature of the implicit traumatic memory. If we can learn to safely activate the somatic trigger whilst maintaining a sense of the present and not becoming too overwhelmed then we may be able to push the trigger into a place of stillness where we can move on. Often it can just be as simple as first becoming aware of the interoceptive sensations that arise when in periods of emotional stress, and then going through a process of gradually befriending them. Once a level of awareness and control is established over our internal world then we can prevent these interoceptive feelings from triggering a negatively spiralling thought pattern that occur on a largely sub-conscious level. We take the leap from being governed by our feelings to taking an active role in stabilising the hold over our emotional wellbeing.
Many people working working with trauma stress the importance of working sensitively and at the right speed for the individual patient. The Chinese medicine perspective also stresses the importance of this idea of not pushing an energetic release out of the body. If either the patient or practitioner forces the process, it will just cause a stagnation in the free flow of qi. The release will happen when it is ready to. Peter Levine calls this process titration or pendulation in some of his books, (see video below) it involves first finding an anchor of safety within yourself, and then slowly re-visiting the sensations over time, without becoming too overwhelmed, in order too take the venom out of the locked emotional energy. We must also bear in mind that an overly acute interoceptive sense can also be involved in negative experiences such as anxiety disorder. Studies have shown that people with anxiety have been recorded as having a better ability to accurately sense the number of heartbeats within a given time as opposed to a control group. Whilst knowing this is clinically relevant, we must not throw the baby out with the bathwater. It is possible for people to become hypersensitive to sensations within the body such as an increased heart beat and for this to become a trigger for a negatively reinforcing thought pattern. For example, an increased heart beat that invokes a sensation of panic then triggers a cascade of associated catastrophising thought patterns that further reinforces the sensation of imminent danger and anxiety response. In this case, the physically felt sensation of increased heart beat has now become a sensitised catalyst to unpleasant emotional arousal, however by bringing our attention to neutral sensations within the body and remaining present at the point of emotional arousal we can create a more balanced perception of self that is able to navigate more safely through our internal world.
It would not be unreasonable, in my opinion, to suggest that many chronic mental and even physical illnesses are derived from dysregulated interoceptive patterns due to the effects of unresolved underlying trauma and chronic stress activation. To work skillfully with the body is to work with the mind, whether we know it or not. Some of the most inspiring people I know are naturally able to connect and bring light into peoples lives through an almost psychically perceptive understanding of human emotion. These people are often the teachers, bus drivers and baristas of our society. Not health professionals, just well intentioned intuitive souls with highly attuned mirror neurons. However, from a clinicians perspective, If we don't take the time to examine the neurobiological mechanisms of held emotional trauma and unresolved physiological survival responses then we may fail to be informed of the potential for re-traumatisation. I believe that if we can learn to integrate this exciting new knowledge of neuroscience with the rich traditions of cultivating mind body awareness that have existed and evolved over thousands of years, then we can significantly progress in our knowledge and practice.
Find your true weakness and surrender to it. Therein lies the path to genius. Most people spend their lives using their strengths to overcome or cover up their weaknesses. Those few who use their strengths to incorporate their weaknesses, who don’t divide themselves, those people are very rare.
Norm Farb interoception
Bessel Van Der Kolk
Introduction to Porges and the Social Brain
" Being able to feel safe with other people is probably the single most important aspect of mental health, safe connections are fundamental to meaningful and satisfying lives. Numerous studies of disaster response around the globe have shown that social support is the most powerful protection against becoming overwhelmed by stress and trauma."
Bessel Van der Kolk
In this series of posts I want to explore the connection between the mind and the body through bringing insight from research that I think really demystifies some of the natural healing methods developed over millennia by our ancestors. What better way to start this topic, which has been like opening one immensely large can of worms for me, than to look at the work of Stephen Porges on the fascinating vagus nerve!! This nerve, which Darwin dubbed the "pneumogastric nerve" is, in effect, a portal between our emotions and our physical being. It signals information from the brain to the body and from the body to the brain like a continuous neural ping pong match. The vagus nerve brings much of the sensation of our viscera into our awareness, just think of your "gut feelings" or a "heartbreaking moment" and you will recognise the potency that this stimulus can deliver. About 80% of vagus nerve activity is signals from the body to the brain, effectively making the vagus our internal CCTV system that relays all the raw data of our internal sensory experience up to our brains. Importantly though, this information isn't always processed cognitively, i.e brought into our awareness. This is what Porges has dubbed "neuroception" and is basically our subconscious neural feed that alters our moods, feelings and ultimately determines the physiological state of the nervous system. This theory, which forms the bulk of this article, stresses the importance of our need for safety. It shows how we are constantly on a largely sub-conscious level, assessing the environment for signs of safety or danger. It gives us a biological understanding of how the subtle changes in facial expression and voice tone alter our moods and how when we can't defend ourselves verbally or vocally it throws us into more primal animal like states that profoundly change our perception of the world around us.
Porges theory explains to us how we have three inbuilt survival mechanisms that are distinct physiological states. These have developed in levels of sophistication throughout our evolution.
Social engagement system
The most recent of our physiological survival states is what Porges calls the social engagement system and forms a branch of our "parasympathetic nervous system" (PNS). This is the part of our evolutionary struggle for survival that enables us to better love and to be loved. Human's have developed a type of social intelligence that enables us to regognise safety or threat in our environment. We observe the subtle cues of others body language, expressions, voice tone and posture to discern others intentions, whilst at the same time, we respond to our own physical and emotional states by exhibiting the same external changes. An example of this so aptly displayed right in front of me as I slurp a cup of tea writing this blog on a monday morning is a Mum going to toilet leaving small girl with Daddy in cafe. Small child reacts by instantly starting to cry leaving Dad desperately trying to pick up the pieces and prevent the disruption to fellow cafe dwellers by telling the child to be quiet. As small girl doesn't relent in her instinctual cry for the safety of her mothers arms the fathers voice deepens into a more assertive, monotonous and low tone as he tells her "there is no reason to cry". This really starts to set her off and soon everyone in the cafe is starting to get a bit unsettled by the young girls screaming just as mummy comes out the loo open armed and nestling child in bosom talking in a high pitched prosody as child settles down and continues developing her still primitive social engagement mode as we all relax back into our Monday morning routine. What the innocent lack of social inhibition and cognitive reasoning displayed by this small child exemplifies so perfectly is how we are subconsciously picking up on cues implicit to our survival.
If you have, what has been termed by Porges ever growing fan club as "good vagal tone" then you will be able to understand social cues and react to them smoothly and succinctly. You will observe and recognise the subtle cues of others body language, facial expressions, vocal tone and posture in order to discern their intentions and you will respond with your own appropriate external changes in expression, voice etc.
Top-down/Bottom Up regulatory system
When we observe safe social cues then our vagus puts on the brakes to our breathing and heartbeat, slowing them down and making us feel more relaxed and calm. Importantly though, not all the signals of this system are from the brain to the body (top down), we can also modulate our mood and feelings through vagal pathways from body to brain (bottom up). If we use slow breathing, such as pranayama or various qigong techniques that focus on the exhalation, it slows down our heartbeat, stimulating our social engagement system and sending messages to the brain that we are safe and relaxed. Singing and chanting are also particularly good at achieving this as it causes us to exhale for a longer duration of time than we inhale, which alone activates our PNS but is also reinforced by a physical vibration of the laryngeal nerves at the brain stem that in turn stimulates stimulates our vagus. How many cultures have singing and chanting as a means to greater social unity and a pathway to relaxation. Pretty smart really!
Scientists had already demonstrated a two-way connection between our facial expressions and moods by putting a pencil into a group of research participant's mouth's, in effect forcing a smile, and then testing their reactions to a series of cartoons compared to a control group. Low and behold, those who were forced into a smile would respond with more positive emotional responses than those who weren't. Studies to back up this bi-directional body- brain business is research done into the more recent trend of inducing localised paralysis via injection of poisonous neurotoxin's into the striated muscles of the face, or as it is otherwise known, botox. One of the more common botox injections is into the muscle on our foreheads that causes us to frown. This study scanned the brains of women whilst they imitated pictures of sad and angry emotions before and after botox. Both before and afterwards, when imitating angry expressions, the women displayed more activity in the amygdala region of the brain (an almond shaped structure of the brain that has been shown to register particularly negative emotions such as anger and fear). But after botox there was less activity in the left amygdala, indicating that the inability to change the structure of the muscles, skin and connective tissue alters the level of the brains processing of emotions. The study also showed that despite no change in amygdala activation in response to sad facial expressions the brain did show changes in areas associated with emotional processing of touch signals.
The studies on botox have spawned a series of ideas and articles that suggest that if we "botox ourselves up" we can treat our depression and anxiety. Another victory for the pill-popping quick fix society? I don't think so... In my opinion, I find the idea of not being able to fully express and cognitively process emotions a very disconcerting idea. Recognising the body's role in modulating our sub-conscious emotional picture only to then isolate a negative affective link and remove the connection leaving us free of it's burden seems really short-sighted to me. These emotions form an important part of our biological quest for safety and are implicit in our connection to the world. What if the ability to express fear and anger is actually sometimes a good thing? This disconnect of mind to body is akin to the pharmaceutical approach to mental disorders, being that if you can nullify the activation of primal responses to negative emotional stimuli by, in effect subduing our mind and nervous system, then we can have better emotional stability. Whilst drugs are an indispensable tool and one that allows many people most afflicted by the harshness of their internal world a foothold in a functional and positively meaningful existence, at what cost does it have? If by, in effect, severing our brain-body connection or at least quitening it, we can dampen the hyper-arousal to negative life experience then what about the connection to positive life experience? Could this effect our ability to feel subtle feelings of love, compassion and happiness? Instead of pathologising our body's signals to our brain, maybe we can befriend them. Begin to explore how we can work with the inner experience of ourselves with insight from the new advances in science and also the mind-body based traditions that have over many centuries cultivated this connection. We are in an exciting point in the history of medicine where we now are beginning to recognise the value of mind-body based interventions but yet our society is so centred around this "quick fix" paradigm or brainwashed by the sacred gold standard of evidenced based medicine that many don't embrace it. The idea that we can just take a pill and it will go away is much more convenient to us than having to spend time and effort on the arduous path to enlightened states of being. To be honest, I don't blame people. It is the society we live in and we have all committed a lot to it.
Where would I possibly find enough leather
With which to cover the surface of the earth?
But (just) leather on the soles of my shoes
Is equivalent to covering the earth with it
Likewise it is not possible for me
To restrain the external course of things
But should I restrain this mind of mine
What would be the need to restrain all else?
It has been a pleasure to spend two months as part of the project living and working with the people of Sipadol and Bhaktapur.
In retrospect my role as a healthcare practitioner here has often been more one of a sports therapist and a personal trainer than I had envisaged. What constitutes the daily grind over here would be seen more as an athletic pursuit in the UK. All through the day you see the village women in their colourful saris and flimsy flip flops bobbing up and down along the near vertical paths through the valley with a giant pile of logs in a basket hanging from their heads.
Sometimes I would ask the patients if their pain was better and would get the reply "a little bit" or often just "no". Initially this would leave me feeling a bit deflated; however, later I started asking how the farm work was going and would get responses like "Oh yes I could harvest a lot more potatoes yesterday"! At this point the penny dropped. It became clear to me that my job was about keeping these folks at the top of their game. The only difference between these hard-grafting subsistence farmers in the steep slopes of the Himalayan foothills and professional athletes is that here the physical exertion comes out of pure necessity. If the potatoes aren't harvested the family will get less food on the table. It would become an ongoing joke in the clinic as I would ask them not to carry too much weight on their heads or stop harvesting the wheat when their back starts to ache and the very next day they would come in saying "it was better before I was working and then...".
This said, they would still keep turning up in the morning and with our palms joined together in prayer position we would respectfully "namaste" and then begin our session.
From this point my focus shifted to how to make my treatments last. I started applying sports tape to take the strain off an inflamed achilles or plantar fascia when negotiating the steep trails around the village, I used herbal pastes, compresses and liniments that patients could go away with, I would have mini revelations whilst going for walks in the hills, my quads in full engagement stepping down unforgivably steep paths thinking, "So this is why everyone has knee pain here… Right! So how can I apply this knowledge in the clinic?" To have the time and space to commit to adapting my skills and techniques to the people I was working with was an invaluable opportunity and one which began to pay off in the smiles and waves I would receive around the village.
The most challenging difficulty, which is by no means unique to Nepal but was quite common, is getting people to really connect with what is going on inside their bodies during a session. Many people will have pushed through their chronic pain for so many years that they would not be able to accurately determine where they had their problems. Often they might just point vaguely at their legs, back, neck, arms, head, or all of the above and then just say "dhukksa'" or "pain" in Nepali. The danger of this I felt at times was becoming too focussed on chasing pain. I wanted to avoid the tendency to just stick needles in where it hurts (a frequent request). This could verge on becoming a sort of "cathartic pain exorcism" which I don't find to be of much use to anyone.
This is not a matter of intellect or cultural nuance but, I would suggest, is the strange and elusive nature of chronic pain and suffering itself. Its insidious and pervasive presence makes a transition at some point from being an interference in one’s life to an unwelcome part of life. This process, at the physical level, involves a lot of neural adaptation that amplifies the intensity of the signal and increases our reactivity to it, whilst at the same time obscuring the specific and the detail.
On the other side you have the emotional and mental adaptation to pain. It is not compatible with our existence and perception of self so we ignore it, block it out and often, in effect, disconnect a part of ourselves from our kinaesthetic body map. Invariably you see these mechanisms outliving their usefulness and becoming a part of people’s existence at great cost. I am interested in interrupting the cycle, opening up to other sensations or conflicting signals. In Nepal, like anywhere, people fight chronic pain every day. It is a big part of my job to bring them from fighting it to managing it. If one doesn't feel what is going on, how does one change it?
The level of commitment on behalf of the patients to attend so regularly, which was so important to the treatment outcomes, was only made possible by the very low cost service that is provided by the acupuncture relief project and its sister NGO run by the esteemed Ayurvedic doctor, Sarita Shrestha. In a society where many people, through fears of unaffordable hospital bills, are more likely to visit their pharmacy for a relatively indiscriminate handful of drugs than see a doctor, the work done here is worth so much more. It is more than just the acupuncture, massage, moxa or cupping itself. It also extends its roots far deeper into the community. It is a place where people can become informed, aware and proactive about their health as well as providing a safe and constructive place to share the burden of their pain with one another. In the aftermath of the devastating earthquake that touched so many here this is all the more important. From providing treatment and basic healthcare advice to giving shelter and basic sanitation in hours of need, I believe this grass-roots community work to be at the heart of good healthcare.
* King Curd is the name given to the deliciously sweet yoghurt that the Bhaktapur district is famous for.
Su Wen Ch 39
"Those who are good at speaking of heaven must have experienced it in man.
Those who are good at speaking of antiquity must have made the junction with the present.
Those who are good at speaking of men must be satisfied with themselves.
When things are like this, one can follow the Dao (ones way) without confusion or distress.
That is called illumination/radiance of life.
I would like to ask how to succeed in listening and hearing, looking at and seeing, feeling and palpating, how through the deep examination of self one can be free of confusion and lift the veil."
A week before I hop on a plane for Nepal, I would like to share some thoughts with inspiration from a seminar with Elisabeth Rochat De La Valle. I have been asking myself what I hope to achieve in Nepal this Spring. As much as my mission is primarily to help others, how best may one do this? I have been mining through old course notes for hidden pearls of wisdom, devouring textbooks, ordering supplies to make the maximum positive impact from my stay in Nepal. These are all going to be useful but I have come to feel that something more subtle is to be gained from my experience in Nepal. Something that paradoxically really isn't about achieving anything! A significant part of my trip will be about cultivating myself to be a better practitioner. But what does that mean? A fundamental principle of Chinese Medicine is that we are a miniature version of the natural world: the macrocosm to the microcosm. The laws of the grander picture (i.e. the natural world) are also applicable to the human mind and body.
"Those who are good at speaking of heaven must have experienced it in man"
Heaven here means nature. If we look at the rhythms of the seasons and the manifestation of life in plants and animals we can begin to understand the patterns of life manifest within ourselves and vice-versa. Of course, to gain an understanding of natural laws in life is also to build an understanding in the disturbances of death, as it is all the same force that governs us. Also noteworthy is that it doesn't say "those who understand heaven". It is not within the scope of the human perception to fathom such a grand principle. As Einstein said: "My religion consists of a humble admiration of the illimitable superior spirit who reveals himself in the slight details we are able to perceive with our frail and feeble minds. That deeply emotional conviction of the presence of a superior reasoning power, which is revealed in the incomprehensible universe, forms my idea of God."
"Those who are good at speaking of antiquity must have made the junction with the present."
Antiquity means the time when people understood and were synchronised with the rhythms of nature. If you don't have a grasp of the present then how can we learn from the past and of course the opposite is also true. This is particularly important nowadays, as even at the time of the Su Wen, already being 2000 years ago, they were already talking about the golden age of antiquity, if only old Huang Di and Qi Bo could see our modern day society they would be more than a wee bit shocked.
We now have an average global increase in life expectancy but we have an increase in many diseases. Sure, you can look at the fact that we now are better able to diagnose than ever and this will have undoubtedly increased the statistics but you can also see, within recent years, a rising trend in illnesses such as autoimmune disease, mental health disorders and cancer. This doesn't invalidate our medicine of old, in many ways it stresses it's importance. What has changed? What can we learn from the great medicine sages of old? And how is it applicable or not to our modern age?
What I see in the clinic today is a massive level of stress. It can just be about giving people the time to take a break from their minds. Bringing them back down to their bodies, NOT just to zone out and dissociate, but actually to connect with what they are feeling within their entirety, right now, in the present moment.
Our current medical paradigm is largely concerned with treating and preventing disease whilst causing the least amount of disruption to our lifestyles.
Not bursting the bubble.
We live in a phenomenally disembodied society; at its demands, we grind out high work productivity and pursue successful social relations at the expense of a meaningful connection to ourselves. We feel tired so we drink coffee or energy drinks, we have a headache so we take a painkiller, we want to relax so we get drunk or perhaps let off some steam by going to a gym and engaging in sweaty cathartic battles with ourselves to the theme tune of Rocky Balboa. Push it a bit further - go the extra mile is the mantra of our pill-popping, quick-fix nation. No wonder we feel the need to drop out and dissociate.
Classical Chinese Medicine as I see it is as much about cultivating the fulfillment of life through meaningful connections with ourselves, and consequently others, as it is about treating illness. We don't all have to meditate or do yoga; just being present for a walk in the park, or singing, or anything that allows us to feel a flow, a rhythm, an expression of the life within ourselves: these things work.
Inevitably, treating in rural Nepal will be a chance to work with people who are used to a very different way of life and a much slower tempo. The people in rural Nepal seem to work very labour-intensive lives, often walking many miles every day with immense weights on their backs. They are also exposed more to the harshness of the elements. I expect to learn a great deal from these people.
"Those who are good at speaking of men must be satisfied with themselves."
Wow, this is a big one! Yesterday someone asked me why I got into bodywork, to which my answer was; "Well, I had an interest in learning about my own body through practice of martial arts, so I decided that I would start to learn to work with other people’s bodies in order to carry on this educational endeavour,” or some words to that effect!!
Despite the convenient and fickle nature of memory, I feel that this is one that sits with me, and demonstrates that previous point quite well: If we don't have a good relationship with ourselves then how do we expect to have a good relationship with others? In regards to healing, a practitioner must cultivate an understanding of the manifestation of life (Qi) within themself in order to recognise and treat it within others. What business do we have to change the flow of others’ lives if we can't take responsibility for our own? To quote the words of Austin Powers; "Don't mess with my mojo, baby!" (A sure way to get lynched by the Chinese medicine community is to quote Austin Powers next to chapters from the Huang Di Neijing.)
My journey into understanding the nature of self began before, way before I decided to go to Nepal. Don't get me wrong, I am not just travelling across the world to sit in the shadows of the mighty Himalayan mountains with the desire of just "finding myself, man." But hey, what a place to take that journey to…
So this "desire" business hits on an important point. To desire too strongly causes stagnation in your intent (yi) and will (zhi). If the practitioner has too strong a desire to heal, it will put pressure on the patient The patient will not heal because we want them to, and actually it is this tendency to ‘mother’ ones patients which, albeit unintentional with many therapists, doesn't do the patient any good whatsoever. What must remain clear is what is me and what is them. If I put my agenda on to my patients because I want them to get better it will only cause a further distortion within the free flow of Qi of that patient and within myself.
To really heal is to remain empty and free of desire whilst facilitating the right conditions in which that person may get better – in order to better align themselves in accordance with the flow of nature.
But how do we become free and empty? Well certainly not by desiring it. Have you ever noticed how insomniacs will count off a whole list of things they do to get to sleep? If you push and desire the mind to do something you end up in inner turmoil. To force ones mind to do something could be compared to pushing water uphill. Better to build a path for it to naturally flow. Most of us will have something that give us a sense of inner flow. Dancing is a great example of the expression of Qi within someone. You can sense when someone is really feeling and moving to the music in the moment.
The reality is that I will go to Nepal and I will probably help some people but then there will be others that I won't be able to help. To cultivate the art of healing is to invest in a lifetime of learning. I intend to go to Nepal to look and see, listen and hear, feel and palpate but I also intend to do a bit more than that...
"Zhuangzhi Ch 4 Translated by B. Watson
Make your will one!
Don't listen with your ears, listen with your mind (xin).
No don't listen with your mind but listen with your spirit (Qi).
The mind stops with recognition, but spirit (qi) is empty and waits on all things.
The way gathers in emptiness alone.
Emptiness is the fasting of the mind."