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Emptiness and the Medical Encounter: The interior spatial requirements of encountering

This article is part of the series:

Thirty spokes converge in a hub
There where there is nothing,
That is the chariot’s usefulness.
Fashion earth to make a vase from it,
There where there is nothing,
That is the vessel’s usefulness

– Lao Zi

Emptiness…makes it possible to move about freely and succeeds in ‘letting pass’. The important thing is not to determine ‘what’ passes – assuming one even could – but to conserve its energy, as physics says, that is, preserve its activity.

– François Jullien

If your body [xing 形] is not correct,
The inner power will not come.
If at the centre you are not tranquil,
Your mind will not be ordered.
Correct [zheng正] your body and gather in the power,
Then it will pour in of its own accord.

– Guanzi jiao zheng, Ch.6

The medical encounter, and perhaps particularly the Chinese medical encounter, requires practitioners to place themselves in relation to the person with whom they are working, to achieve an intra-active entangled relation to the other. And we need to do so in a way that can enfold [4] knowledge of the patient-other into our frames of meaning, those diagnostic resources we hold for just this purpose to facilitate therapeutic intervention(s) and guide us through the conundrum of dis-ease, navigating the perturbations that afflict the patient-other. The messy, sticky, distracted business of encountering disorder can engender a multiplicity of resistances and vulnerabilities, which can both allow and impede the clear sight of what ‘really’ is ‘wrong’ and what might be fixed/transformed by the tools available. There are all manner of delusions about this encounter – that there is, for example, an objective reality that is knowable and becomes known, or which the doctor might divine by doing tests, or by touching or looking or smelling, which discoveries will clearly indicate a way to intervene for the doctor.[a] The Chinese medical literature recognizes a hierarchy of skills in the art of encountering that particularly relies upon the disposition or ‘heart’ of the practitioner. The ancients valorized those healers who, fostering an inner silence, could open themselves to receive their patient-other as fully or as clearly, with as little interference, as possible. Their task was to discern the nature of the disorder and find the correct way through [7] and then out of the situation of disorder – they needed to manage the reality of the situation. And it was not just the ancients – as Volker Scheid showed me when he gave me his translation from the Ming dynasty physician Yu Chang 喻昌:

“How could we fail to ‘investigate’ the myriad things, and how can we fail to ‘extend’ all there is to know? Conception is something that sprouts out of emptiness at the great foundation [of our being]. … if we fear to pursue things seeking to know, we will end our days investigating disease without [ever] knowing what kind of thing disease is. Still, how hard it is to produce conceptions that are both fit and proper [to a given context].”

As Yu Chang explains – in a statement I include later – to apprehend the situation of the patient in their context the practitioner joins the process of disorder.

An image that emerges is of an empty vessel, the very emptiness of which allows the intrusion/inclusion of material from outside [3]– to allow information from the encounter to ‘pour’ in of its own accord, to be received, and only then to be ordered and sifted.  This process brings to mind Richard Sennett’s distinction between sympathy (‘my heart bleeds for you,’ which he characterizes as the self-consumed attempt to recruit the other into one’s own perspective) and empathy (‘tell me your experience’, which is more like the attempt to understand the other from her or his own perspective) [9]. Both of these orientations to recognition routinely appear within the medical encounter. Sympathy, though, seals people from each other (although it may feel nice to be the recipient of sympathy, and even more virtuously enjoyable if you are the giver of sympathy). But empathy allows for a bond to be forged that will allow or approach authentic understanding of one for the other – an opening up, perhaps a mutual opening up.

Emmanuel Levinas’ encountering of the other starts from the assumption that “the other is invisible” (Burggraeve, 1999) and has value purely by virtue of their otherness. To assume that we know ‘them’ by invoking their type or category precludes any possibility of encounter, damages others in their uniqueness, and limits the rewards that could have accrued from listening/ seeing/ touching their complexity and awe-inspiring otherness. Discerning the ‘thou-ness’ in the you accentuates and gives permission for the ‘I-ness’ in me to flourish (Buber, 1937(2004)), and only in those circumstances can the dance of encountering proceed in all its possible thickness and richness.

That health care, and care generally, is not a merely technical issue, but is, rather, deeply embedded in webs of relationality, has not always been evident in medical education or medical practice[b]. The increasing costs of health care and the expanding burden of chronic disease (not to mention iatrogenic disorders) has drawn attention to both technical failures and the failure of relationships of care. Yet parallel and intersecting with this concern for the economic and the humane, a contagious culture of fear of contamination has emerged, erecting  “new walls, new blockades, and new dividing lines … against something that threatens, or at least seems to, our biological, social and environmental identity” (Esposito, 2013) [11]. The identity we construct/that is constructed has the appearance of a fullness or completeness sealed off with carefully controlled apertures to allow passage and transmission – it is not empty [1, 10, 11]. A tendency to remain defensively “immune” to contamination by the patient-other permeates contemporary health care [11]: the first instruction of any healthcare-related risk assessment is  “assume the worst” – the assumption is that any substance that emerges from the other will endanger you. Sealing yourself off from the patient-other by all and any means becomes a priority that is both a prelude to and dominates care. We don masks, gloves, gowns along with cultivating an objective distanced gaze: these are essential equipment for the medical practitioner… And now avalanches of ‘contaminated’ waste pour out of health care facilities, creating disorder within our communities.

“You are aware that most of you is not human. The human body contains 10 bacterial cells for every one of its human cells. There are 500 species of bacteria living in your intestines alone. Without these bacterial cells you would not survive. Your digestive system depends on them. Your immune system depends on them. Your you is you only because it contains them. Your you is, in fact, in some senses a we. You are not unitary, unified, self-contained. You are a host, a server, a router.” (Mohsin Hamid opening the 2015 Sydney writer’s festival 2015)

Esposito argues that “the immune system must be interpreted as an internal resonance [9] chamber, like the diaphragm through which difference, as such, engages and traverses us”. He argues that we can choose to be open to ‘community’ or establish (auto)immune barriers (Esposito, 2011) [1, 2, 11].[c]  The ‘internal resonance chamber’ of Esposito and the inner emptiness of the early Chinese philosophers are surely the same space – as is Hamid’s host or server.  One (of many) questions is how we make this resonance chamber or space useful [5, 9]– how do we bring it productively to our engagement with the patient (or impatient) patient before us?

There are those who argue it is spirituality that we need to bring to our therapeutic encounters. Elizabeth Sutherland, for example, uses the term ‘wholeness’ (Sutherland 2005): we should be aware of the wholeness of the self in order to bring this same awareness – or grace of presence – to the other. Are ‘wholeness’ and ‘self-awareness’ really what is required here? I picture the self-referential doctor, full to the brim or to their careful ‘boundaries’ [1] with self-awareness and boasting a complete set of knowledges, diagnostic frames and treatment trajectories – and ask, is there room for an ‘other’ within the encounter with him or her? One is reminded here of Karen Barad’s caution about self-reflexivity and the image of one’s image bouncing interminably off mirrors. As Karen notes, to see your image in a mirror you need to stand at a distance to it. Her advocacy of diffractive methods is because they require and acknowledge entangled engagement [4]. Is the turn toward a full ‘self’ – the whole self – another immunizing movement that ‘interiorises’ our focus even more? [3, 11] I don’t think the call for spirituality is compulsory. Psychotherapists (here, from the Rogerian tradition) argue for a similar self-focus, but without the notion of God: “Presence involves (1) being fully in contact with one’s self in the moment, while being (2) open, receptive, and immersed in what is poignant in the moment, with (3) a larger sense of spaciousness and expansion of awareness and perception …. This grounded, immersed, and expanded awareness is accompanied by (4) the intention of being with and for the clients, in service of their healing process” (Geller, Greenberg, & Watson, 2010). Is this the same as emptiness? Is it self-transcending enough?

The interiorized, individualized, defended, falsely-bounded (and perhaps self-obsessed) self does not seem a suitable platform or tool when we seek to assess the situation of disorder and heal the sick [1, 3, 10].

Laozi went further than a self-focus, claiming that xu 虚 (which can be translated as ‘emptiness’) is the ultimate root of the universe,[d] and he suggested in consequence that the human mind/body should be empty: “I do my utmost to attain complete emptiness; I hold firmly to stillness. The myriad creatures all arise together and I watch their return … All return to their roots.”[e] Liu posits that the Dao De Jing locates this emptiness as the necessary condition for apprehending the roots of the world, not just giving it attention. Paying attention, attentiveness is perhaps too involved in a cerebral cognitive tradition that mediates the ‘translation’ of the other through embedded ideas and judgements, one that is unhelpful, as it remains too concept-centered. As Vincent Duclos asks “could we expect an ‘’unmediated’’ or least minimally mediated encounter – an encounter in which there is less translation (at least cognitive translation) involved? Or is ‘translating vitalities’ inherent to care?” [8] Which brings us to the issue of the place of vitalities in health, in ease and dis-ease. When apprehending the roots, are we connecting to the vitalities that move there?  Zhuangzi thinks of emptiness as the ‘fasting of the mind,’ a non-cognitive means of gaining accurate knowledge of the external world. Vitalities, flows and movements pour in when one is empty [5].

But can the skill of encountering from a position of ‘emptiness’ be taught? [6, 8]

Xunzi, a 3rd century BCE Confucian synthesizer, teaches a technique for “achieving the best or most accurate knowledge of the external world, including the political Way.” He advises keeping the mind focused on one object that you seek to know, without straying to another object or going off in reveries about another object, and don’t allow an already stored impression to interfere with the reception of a new one.

Confucius advises his student to:

“Unify your intent (志 zhi). Listen not with your ears but with your heart; listen not [only] with your heart but with your qi氣.  Listening stops at the ears, the heart stops at tallies. As to qi, it is what is empty (xu) and waits on things.  Only take as your dao [the path of] gathering emptiness [6].  Emptiness is the fasting of the heart.” (Fraser, 2014)

Yu Chang proposes a similar approach to the patient. He describes it thus:

“From youth to old age I have paid close attention to the external symptoms of disease. In each case sitting quietly and attentively [and regulating my breathing] I began by making my body the body of the patient. Becoming their shadow, groaning with their distress, I gradually transformed my heart/mind into their heart/mind. If I surmised they would live, I seriously hoped they would and exerted every sinew and bone to contribute at any price. If the disease was characterized by complexity, I treated it carefully paying close attention [to any change in the condition] so as to understand [its development] even before any manifest changes would become apparent. If my body became exhausted before their illness was cured I concentrated my attention to understand whether this feeling was not mistaken and there was nothing further I was able to do. Yet, however sincerely we expend our thoughts, [all life is in the end] a solitary and sad turning on the wheel of life and death.” (courtesy of translator Volker Scheid)

Dan Bensky and Charles Chace, with their focus on using diagnostic touch to guide an acupuncture intervention, advocate a simple breathing technique: take a moment, they say, to breathe to your heels or bottom – ‘to get oneself out of the way.’[f]

When I was being trained in qigong healing, we were asked by our teacher to use our focus to visit someone we knew, to explore whether they were unwell. I chose a friend I was to have dinner with later that evening.  As instructed, using the imaginative powers I was developing in qigong, I entered her body to investigate whether she was unwell. I felt a deep aching pain in the vicinity of my/her left sacroiliac joint. When I withdrew from ‘her body’ the ache disappeared.

When I saw her that evening I asked how she was and she placed her hand over her left sacroiliac joint in precisely the location I had identified, and talked about a deep aching pain that she had not been able to relieve in recent days.

Zhuangzi argues that with an overgrown, weed-choked heart one becomes incapable of creative adaptation to change and the new [10]. A degree of forgetting is necessary to encountering. Incorporating the other requires making space within one’s self to enable a response [9].

What is response-ability? What are the best relational ethics in the complex and intra-active medical encounter? We know of course that the structures and imperatives of the health-care ”system” actively intervene to regulate the encounter[g] – there are defined times, places, and technologies; there are acceptable diseases and unacceptable bugs; there are ‘good’ and ‘bad’ behaviours – these rules and protocols reflect a way of doctoring that is created outside the experiences and intentions of the participants in the encounter. So to ask the doctor to change how they bring themselves to an encounter with the ‘patient’ patient is requiring a change of practice that will not be supported or reinforced by the standardized, managed medical workplace. Can practicing doctors create a moment that can pivot the encounter, shifting the rigidities, allowing the other her or his active presence? Emptiness is a transitory embodied opening (among the crowd of beings) that allows movement through [7].

As Donna Haraway has famously said: “Life is a window of vulnerability. It seems a mistake to close it.” (Haraway, 1991:224).

Works Cited

Buber, M. (1937(2004)). I and Thou.: Charles Scribner’s Sons. Reprint Continuum International Publishing Group.

Burggraeve, R. (1999). Violence and the Vulnerable Face of the Other: The Vision of Emmanuel Levinas on Moral Evil and Our Responsibility. Journal of Social Philosophy, 30(1), 29-45. doi:10.1111/0047-2786.t01-1-00003

Esposito, R. (2011). Immunitas: The Protection and Negation of Life: Wiley.

Esposito, R. (2013). Terms of the Political: Community, Immunity, Biopolitics.: Fordham University Press.

Fraser, C. (2014). Heart-fasting, forgetting and using the heart like a mirror :  Applied emptiness in the Zhuangzi. In J. Liu & D. Berger (Eds.), Nothingness in Asian Philosophy. London & New York: Routledge Press.

Garcia, J. (2015). Teaching the Placebo Effect. Academic Psychiatry, 39(1), 122-122. doi:10.1007/s40596-014-0225-5

Geller, S. M., Greenberg, L. S., & Watson, J. C. (2010). Therapist and client perceptions of therapeutic presence: The development of a measure,. Psychotherapy Research, 20(5), 599-610. doi:10.1080/10503307.2010.495957

Haraway, D. J. (1991). Simians, Cyborgs and Women: The reinvention of nature. New York: Routledge.

Kroll, P. W. (2015). A Student’s Dictionary of Classical and Medieval Chinese. Leiden & Boston: Brill.

Mol, A. (2008). The Logics of Care: Health and the problem of patient choice. London & New York: Routledge.

 

Suzanne Cochrane, who teaches at Western Sydney University, has had a 30-year career of study and practice of Chinese medicine. She is interested in the practice of Chinese medicine and the transmission of skills– how do we (and how do we learn to) work well with other people’s vitality? Doing an acupuncture related doctorate has led her to speak outside the discipline of Chinese medicine. She has used qigong disciplines as a means to work with her own qi and connect with the wider matrix of interior/exterior intra-actions.

Notes

[a] There is also extensive literature that shows the patient as an actor in determining the effectiveness of the encounter based on their regard for the practitioner, the color of their medicine, the length of time they have waited, the reports they have heard from other patients, the presence and absence of a white coat, and so on. “Many factors help trigger the placebo effect. The ones supported most frequently by empirical evidence include (1) positive expectancy on the part of the patient, (2) positive belief on the part of the health care professional, and (3) quality of patient-physician relationship or therapeutic alliance” (Garcia, 2015).

[b] “The social origins of suffering and distress … even if fleetingly recognised, are set aside, while effort is expended in controlling disease and averting death through biomedical manipulations.” Margaret Lock

[c] Such barriers might be both immune and autoimmune, because the barriers we erect deny the importance of the communal nature of ourselves – there is no ‘auto-I’ without others of all shapes & sizes & forms.  We are intra-actively in common. “Esposito argues that community is a non-entity, a non-being that precedes and cuts every subject wresting an identification from the self and submitting him or her to an irreducible alterity. The communal dimension of life sweeps away individual life—that is, by the lack of identity, individuality and difference”.  Vanessa Lemm in Roberto Esposito: Terms of the Political : Community, Immunity, Biopolitics. Bronx, NY, USA: Fordham University Press, 2012. For Esposito community and immunity (or the inside and the outside) are always in tension and neither fully achievable (or desirable).

[d] kong is also translated as ‘emptiness’ or void, vacant, unoccupied – and is a term that translates Sanskrit ‘sunyata’or ‘sunya’ – “the essential insubstantiality and illusoriness of all phenomenon”.  But Paul Kroll says that in Buddhism the terms can sometimes be used synonymously (Kroll, 2015).

[e] Translated by Liu, 2003.

[f] Guided at least in part by osteopathic (craniosacral) techniques and the Toyohari acupuncture tradition and taught in workshops to acupuncture students and practitioners – some of which are called ‘Opening to the Source’.

[g] To gain access to a window into this system without becoming a patient or a practitioner, Annemarie Mol’s work wonderfully displays what can be the contradictions of care (Mol, 2008).


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