by Alan Howe
As a contribution to Oracy Cambridge’s exploration of spoken communication in the world of work, I discussed the value and role of workplace talk with Janice Booth, a traditional Chinese acupuncturist. Janice has been practising acupuncture for over thirty years, and also lectures in Chinese medicine training would-be acupuncturists.
When Janice sees a patient she allows up to 90 minutes for an initial consultation, with successive treatments lasting between 45 minutes to an hour. Whilst a significant proportion of this time is taken up with the range of treatment approaches that she uses – for example: taking pulses, scrutinising physical aspects such as tongue, eyes, skin tone, inserting and manipulating needles – consultations are also characterised by a particular kind of dialogue. We talked about how she uses oracy skills to carry out her consultations and to take a patient through a course of treatment. In so doing we touched on some interesting aspects of the relationship between talk, professional decision-making, and patient self-awareness. I have reproduced the bulk of our discussion largely as it unfolded.
How important is oracy to you in your work as an acupuncturist?
If I don’t listen then I’m not a receptor of what comes to me at all levels. My listening skills involve picking up the nuances of someone’s complaint and that also entail me being perceptive enough to ask the right questions to narrow down into the details of someone’s problem, whether it be physical, mental, emotional or even spiritual…and the only way to find that is to take the patient to another level either with the specificity of words I use or picking up on anything emotive in what the patient says that is inviting me to ask another question. It could be that someone repeats something or that they seem to skirt around something so that there’s no disclosure, or something that they emphasise. It’s in the initial diagnostic discussion where the most narrative happens, where the ‘I don’t know you and I’m getting to know you and establishing the roles’ occurs and there’s a certain weight to getting facts and then for me to interpret them. My mission is to diagnose and that’s what the patient comes for and so clearly close listening is vital because that’s when I am at my best for observing. Someone coming for the first time is totally new so in that sense the dialogue is really key.
And as the treatment progresses?
Probably the most interesting therapeutic dialogue isn’t in the first session even though that is really important. Where it becomes more interesting and more critical is probably from the second treatment onwards when you have embarked on a journey with someone. In many ways it’s a verbal/linguistic journey. I might kick off with some leading questions and prompts that pick up on the first session – things that I need to know more about if I am to work wholistically, where I have felt there’s something there that has or hasn’t been said or in the way that its been said that I want to allow the patient time and space to look at themselves a little bit more.
Do you always start with dialogue?
In the first session most people come in and they sit there and wait for me to lead so I might say “OK, so tell me a bit about why you’ve come”. In the next session my prompts depend so much on the patient and what they ‘ve already said to me. There’s a whole spectrum of people. Some are very matter of fact and they model their coming to see me on a typical GP appointment although they know they’re paying me and they expect it to take a bit longer but they still model it on a biomedical model so it almost like, ‘OK so what do you want to know?’ or before I’ve even started they’re already rolling up their trousers to show me their bad knee! There are other people, quite rare…but they might say, ‘There’s kind of nothing wrong but I’ve heard that acupuncture is good for well being,’ and that’s a whole different starting point of course.
I’m interested in the relationship between the dialogue, the talking and listening, and how that relates to the treatment?
I think that’s really interesting because I’m not a counsellor or a psycotherapist, where the talk is all and that’s all that is done, what people call ‘talking therapy’ – talk and silence, talk and silence – I do that but not fully. There’s a point where I take a more proactive role because I have to wrap up what people have told me towards a diagnostic decision and subsequent use of needles. Where there hasn’t been much talk – for example where a patient doesn’t want to say much, or where there might be issues with English as a second language – I sometimes struggle to be really clear about the depth of treatment I’m going to offer. I obviously have other skills I use to make a diagnosis – taking the pulse, looking at the tongue, taking the temperature, observing colour on the face – all of that which can give some clues but without getting to know someone it’s so much more difficult. It’s almost like the chit-chat at the start that goes further and then I turn to my use. It’s building the rapport, so that there’s a working relationship. It is a relationship, there’s no doubt about it, and that’s so different to what a lot of people usually experience in a typical ten minute consultation with their GP. There is time for talk between two people to take you to a very creative place of understanding on both sides and it is a gift to me as a practitioner because of the insight into how someone has put or is putting their life’s meaning together: I am facilitating that. And that potentially has a profound impact on someone’s well-being.
So you partly use talk to help you to a clearer diagnosis?
Yeah.
But you just started to talk about how getting the patient to talk could be seen as part of the treatment itself – as having an impact itself.
Well, I think that’s the most interesting area and many patients eventually realise that too. They bring to me all their disparate ailments, memories, all the disparate aspects of their lives and sometimes they come to ‘see’ themselves differently. Through a prompt such as, ‘Tell me a bit more about that…’ or, ‘I’m really interested in…’ or, ‘Have you ever thought there’s a connection between this and that..?’ you know, for example, ‘Might there be something between your fear of failure and how your immune system is so compromised?’ I might nudge someone towards that or even better if they start to do this themselves. For example a patient might say, ‘You know it’s odd isn’t it, but I’ve just been wondering the reason why I seem to get ill every Autumn is because that’s the time of year when my parents died, that’s twenty years ago, do you think that’s possible?’ and I might just say, ‘Well it is interesting isn’t it, that’s worth thinking about…’ You kind of leave it hanging but it’s language that’s taken the patient and me on that little route to looking at something a bit more deeply.
What is it about that, helping the patient to talk that through, to find the words themselves, that’s part of the work that you do?
Because as a traditional acupuncturist, one of the key tenets is that nothing is unintegrated, nothing happens – OK trauma, car accident, whiplash, they are random issues, yes – but once something’s become chronic, we have a world view that’s become established, we’re grown ups, then the narrative that we tell ourselves, it’s complex and sometimes it’s helpful to unravel it a bit…
And is that part of the cure…if that’s the right word?
And that’s not a word to ever use, I agree (OK, so what…?) I wouldn’t use ‘cure’, I wouldn’t use ‘healing’, although I’ve touched on taking someone into deeper places of themselves. I think ultimately the patient does the work. I think the needles… I think they’re great actually, because they create an end point to the discussion and once the treatment starts there isn’t much talk.
Do some patients ‘get it’ in the sense that they come not just for the needles but to have a chance to talk things through in a way they never normally do?
Yes, people say things like, ‘Gosh, I’ve never spoken as much’ or, ‘I’ve never told anybody this,’ or, ‘How interesting, I’ve never thought there might be a link between this and this…’ I often talk about ‘the artistry of practice’ and there are times when I almost don’t want to start needling because I think the work is being done at the level of talk, of listening and responding, of being there. You’re just holding onto that very delicate web that’s being woven where words come out, they evaporate but they’re being held by the practitioner, being held just long enough to explore them further. I do write stuff down, however!
But do you also revoice…?
Yeah, I do revoice. I’ll sometimes say, ‘Can we just pause a minute because you’ve said some really useful things there,’ and then I might say, ‘Can I just read something back to you that you said to me,’ or ‘You said to me and I don’t quite understand ‘ or ‘Can you just tell me more…?’. But sometimes I’ll just use the pause, especially with some patients who are talking so much they can’t hear themselves….
What’s going on in your head while the dialogue is unfolding?
This is where I’ll hold what I feel is most significant. But I’m making the whole thing sound very esoteric; often I do really need to know whether a pain is for example: stabbing or sharp, bruisey, achy, dull, easy, heavy, impedes movement, better in the summer, better in the winter, after a bath; and that takes up a long time because you want the exact word. And people go, ‘Oh, yeah’, or ‘I don’t know how to describe it, goodness, it’s just pain…’ and I’ll probe with words: ‘Is it…?’ and they’ll go, ‘Oh yes, it’s a bit like that‘ and we’ve established a word. There’s something useful because two treatments down the line you return to that description and ask again…’’Two treatments ago you told me that your pain was…is it still like that?’
In your professional practice you have specific acupuncture skills…but in addition, in terms of talk, what skills do you also have to use? (You mean what would I tell a practitioner in training?) Yes, what do you have to be good at?
At one level there’s a role that involves totally engaging with the patient through the session to listen fully, to develop rapport and create an environment of trust and safety.
Then there’s the constructive use of language to scrutinise the issue: ways of asking questions that take the patient further in their understanding of themselves. And often that involves echoing back a patient’s words.
There’s a being there with someone at an emotional level, at an empathetic level (not sympathetic because I think sympathy can be quite destructive) – the heart level.
There’s the creative level – I have to take stock of where I am, that I am who I am and beware of not letting my own stuff get in the way: why do I go off in directions, why am I interested in certain things? The creative level is not knowing: not knowing where a patient’s narrative is going to take them…and not knowing because although someone comes in with a main complaint (‘I’ve come to see you because’), down the line you find out that you’ve gone a long way from that initial starting point. You’re on another level of discourse, which is about self, connecting the threads, asking for understanding rather than just on a functional level or mechanical need.
Language at the transition point between the initial dialogue and the treatment – that’s an area that really interests me. If I allow best part of an hour, usually after about twenty minutes I have to move us towards the treatment, so each session involves a certain amount of wrapping up.
It has the trappings of friendly conversation, of chat, but it’s not like that at all really is it? You’re controlling it to some purpose…
Well it’s also about power. I’m the practitioner, they’re the patient. It’s professional. Ultimately you have to step back, have a clear mind, a clear intention, wisely use everything you’ve heard and seen and perceived and then formulate a treatment. I suspect that the needling may be more powerful if the patient is receptive to it, which is linked to all of what’s gone before: the narrative, the understanding, the trust. Though sceptics do also get better!
Can you sum up? How important is oracy to you as a therapeutic practitioner?
Well…it’s obviously important but not essential, because you can do a treatment, for example on a child, without all the talk. But then there is something really important missing that supports the treatment, that becomes part of the treatment. The best treatment session is often one between two people where you have a backlog of really close understanding, a patient having felt totally heard (not intimately, not everyone wants to tell you everything). Some people come for the long haul, patients who I know very well, who I’ve been seeing periodically for years. Some people don’t want to stop having treatment. Undoubtedly the actual treatment I’ve formulated for them has to be the right one, but I do have a sense that it’s not just about the treatment: it’s about the dialogue, it’s about a real sense of having been heard. In my filing cabinet I have narratives from all the people I’ve seen over the past thirty years. And it’s also all there in my head, all of the endless conversations towards something fruitful…
It’s interesting, isn’t it?
Alan Howe was in conversation with Janice Booth, Lic Ac FBAcC.