International Journal of Applied Psychoanalytic Studies

Int. J. Appl. Psychoanal. Studies (2013)

Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/aps.1358

Reinforcing and Reducing: Dialogue

between Traditional Chinese
Medicine and Psychoanalytic
Psychotherapy

PEICHAO ZHANG AND XINLI CHI

ABSTRACT

The adaptation of forms of psychotherapy from the West in China such as psychoanalytic
psychotherapy should include the rich cross-fertilization with traditional Chinese medicine
(TCM). This article suggests the category of Reinforcing and Reducing as a point of
convergence where Reinforcing/Reducing is seen as like Supportive/Expressive approaches
in psychotherapy. A tentative integrative Paradigm called “Talking Acupuncture” will be
discussed.

Key words: traditional Chinese medicine, psychoanalysis, psychotherapy,

reinforcing and reducing, indigenization

Nearly every community or culture developed its own way of understanding and
treating mental disorders. Some of them crystallized as unified knowledge
systems like psychoanalysis, and some retained significant relations with its
maternal matrix, such as TCM. Empirical research has proved that East Asian
medicine is deeply influenced in any aspects by Naïve Dialecticism, which can
be traced back to the universal Yin/Yang symbol (Spencer-Rodgers, Williams,
& Peng, 2010). This characteristic oriental medicine contains profound
thinking about psychotherapy. “Reinforcing” (add something positive into the
system) and “reducing” (remove something negative from the system) are
important categories of TCM methodology, which govern innumerable specific
treating skills, including psychological interventions.

Int. J. Appl. Psychoanal. Studies (2013)

Copyright © 2013 John Wiley & Sons, Ltd. DOI: 10.1002/aps
Zhang and Chi

MENTAL HEALTH AND PSYCHOPATHOLOGY IN ANCIENT CHINA

The development of mental health and psychopathology took a different path

in China than elsewhere. Several features are specific to TCM: first, TCM never
tries to separate mind from the body. Second, it regards tiān-rén-hé-yī
, the harmony between man and heaven/nature as the criterion of health,
rather than simply the absence of symptoms. Third, it takes the method of Qu-
lèi-bı-xiàng , analogy by classification as the chief way to perceive how
mind works normally or pathologically, which can find its origin in the most im-
portant canon in ancient China, yì-jīng , The Book of Changes, rather than
the reduction method adopted by Westerners, which attribute the complex phe-
nomena to simpler elements like biology.
However, with the introduction of globalization into every corner of China,
Chinese traditional study has lost its original connections with nature, the
Lebenswelt (Living World) that our ancestors grew up within. So the mind is
no longer seen in China as a purely integral dynamic of nature, but can also
be viewed as an epiphenomenon of chemical reactions in the brain. More
dimensions imply both positive and negative features. Every perspective has its
raison d’être because mental suffering is hard for humans, and each human is
unique in the way the suffering is experienced and handled.

ONTOLOGY OF THE MIND: DYNAMIC QI AND DYNAMIC

UNCONSCIOUS

The term “qi” is a very important concept in Chinese classics. Literally it can
be translated as the vital energy or vital force, yet its connotation inside or outside
TCM goes far beyond that. Several treatises in the Ling-Shu Miraculous
Pivot, The Book on Acupuncture suggested that the concept of qi resulted from
an attempt at broadening an older concept of wind, which reflects its dynamic
and transformable nature. The fluidity and consistency of qi maintain perfect
health in the physical body. This fluidity is managed by keeping mental, spiri-
tual, emotional and physical attributes in balance. An imbalance in the equilib-
rium of this energy is believed to leave the body open to illness and disease.
TCM devised an open system of Mind–Body–Nature in which qi is para-
mount, and changes of Yin and Yang dictate the health of the individual. The
introduction of qi as an unavoidable environmental factor, as a physiological ne-
cessity, and as a potentially harmful agent represented a significant cultural
achievement in the quest for answers to issues such as causation and response,
or normality and deviation (Unschuld, 2003). Pathogenic conditions of qi can
be categorized as surplus or insufficiency, and move in the wrong direction, as
well as creating blockage. Many methods were developed to restore the
balance of qi, such as massage, acupuncture, moxibustion, herbs, zhù-yóu
incantation pray, and dao-yın physical and breathing exercise.

Int. J. Appl. Psychoanal. Studies (2013)

Copyright © 2013 John Wiley & Sons, Ltd. DOI: 10.1002/aps
 Reinforcing and Reducing

To understand the symptoms of hysteria which cannot be deduced from vis-

ible or detectable physical changes in the brain, Sigmund Freud and Joseph
Breuer developed a novel interpretive system called psychoanalysis. Physical
problems such as palsy can be understood as a disorder deriving from uncon-
scious conflict, which can be compared to a finely tuned system fueled by drives.
Freud mapped two graphic representations sequentially, the topographic model
and the structural model, which were detailed and modified by many later the-
orists, including Carl G. Jung, Melanie Klein, Wilfred Bion and Jacques Lacan.
Still, we can find an implicit line beneath the symptomatology – imbalance and
blockage, be it among Unconsciousness, Pre-consciousness, and Consciousness,
or among Id, Ego and Superego; or among different archetypes and so on.
There are many similarities or parallels between the two disciplines. First,
they are both based on some philosophical presumptions, the former being yì-
jīng and the latter being the philosophy of the unconscious. Second, to some ex-
tent they can both be regarded as some kind of hermeneutic theory rather than
positive science like biochemistry. Both qi and the unconscious are theorizations
of related or grouped phenomena, the meaning of which lies in an ongoing evo-
lution fostered by novel clinical findings. Third, the handing down of knowl-
edge depends on a person-to-person relationship. Fourth, they are both
culture-loaded theories rather than metaphysics which have nothing to do with
the social and historical context. Fifth, they are both challenged and enriched
by modern science. Given these parallels, we feel confident that there is room
for some intensive and fruitful dialogue.

REINFORCING AND REDUCING VERSUS SUPPORTIVE AND

EXPRESSIVE

The category of bu Reinforcing and xiè Reducing is the meta category of ev-
ery intervention in TCM, which applies from micro- to macro-system levels. To
understand this category we need to go back to the yīn - yáng syzygy, which
is one of the most fundamental concepts in Chinese philosophy and TCM. In
Chinese philosophy, yīn refers to the feminine, latent and passive principle
(characterized by dark, cold, wetness, passivity, disintegration, etc.) of the two
opposing cosmic forces into which creative energy divides and whose fusion in
physical matter brings the phenomenal world into being; while yáng denotes
the masculine, active and positive principle (characterized by light, warmth,
dryness, activity, etc.) The yīn yáng category is in charge of other three
binate categories called: biao exterior- lı interior, hán cold- rè heat,
xū deficiency -shí excess, which could be called as bā-gāng eight principles.
If the syndromes are diagnosed as xū deficiency, Reinforcing will be launched.
If the syndromes are diagnosed as shí excess, Reducing will be applied to re-
store balance state. This methodology can be illustrated in Figure 1, in which

Int. J. Appl. Psychoanal. Studies (2013)

Copyright © 2013 John Wiley & Sons, Ltd. DOI: 10.1002/aps
Zhang and Chi

Figure 1: Balance and harmony state. Too much Yin and insufficient Yang could be
moderated by either reinforcing of Yang elements or reducing of Yin elements.

the imbalance state, too much Yin and insufficient Yang could be moderated by
either reinforcing of Yang elements or reducing of Yin elements.
The Supportive/Expressive continuum has been well developed in psychoan-
alytic psychotherapy (Luborsky, 1984). This involves making patients more
aware of their unconscious thoughts and feelings (expressive goal) and
supporting weakened ego functions (supportive goal). Yet some authors argue
that psychoanalytic interventions cannot be sharply divided into opposites as
supportive and expressive. They suggest all psychodynamic psychotherapies
use both techniques in a flexible way depending on the moment-to-moment
needs of the patient, and thus an integrated model is the most useful for
conducting this type of psychotherapy (Cabaniss, Arbuckle, & Douglas,
2010). This seems like a reasonable critique because each expressive interven-
tion implies the element of support, and vice versa. The expressive intervention
cannot be given without an atmosphere of rapport or support. However, support
cannot yield its full effect without helping the patient understand something.
This is similar in TCM, which is rich in dialectical thoughts. Deficiency and
excess fall within a dialectic relation because the deficiency of yáng can be
viewed as excess of yīn, which can be restored to balance by reinforcing of yáng
or reducing of yīn. Each intervention has reinforcing and reducing facades. This
way of thinking also maintains the dialectical tension between the supportive/
expressive poles.
Self psychology was developed to address the so-called self disorders by
strengthening one`s subjective well-being, so it has somewhat supportive impli-
cations. Yet others argue that self psychology is not supportive psychotherapy
(Jaenicke, 1993). Indeed, self psychology treatment is still based on insight
through interpretation rather than to help the patient to develop better defenses
or a stronger ego through which a more stable sense of self will be built as being
the ultimate inner resource. If we try to broaden the concept “Supportive”, self

Int. J. Appl. Psychoanal. Studies (2013)

Copyright © 2013 John Wiley & Sons, Ltd. DOI: 10.1002/aps
 Reinforcing and Reducing

Reinforcing the self

self

Vital Qi

Defensive Qi Reinforcing the Ego

Figure 2: self psychology and supportive psychotherapy.

psychology does help to support at the deeper level. According to the theory of
TCM, when there is sufficient zhèng-qì vital qi inside, pathogenic factors
have no way to invade the body. The solidifying of self by transmutating inter-
nalization of the selfobject function can help cope with interpersonal or intra-
psychic conflicts. This is similar to the healthy qi inside, which can prevent
the intrusion of pathogenic factors from outside. Thus supportive psychotherapy
in the narrow meaning can be viewed as the solidifying of wèi-qì defensive
qi. Self psychology and supportive psychotherapy can be included in a larger sup-
portive category, where their antagonism and unification coexist in dialectic and
dynamic tensions. This can be signified in Figure 2.
The category of Reinforcing and Reducing has beautiful synthesizing func-
tions, which can bring the psychoanalytic concept together, like the abreaction,
defense mechanism, selfobject and so on. Though the category of Reinforcing/
Reducing and Supportive/Expressive is not entirely parallel, it still contains a
large space to echo and enrich each other. This way of thinking may offer some
help to overcome the fragmentation of psychoanalytic theory after Freud’s
death. The synthetic function is of vital importance to mind, body and theory.
This function is also rich in ancient Chinese ways of thinking, including TCM.

AN INTEGRATIVE PARADIGM: TALKING ACUPUNCTURE

How does the talking cure work? Let us look at some comparisons with TCM.
Empirical studies have shown that through long-term psychoanalysis, some
change happens in the brain. So does acupuncture. Though there are no
chemicals like neural transmitters being injected into the patient’s body when
they are been given a talking cure or acupuncture, they do change both physi-
cally and subjectively. Here we can think in an integrative way: since psycho-
analysis and acupuncture both based their theory and technique on a

Int. J. Appl. Psychoanal. Studies (2013)

Copyright © 2013 John Wiley & Sons, Ltd. DOI: 10.1002/aps
Zhang and Chi

metaphorical or symbolic body, we channel their findings together to an integra-

tive paradigm: talking acupuncture.
As has been discussed earlier, the methodology of acupuncture in TCM is
also based on the Reinforcing and Reducing category. There is a detailed de-
scription of how to conduct reinforcing acupuncture or reducing acupuncture,
depend on an integral diagnosis by the practitioner. The data is collected from
four dimensions called: Wàng-zhen inspection, wén-zhen listening
and smelling examination, wèn-zhen inquiry, and qiē-zhen palpation.
This diagnostic system is rather complex and cannot be thoroughly discussed
here. Despite its complexities, it has some similarities with psychoanalytic diag-
nosis. They both rely more on the relation between patient and practitioner
than upon objective examination. They are also both essentially phenomeno-
logical. The TCM practitioner applies acupuncture according to many princi-
ples, the most important being where to give an acupuncture needle and what
kind of manipulation should be given. Sometimes the patient’s symptoms are
rather complex, like a mixture of deficiency and excess, which means some
jīn-luò meridian or xué-wèi acupoint need to be reinforced while
the other needs to be reduced. The decision is made not only by the practi-
tioner’s knowledge and judgment, but also by the here-and-now intuition and
the feedback of the patient.
This dialectical and dynamic way of thinking can be used in psychoanalysis
and psychodynamic psychotherapy, especially with patients with borderline per-
sonality organization, which can be seen as a mixture of deficiencies and excess.
On the one hand, their self is rather weak, and needs to be reinforced. On the
other hand, their pathological defenses need to be reduced. Viewed from this per-
spective, both Kohut and Kernberg’s understanding of personality disorders make
sense on a larger platform. If we can use Reinforcing and Reducing dialectally and
dynamically, like practicing acupuncture to the mixture of deficiency and excess
syndrome, the splitting will be fused and a more integrative way will be found.

SUMMARY

Everything exists together in a delicate balance. These span mind and body, qi
and its other forms, man and nature, normality and abnormality, past and pres-
ent, patient and analyst, East and West. Inner compartmentalization from
blocked interflow gives rise to symptoms and further compartments. This article
focuses more on calling attention to this phenomenon rather than reaching a
conclusion as such. Much work needs to be done in building a methodological
paradigm for more extensive dialogue between TCM and psychoanalytic psy-
chotherapy, in comparative concept research in each field and in combined
qualitative and quantitative research.

Int. J. Appl. Psychoanal. Studies (2013)

Copyright © 2013 John Wiley & Sons, Ltd. DOI: 10.1002/aps
 Reinforcing and Reducing

REFERENCES

Cabaniss, D. L., Arbuckle, M. R., & Douglas, C. (2010). Beyond the supportive-expressive con-
tinuum: An integrated approach to psychodynamic psychotherapy in clinical practice. Focus:
The Journal of Lifelong Learning in Psychiatry, 8, 25–31.
Luborsky L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive-expressive
treatment. New York: Basic Books.
Jaenicke, C. (1993). Self psychology is not supportive psychotherapy an answer to its critics.
Psychoanalytic Review, 80, 253–264.
Spencer-Rodgers, J., Williams, M. J., & Peng, K. (2010). Cultural differences in expectations of
change and tolerance for contradiction: A decade of empirical research. Personality and Social
Psychology Review, 14, 296–312.
Unschuld, P. U. (2003). Huang Di Nei Jing Su Wen: Nature, knowledge, imagery in an ancient
Chinese medical text. Berkeley, CA: University of California Press.

Peichao Zhang, PhD

Adjunct Researcher, Center for Modern Psychological Studies,
Wuhan University, China
drzhangpeichao@gmail.com

Xinli Chi, PhD Candidate

Faculty of Education, University of Hong Kong, China
chixinli@hku.hk

Int. J. Appl. Psychoanal. Studies (2013)

Copyright © 2013 John Wiley & Sons, Ltd. DOI: 10.1002/aps