adambroder: September 18, 2019, 5:19pm
Let me preface this by saying that I’ve only been using Sa’am in select cases so far, 8 to be exact (one of those
being myself). In that short time I’ve had some nice successes and some lessons learned, but this situation is really
confounding and upsetting. A woman in her 50s had been coming into the clinic where I work to get medical
massage and acu (we do a co-treatment sort of thing). She’s been enjoying my work and eventually scheduled an
acu-only treatment with me. After doing one or two of those I thought she’d be a good candidate for Sa’am. Her
chief complaint was recurring vertex headaches, and secondarily insomnia, which wasn’t all that bothersome she
said. Her demeanor is a mix between GB and PC excess. I’d been meaning to start a thread or see if there’s one
already about the idea of passive-aggressiveness and how it relates to the GB/PC dynamic, as I saw her very much
walking this line. I was leaning toward PC+ but after doing a more thorough intake I decided on LR+ (her feet get
cold, she has sudden temperature changes, her pulse is thin, the LR primary channel goes to the vertex). I saw her
the following week and she reported better energy, slightly less frequent and less painful headaches, and no change
in insomnia. Then I made my first mistake, which was to change up the treatment. I guess I wanted more dramatic
results. I did a PC+ (insomnia, irritability, passive aggressive, GB sinew channel goes to the vertex). She felt fine
on the table but after one week reported worsening headache symptoms. Feeling confident in my Sa’am teachings
(if one treatment doesn’t work, do the exact opposite), I did a GB+. Now, four days after the treatment, she’s
contacted me to say that she won’t be coming back in because the treatments aren’t working. I didn’t ask but can
only assume this means continued worsening of headache symptoms. Bearing in mind that my first mistake (not
repeating the LR+ treatment that provided mildly positive results) may have been the crucial factor here, why
would two of the main clinical teachings have failed me? I’m referring specifically to:
1. If you get it wrong you’ll know immediately (this did not happen; both times she felt fine during and
immediately after the treatment, and I didn’t observe any changes in complexion or demeanor)
2. If you get it wrong, do the exact opposite (this did not work; PC+ followed by GB+ were both negative)
Maybe she’s so LR xu that she needed LR+ one or two more times so badly that anything else threw the whole
system off? I’m willing to accept that as an answer. Still the fact that things went the way they did aren’t quite
squaring in my thinking. Any help would be greatly appreciated.
amyjenner: September 18, 2019, 5:39pm
was it that the symptoms worsened after 1 week or that it was reported after 1 week? When did the symptoms
worsen?
adambroder: September 18, 2019, 5:41pm
I did 3 treatments one week apart:25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/recent-failure-trying-to-suss-out-the-lesson-s/620/print2/13
1. LR+
2. One week later, mildly positive results; PC+
3. One week later, worsening sxs; GB+
Now, four days later, she says the txs aren’t working
adambroder: September 18, 2019, 5:42pm
I guess that doesn’t really answer your question. During each of those weeks is when the symptoms changed. She
tends to have 2-3 headaches per week.
amyjenner: September 18, 2019, 5:53pm
so, if there is elapsed time, then the “do the opposite” doesn’t apply. You have to start over and treat what is there.
A week is too long. If she has a poor reaction on the table, you can do the counterbalance on the opposite side to
correct it then and there.
amyjenner: September 18, 2019, 5:56pm
If you wanted to put your case up in the suggested format to give us a better picture of her, the feedback would be
more useful.
Sorry about your person, I hate it when my learning curve negatively impacts my patients. Feels terrible.
adambroder: September 18, 2019, 6:06pm
I was definitely misinterpreting that piece of advice about counterbalancing. Thank you. I’ll apply the formatting
when I have some time.
adambroder: September 18, 2019, 6:32pm
Still I wonder why she felt fine on the table for each of the 3 treatments. Why didn’t I see that immediate negative
reaction that Toby talks about? Or maybe that doesn’t apply to all patients?
amyjenner: September 18, 2019, 10:44pm
5/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/recent-failure-trying-to-suss-out-the-lesson-s/620/print3/13
I find there is a range of ok-ness or not ok-ness. When it goes really bad, you know it without a doubt. The person
will tell you it doesn’t feel good. Your treatments may have been close enough that they were partly right and
partly not right. Just not at the root of the situation.
KristinWisgirda: September 18, 2019, 11:38pm
amyjenner:
Sorry about your person, I hate it when my learning curve negatively impacts my patients. Feels terrible.
Me too! My mistreatment once made a patient cry on the table because her headache became so much worse. I
prefer when learning is less painful for everyone.
An adverse reaction to treatment can occur up to 2 days after the treatment but it is rare for it to take that long. I
wonder if the patient had a true adverse reaction to P+ or just a so-so reaction. If the reaction was just so-so, then
using the counterbalancer is not indicated.
I wonder how reliable a reporter your patient is. Some patients of my patients are better than others. With some of
my patients, getting good info out of them is like trying to untangle a knotted cord. Was worse really worse- more
frequent or more intense headaches? Or was worse just not better? There is also the nature of chronic, recurring
headaches that can easily be made worse by other factors, like a night of poor sleep or other triggers.
adambroder: September 19, 2019, 5:18pm
Here is my reformatted report on the case:
61 year old woman
Chief complaint : vertex headaches for the past 4 years following TIA; when at their most frequent they occur
every other day and range in pain from a 3 to an 8/10. History of four separate injuries which caused trauma to the
neck.
Second complaint: insomnia most nights; wakes between 1-3 each night and is awake for several hours before
falling back asleep
Appearance and demeanor : bookish, wears glasses, dresses casually, speaks deliberately, intellectually snobbish
+5, passive aggressive +5, says her husband tells her she needs to work on irritability
Lifestyle: married, former body worker, likes to hike and do other outdoor activities, trying to sell her house but
having difficulty which causes stress +6
Body morphology and flesh quality: Average frame, soft flesh25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/recent-failure-trying-to-suss-out-the-lesson-s/620/print4/13
Skin Quality: normal
Body Temp: extremities cold (feet more than hands) +3; will get full body cold when highly anxious, accompanied
by SOB and panic (hasn’t happened in a while) +3
GI: no issues as long as she eats the right foots
Respiratory: no issues aside from SOB which come from infrequent high anxiety
Sleep: see secondary complaint
Emotions: irritability +7, intellectually snobbish +5
Urination: no issues
Other Body: minor bruising on lower legs
Tongue: pointed/narrow +6, dusky +4, little coat
Pulse: thin +3
Excess Presentations:
Heart: none
UB: full body cold when experiencing anxiety
GB: insomnia +5, irritability, passive aggressive (emphasis on aggressive), sinew channel goes to vertex
P: intellectually snobbish +5, intelligent +7, passive aggressive (emphasis on passive)
SJ: extremities cold, feet more than hands +4, sudden temperature changes, thin pulse
Liver: primary channel goes to vertex, poor vision (wears glasses)
Lung: none
Stomach: none
LI: none
Spleen: Spleen channel pain
SI: musculoskeletal pain
K: none
The Grossest Thing(s) in the Room: vertex h/a, insomnia, passive aggressive/snobbish demeanor and irritability
Main treatment ideas: LR+, PC+
Other treatment ideas: GB+ (based on her passive qualities and channel considerations)
Treatment 1: Liver+ on right25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
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· one week later reported decreased severity and frequency of h/a and increased energy; no change in sleep
Treatment #2: PC+ on right (I wanted some traction with insomnia)
· one week later reported increased severity and frequency of h/a; no change in sleep
Treatment #3: GB+ on right (I thought that doing the opposite of what didn’t work would be a good approach)
· got a text 4 days later saying that she won’t be returning as the treatments aren’t working, no other details
reported or requested
adambroder: September 19, 2019, 5:20pm
KristinWisgirda:
I wonder how reliable a reporter your patient is. Some patients of my patients are better than others. With some
of my patients, getting good info out of them is like trying to untangle a knotted cord. Was worse really worse-
more frequent or more intense headaches? Or was worse just not better? There is also the nature of chronic,
recurring headaches that can easily be made worse by other factors, like a night of poor sleep or other triggers.
You make some good points, still I have to consider if she left me as a patient that things really were getting worse
adambroder: September 19, 2019, 5:23pm
I’m starting to consider that HT+ may have been a good option, if there was fear around not selling her house. I
know it was causing stress but I didn’t go into depth with her on the emotions she was feeling. Also she has some
cold signs.
KristinWisgirda: September 19, 2019, 5:54pm
adambroder:
Her demeanor is a mix between GB and PC excess.
When a counterbalancing pair is pretty equal in presentation it is often a better idea to look elsewhere.
My (many) failures are more memorable than my successes and spur me to double check my assumptions, time
and time again.
1 Like25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
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Adina_Kletzel: September 19, 2019, 9:40pm
adambroder:
Maybe she’s so LR xu that she needed LR+ one or two more times so badly that anything else threw the whole
system off?
HI, I have found that if tonifying a certain archetype brings some improvement that it is better not to jump to the
next idea before doing int 2-3 times. I sometimes toggle back and forth between just two different archetypes until
lasting results are achieved. Two weeks of one and then two weeks of the other and then back again. It could take
time to see lasting improvements. As Toby says, these are most often slow miracles.
mariamorris: September 22, 2019, 4:08am
I agree that this particular case may not need a counterbalancing treatment, but not because of the time elapsed,
rather because we don’t clearly know how reliable a reporter she is.
amyjenner:
so, if there is elapsed time, then the “do the opposite” doesn’t apply. You have to start over and treat what is
there. A week is too long. If she has a poor reaction on the table, you can do the counterbalance on the opposite
side to correct it then and there.
I thought that we needed to counterbalance in order to “apologize to the body”, as Toby put it. I don’t recall him
putting a time-limit on that, and doesn’t seem like a week is too long to counterbalance.
I also recall Kristin writing that counterbalancing after a week should still be done but just that the side doesn’t
have to be opposite to the original treatment. One should counterbalance but choose the appropriate side according
to gender/ side of symptoms.
Could someone please clarify if there is indeed a time-limit after the “offending” treatment to make a correction or
to “apologize to the body” ?
ngmatthews: October 4, 2021, 5:15pm
As to counterbalancing to correct, I think a week is too long. By then, the impact of the aggravating treatment has
faded and we need to see what is there at present.
The term “passive aggressive’ here is a bit confusing, and I think it does not lead to clear diagnosis when we are
thinking along the Pc/Gb continuum. Pc types are not passive, and Gb types are certainly aggressive. I think the
term passive/agressive is also not clearly defined. In other words, we don’t know exactly what you mean by that.25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
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Problem is that if she tends to be irritable, supporting Gallbladder is very risky because it could amplify that. To me
she sounds stressed and anxious to a degree and I would not want to tonify Gb in that scenario.
The fact that the Liver treatment helped the first time is diagnostic. I believe she is more of a San Jiao dominant
type, very sensitive to everything and easily overwhelmed. I agree with Adina that when we find something that is
working, we should not be hesitant to repeat it 2-3 times and then consider what pattern is next.
We tend to want to adjust the treatment every time instead of repeating, at least I do. I sometimes feel that if I
repeat the same treatment as last week I am not working hard enough, even if we have seen an improvement. Or I
am hoping that by changing patterns I’ll find something “better” than what I did last time.
Most often our patients also do not clearly report their improvements. They tend to report what is still there, or add
new problems to their complaints. Thus we feel the necessity to add more stuff, do better, or reconsider our
diagnosis. And yes, people often reveal major issues such as cancer, after the third treatment. Funny how that
happens.
Unless you think you have been totally wrong about something, I think it is great to repeat a treatment that is
working to get the most out of it that you can.
On the inside cover of the patient’s folder I write my 3 top patterns for that person. That really helps me stay clear
about my impressions and stick to a plan with each person.
KristinWisgirda: September 22, 2019, 6:29pm
Adina_Kletzel:
I have found that if tonifying a certain archetype brings some improvement that it is better not to jump to the
next idea before doing int 2-3 times.
Back and forth with Toby about the how many times a treatment can be repeated:
Twice, rarely three times. Only in extreme cases would you supplement the same channel 3 times in a row because
there is more of a risk of too much of a good thing.
As well, very depleted patients often do much better varying the treatment every time. They often will respond
poorly if a treatment has done twice in a row, even if they clearly benefited from that treatment the weeke before.
mariamorris:
Could someone please clarify if there is indeed a time-limit after the “offending” treatment to make a
correction or to “apologize to the body” ?
Adverse effect of a treatment absolutely requires that you supplement the counterbalancer. There is no clearer
indication for a treatment than an adverse reaction from the counterbalancer! There is no time limit. If someone
comes back after a week or a month, supplementing the counterbalancer shoulder be your #1 thought.
Theoretically, in the interim some emergency not related to the involved channels might have happened where you25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
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might have to consider other channels. Few rules in the clinic are absolutely cut and dry but supplementing the
counterbalancer after an adverse reaction is pretty close.
ngmatthews:
As to counterbalancing to correct, I think a week is too long.
Yes! The sooner the better, but that isn’t always possible.
ngmatthews:
Most often our patients also do not clearly report their improvements. They tend to report what is still there, or
add new problems to their complaints. Thus we feel the necessity to add more stuff, do better, or reconsider our
diagnosis. And yes, people often reveal major issues such as cancer, after the third treatment. Funny how that
happens.
Agreed!
ngmatthews:
I sometimes feel that if I repeat the same treatment as last week I am not working hard enough,
I’ve been afflicted with the same idea- isn’t putting in 4 points too easy?
ngmatthews:
On the inside cover of the patient’s folder I write my 3 top patterns for that person.
Many people will have more than 3 patterns to consider. At the first visit, and every visit, considering all the
possible patterns and writing them down is so helpful. Ranking them is even more helpful.
KristinWisgirda: September 22, 2019, 8:00pm
@adambroder Writing up this case again tells me that you are really interested in understanding what happened
and how to move forward with learning Saam. Wonderful! I know it takes effort but it helps me see your thought
process. It also shows what you are looking at but what you might be overlooking.
Practice of Saam requires specific observational skills and a precise understanding of the channel patterns. It takes
time and practice to look at your patients through the lens of Saam. As well, contemplating and experiencing the
channel patterns is a life time worth of work.
Though her response to Liver+ was
adambroder:25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
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better energy, slightly less frequent and less painful headaches, and no change in insomnia.
the indicators of SJ excess that you report
adambroder:
extremities cold, feet more than hands +4, sudden temperature changes, thin pulse
can also be explained under other patterns. Cold extremities and sudden temp changes can be part of SI/K excesses.
If the sudden temperature changes were in response to environment, this would be more characteristic of a SJ
excess who is more open and exposed by nature. Since pulse isn’t used in Saam- with the exception of chronically
rapid pulse indicating H excess- we can discount the thin pulse here.
Since cold extremities and sudden temp changes can be Sj excess, I would look for other signs to strengthen that
diagnosis before Liver+ again given the mediocre response to the first Liver+ treatment. Bright eyes, politeness,
light/lithe movements, light sensitivity would be some strong SJ excess indicators.
To help organize your Saam thinking: vertex headache can be put under SJ excess heading since the vertex is on
the counterbalancer Liver’s channel trajectory.
Poor vision is not an indicator of Liver excess. Poor night vision is an indicator of Liver excess.
With the cold extremities, sudden temperature changes, the dusky tongue, the 4! separate traumas to her neck and
history of TIA, especially since the headaches started following the TIA, I am really interested in her SI/K balance,
guessing that there might be enough blood stasis to require SI+. The trauma history is enough to strongly consider
SI+, but the presence of Kidney excess signs would strengthen that diagnosis even more.
Is she pretty/symmetrical? Does she have any varicosities? She dressed casually but does she have any signs that
she makes special efforts with her appearance as if she is really into herself? If managing her stress is really
dependent on her movement activities, this can be a sign that SI+ might benefit her as well.
adambroder:
musculoskeletal pain
The pain part technically puts it under Kidney excess, since pain is an indication that SI+ might be appropriate. I
know the issue of pain and blood stasis signs going under K excess is a little confusing. You can think of them as
too much consolidated self in a way. I’m not seeing where the musculoskeletal pain is in the descriptions- maybe
the Spleen channel since you mention it. Since Saam is interested in everything, note the location of the pain under
the involved channel and its counterbalancer.
adambroder:
soft flesh
This is a damp sign. Likely internal damp. Just to get into the habit- you can put that under Lung or Spleen excess
with a question mark.25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
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adambroder:
GI: no issues as long as she eats the right foots
It would be helpful to know what happens when she doesn’t eat the right foods. Diarrhea, bloating, reflux? Might
not be a big deal but it is a good habit to get into asking.
adambroder:
Spleen channel pain
can also go under LI excess, since it is pain on the counterbalancer.
With the mixed P/GB excess picture. With mixed behavior picture it is helpful to ask yourself if some of her
behaviors feel more authentic than others. Was she really passive or was the “passivity” her attempt to control her
aggressive tendencies? I have very intelligent patients who use their intellects like weapons, so their balance is
clearly more GB excess. It sounds like the GB excess is more heavily weighted especially given the input of her
husband.
adambroder:
I have to consider if she left me as a patient that things really were getting worse
Absolutely. However, you reported the aggravation here without any details. This made me wonder if you had
asked her to describe the aggravation. Maybe you did but if you didn’t, it would have been helpful to know exactly
what happened. Especially since aggressive folks aren’t always the best reporters. With Saam, we are interested in
everything.
Her experience of insomnia would also be helpful information to flesh out her picture. Is she hot/cold, physically or
mentally restless?
Cases can seem like lots of work but they are such excellent learning tools. I am happy to look at other cases you
write up.
4 Likes25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
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adambroder: September 23, 2019, 7:45pm
mariamorris:
I agree that this particular case may not need a counterbalancing treatment, but not because of the time elapsed,
rather because we don’t clearly know how reliable a reporter she is.
Interesting point, but I’m not sure I see it that way. It leads me to the question, how would we know if she is a
reliable reporter? What do patients who report reliably do or say that this patient wasn’t?
adambroder: September 23, 2019, 7:55pm
ngmatthews:
The term “passive aggressive’ here is a bit confusing, and I think it does not lead to clear diagnosis when we
are thinking along the Pc/Gb continuum. Pc types are not passive, and Gb types are certainly aggressive. I
think the term passive/agressive is also not clearly defined. In other words, we don’t know exactly what you
mean by that. Problem is that if she tends to be irritable, supporting Gallbladder is very risky because it could
amplify that. To me she sounds stressed and anxious to a degree and I would not want to tonify Gb in that
scenario.
This is kind of my point, that the idea of passive-aggressive, while I don’t believe it to be as slippery as you
suggest, can be slippery in a Sa’am GB/PC context. I want to encourage someone who is passive to express
whatever is irking them in a healthy and positive way. Wouldn’t GB+ accomplish that? The answer is more case-
by-case than a pure black and white, but I tend to understand GB+ in this context as having this effect. Of course
this is all speculation and musing and I will have it clearer in my head before attempting another GB+ on someone.
The reason I say I don’t think it’s that slippery is because sometimes it can be very gross. I’ve recognized Toby’s
image of sword out, attack mode, in patients who are doing it while trying to hide behind a facade of politeness and
I see right through it. To my mind that’s clearly passive aggressive. Would PC+ encourage more passivity with
someone who clearly needs to have their voice heard and their anger/emotions understood and validated? Again
case-by-case.
adambroder: September 23, 2019, 8:00pm
ngmatthews:
Unless you think you have been totally wrong about something, I think it is great to repeat a treatment that is
working to get the most out of it that you can.25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/recent-failure-trying-to-suss-out-the-lesson-s/620/print12/13
I think this is the main lesson from this patient. LR+ was the right choice because it produced results. I was
cavalier with my new weapon (Sa’am) and I wanted it to knock out her insomnia with one treatment. When that
didn’t happen I switched it up in hopes of achieving that. I know better now. The learning process of Sa’am so far
has been one of the most rewarding aspects of the system for me.
adambroder: September 23, 2019, 8:28pm
KristinWisgirda:
we can discount the thin pulse here
I thought I heard Toby say in the NY class that with a thin pulse especially on the left wrist he’s always thinking
LR+
adambroder: September 23, 2019, 8:30pm
KristinWisgirda:
If managing her stress is really dependent on her movement activities, this can be a sign that SI+ might benefit
her as well.
Makes sense, I hadn’t considered that
Adina_Kletzel: September 24, 2019, 8:47pm
KristinWisgirda:
can also go under LI excess, since it is pain on the counterbalancer.
I was under the impression that pain on a particular meridian indicates either excess of that archetype or its
counterbalancer. In this case, pain on the spleen meridian could mean sp excess or LI excess. Did I misunderstand
that?
KristinWisgirda: September 24, 2019, 8:51pm
Adina_Kletzel:25/01/2024, 11:54Recent failure, trying to suss out the lesson(s) – Sa’am Clinical Questions – Qiological Community
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can also go under LI excess
“Also” is in there, meaning
Adina_Kletzel:
pain on the spleen meridian could mean sp excess or LI excess
We both got it right!