The Root Treatment is the Room
To articulate Liberation Acupuncture as a particular and distinct school of thought is a somewhat challenging undertaking. Liberation Acupuncture is a development of Community Acupuncture (CA), and for a long time the acupuncture profession in the West has seemingly regarded CA as a kind of short-version, half-assed sort of therapy, good for relieving stress and not much more. But LA has its own perspective, its own logic, its own agenda. To understand it, some common assumptions of the acupuncture professional and academic viewpoints must be discussed.
Profession Relationship to Textual Sources
It must be said that Acupuncture and Oriental Medicine (AOM) in the West (and even in the East) has its basis in textual sources which date back to the Han Dynasty, more than 2500 years ago. The Ur-Text of the profession is the Huang Di Nei Jing, itself a heterogeneous and likely incomplete work (two books, Su Wen and Ling Shu, are extant with a third, Tai Su, hardly mentioned) based on earlier sources, most of which are lost. Acupuncture, as a therapeutic modality, is absent from the historical record before the Nei Jing, and the meridian system is found in the Mawangdui manuscripts which predate the Nei Jing, yet moxa cautery is the only modality associated with them in those texts.
Since the Han period, the Nei Jing has been rearranged (for example, the Zhen Jiu Jia Yi Jing, which served as the standard text book of acupuncture for centuries) and expanded upon, to the extent that it could well be said that virtually the entire corpus of AOM literature is a commentary on or extrapolation from the Nei Jing. It is difficult to overstate the importance of this text; even in modern journals, justification for a particular theoretical point or therapeutic intervention must include reference to the Nei Jing in order to gain currency and be considered as a respectable innovation in the eyes of many if not most of the field's academics and practitioners.
This last point was driven home to me when, at mid-life, after a decade in the profession as practitioner and teacher, I converted to Islam and began studying religious law. The parallels were uncanny; any justification for permissible practices had to either come from the root text or a rigorously authenticated tradition associated with it. The major difference, as I saw it, was the rigor with which the ideas were authenticated; in this, AOM practice would have as its final arbiter either the word of a particular senior practitioner and/or teacher, or, barring that, claims (generally subjective and as such difficult if not impossible to substantiate) of clinical efficacy. The ideas of the Nei Jing were themselves considered as if they were a revealed religious text, and the clinical experience of the anonymous authors was assumed to be unassailable.
So, despite the fact that we have advanced technologically to the point that we can detect the tiniest physical particles and can accurately map the most obscure structures of the human body and have yet to find the traditional meridian system, the profession persists in unquestioning acceptance of the tenets of the Nei Jing. Research which contradicts our cherished theories is met with howls of derision even as we trumpet any positive outcomes that are published, no matter how suspect the research methods which produced them.
In any case, we use the theories of jing-luo, Yin-Yang and so forth because we are trained to do so, just as two milennia worth of our progenitors have done, and because, at this point in time, we lack a more satisfactory framework from which to proceed. The matter, however, is complicated by the heterogeneous nature of our source text itself as well as the multitude of existing interpretations of the theories contained therein. Schools of thought differ widely in their diagnostic criteria, therapeutic methods, treatment staging, even down to point location. Some practitioners and teachers are tolerant of such differences while others are openly hostile. The emergence in recent years of more obscure lineage styles of AOM alongside traditional medical systems of other Asian and non-Asian cultures, aided in their dissemination by the internet, has only served to further the confusion.
Thus it is useful, if we are to be honest, to be open minded and cognizant of both our own biases as well as the limitations of our knowledge when engaging in dialogue on this (or indeed any) topic.
Delineating LA as a "School of Thought"
One of the most striking features of the CA movement has been its diversity in clinical approaches; describing common features of practice again requires one to re-examine some of the basic assumptions of the profession.
Various styles of acupuncture tend to differentiate themselves on one or more of the following:
- Underlying theory of pathomechanism (Evil Qi, Aggressive Energy, 3 Causes of Disease, etc, plus various integration of biomedical theories)
- Diagnostic examination and interpretation
- Treatment parameters, primarily involving point selection, needle technique, and adjunctive techniques (cupping, bleeding, moxa, etc)
-Concept of Root Treatment
We will consider each of these in turn.
Styles of AOM differ in fundamental ways. In one sense, there may be a difference in how the particular style locates the human being. TCM for example, tends to locate the individual in the context of the individual as he/she relates to his/her physical environment. Climate factors, both internal and external (six evils), and physical substances both physiological (qi, blood, essence) and pathological (phlegm, stagnant qi/blood/food) are seen as the basic factors influencing health. Traditional Five Element ("Worsley style") places its emphasis on psychological, emotional and spiritual factors as they relate to the individual. LA views people as social beings as much as individuals, and the forces that shape them socially, such as class, race and economic status, are seen as significant factors in health and disease. Stress and trauma related to these factors are posited to be primary causes of disease. Indeed, modern research has given a clear picture of stress causing inflammatory and degenerative processes in the body (1), and lack of human connection has been recently been demonstrated to be a probable causative factor in addictions (2).
Stress is posited to be a primary mechanism in the genesis of Yu, stagnation (Wiseman: depression). This echoes the Song Dynasty master Zhu Danxi's axiom that "Depression is the mother of 10,000 diseases" (itself an evolution in thinking from the Nei Jing's assertion that "Wind is the cause of 10,000 diseases). (3) As a co-factor (or even primary factor), poor nutritional status from processed foods based largely on monocultural crops can lead to significant deficiencies in qi-blood-essence, which can then lead to formation of phlegm and other obstructive pathologies. Physical and psychological trauma is a primary cause of qi stagnation and blood stasis; the prevalence of trauma in modern society is elucidated at length in other sections of this book.
While acupuncture can, by itself, do nothing to correct the economic and social conditions which lead to the formation of these pathomechanisms, it can alleviate their physical effects and afford the afflicted a respite where their body's own Zheng Qi can reorient itself and begin to correct the imbalances in itself, resulting in decreased pain and increased energy and mental clarity to better adapt and hopefully overcome the outside forces which challenge one daily. Because humans are social and human connection is considered in itself to be healing, the respite is best done in a communal space, where the activation of Zheng Qi in one can, through a process of entrainment, aid in its activation in another.
While the influence of nutritional and other factors in health can scarcely be denied, LA recognizes that we operate in a multicultural space, and each culture has its own wisdom as well as its own preferences in choosing the most efficacious way in which to mediate these influences. The majority of dietary recommendations given in AOM practice derive from a homogenous culture tied to a certain era and geographic location with a particular climate, agricultural practices, wildlife, etc. Thus we find it more useful to refrain from specific dietary recommendations and encourage each person to seek answers according to their own culture, whether it be natal or acquired.
In some ways we can look to some of the modern acupuncturists - Miriam Lee, Michael Smith, Takeshi Sawada, the early Keiraku Chiryo movement, probably others - who, for whatever reasons, adopted either a restricted etiology or restricted/basic set of treatment points. (4) Takeshi Sawada's underlying pathomechanistic concept was dysfunction in the Triple Warmer, and his methods were a combination of his basic whole-body (taikyoku / taiji) non-pattern root treatment with empirical treatments. The early generation of the Keiraku Chiryo (Japanese Meridian Therapy) movement based their style squarely on a few chapters of the Classic of Difficulties. The theories have been augmented by some notable personalities in more recent years, but whether this has led to improved clinical outcomes is little more than a matter of opinion.
Diagnostic Methods used in LA are varied and flexible in application. Skill levels in palpation, for example, vary widely, and various senses in a given practitioner may be more developed than others, or even absent (the author studied extensively with blind practitioners, for example). Diagnosis, then, is a very personal and subjective (5) process which may differ in its particulars from one practitioner to the next; thus no one method is thought to be the basis of diagnostic examination in LA.
That having been said, the guiding principles of Trauma Informed Care are of central importance. Thus our approach is to regard the patient as a reliable informant of their own symptoms (a key difference from some acupuncture approaches) and to respect their sense of what is going on in their particular situation. In addition, given that even the most general of acupuncture treatments can be enormously helpful, we discourage any process which attempts to coerce the patient into revealing more than they are comfortable with at the time of the examination. Given that we have adopted a Trauma Informed model and that, as in all healing practices, the axiom of Primum Non Nocere (First Do No Harm) is uppermost in our minds, we consider that the risk of re-traumatizing the patient is much greater than the risk of doing harm to them by performing acupuncture with incomplete diagnostic information (the latter of which is nearly always the case anyway). Acupuncture has been shown to be in general a very forgiving and benign intervention, and our preferred methods of treatment emphasize its gentle nature.
Diagnosis in AOM has a transient nature in any case, and the diagnostic process in LA unfolds over times as the relationship of the patient with the clinic develops. The patient and practitioner both gain awareness of the patient's physical processes over time, what is relevant and lasting and what is not. Since the economic structure of the practice model allows many patients to receive treatment more often, the relationship and mutual trust generally occurs in a time frame similar to what might happen in a more conventional one-on-one setting.
Treatment parameters, generally involve such things as point selection, needle technique, and adjunctive techniques (cupping, bleeding, moxa, etc). Some important parameters which are less emphasized in most acupuncture styles include treatment frequency and treatment setting.
Treatment methods among LA practitioners may vary in the details, but in general the preferred method is the insertion and retention of needles, generally without manipulation (or only manipulated at the beginning of the session). Needles are retained for thirty minutes to several hours, based on the patient's preference and guided by the practitioner's experience. As typical in the acupuncture profession, observers might disagree whether this technique constitutes a draining or supplementing technique (or neither). Where J.R. Worsley's students would consider needle retention draining, followers of Japanese Meridian Therapy might consider it supplementing. Given that views on such matters vary dramatically - consider that a practitioner of Japanese Toyohari would find a standard TCM supplementing technique to be severely draining,while a TCM practitioner would likely regard the Toyohari non-inserted supplementing techniques as acupuncture in name only - we don't find such a distinction particularly useful. Retention of at least some of the needles, however, is generally desired to allow the patient to relax and to aid in the entrainment phenomenon described earlier.
In addition, individual practitioners may employ bloodletting, gua sha, cupping, etc, as they see fit. Due to possible sensitivity to smoke among those who may be sharing the treatment space, moxa is less common, though there is the possibility of using electric heating devices. Punks may apply any techniques within their scope that they judge to be safe, effective and within the TI context.
Point selection is likewise very individualized. One generalization that can be made is that extensive use of distal points is employed, often using advanced meridian theory and/or mirroring techniques. The points and methods of Master Tung and his students are very commonly used, as are the methods of Richard Tan. Microsystems are popular among LA acupuncturists as well; Auricular therapy is commonly used, both in the form of needles and ear seeds, as is scalp needling.
In general, since acupuncture theory is based on meridian theory, the majority of punks tend to employ those kinds of interpretations to their clinical encounters. However, belief in qi or acupuncture theory is not a prerequisite to doing this kind of work; using biomedical models such as autonomic balancing, scalp acupx, European auriculotherapy, etc, are considered legitimate.
It is important to realize that LA doesn't automatically exclude points (except possibly Ren1/Du1). The method of treating points difficult to needle in an open setting is up to the practitioners' own resourcefulness. Some examples have included taping back needles in place for the duration of a seated acupuncture session, simple insertion, contact needling, etc.
Again, principles of Trauma Informed Care and cultural sensitivity are extemely important; patients must not feel pressed to reveal more of their body than they find comfortable. The practitioner must have an attitude of flexibility and a variety of different point selection approaches at their disposal. Given that the patient may not feel ready to divulge much more than a minimum of detail about their condition, general treatment protocols are frequently employed. This is not a strategy which orginated with the community acupuncture movement; such renowned acupuncturists as Miriam Lee and Takeshi Sawada routinely employed their own standard universal protocols, and versions of these and others, such as the NADA 5-Needle Protocol or the Battlefield Acupuncture protocol, are frequently given by LA practitioners.
Expanding the Definition of Treatment Parameters: Frequency and Setting
Another aspect of acupuncture therapy which is of crucial importance but often overlooked in the West is that of treatment frequency. When one looks at studies done in Asia, one can see a disconnect in terms of the courses of treatment descibed in the Asian literature and those most commonly practiced in the West. In Asia, treatments tend to be performed multiple times in a week, or even daily, whereas in the West weekly treatments are much more the norm (6). Western acupuncturists are fond of citing positive outcomes of Chinese research specifically, and may even adopt the point selection of the published research protocols, yet they seldom recommend the same treatment frequency which was part of the research design. While the reasons for this may be multi-factorial (economic constraints of the patient, lack of available space in the clinic or appointment schedule, physical or psychological limitations of the practitioner), the expectations of a similar outcome to the research may be fanciful if one considers that frequency of the treatment is an important variable in the study design. Even the GERAC studies, the most comprehensive studies done in the West to Western standards of research, rarely give the frequency of treatment at rates exceeding twice weekly. (7) One ponders whether the outcomes of that research, hailed as demonstrating acupuncture's efficacy, would have been even more convincing had the frequency of treatments been increased.
In LA, treatment frequency is considered to be one of the most important factors influencing the outcome of therapy. Even though the GERAC studies limited the weekly frequency of treatment, the researchers noted that increased number of treatments was one of the few factors which could be reliably demonstrated to improve the treatment outcomes. Because of the pricing structure inherent in the model on which LA is based, most participants in therapy can afford to receive treatment more frequently than would be the case if they sought care from a more conventional Western one-on-one practice. A number of LA clinics have the kind of patient volume in which they can afford some flexibility in pricing the treatments in order to encourage compliance with the treatment plan, which is a felicitous circumstance made possible by the clinic setting itself.
Clinic setting is another factor which is seldom mentioned. It is generally either a happenstance occurence, a byproduct of the economic situation of the practitioner, or based on the assumption that a superior treatment environment should most closely resemble a medical office or a spa. But the setting in LA clinics most often resembles something akin to a large living room: comfortable reclining chairs in an open indoor space, generally with soft lighting and/or natural daylight. While the genesis of this idea was something closer to happenstance, it was soon found to be a useful facet of therapy and quickly replicated by scores of clinics across North America. Recent research in group acupuncture settings has suggested the desirability of this environment to many patients (8).
Administration of acupuncture to seated patients has been common in addiction treatment settings for decades (cf NADA), and well-regarded practitioners such as Miriam Lee and Richard Tan would routinely give acupuncture in chairs. Seated positioning in acupuncture has been demonstrated to have an important autonomic balancing effect (see below), recliners giving the benefits of parasympathetic activation while the option of easily sitting upright ensures that those patients with excessive parasympathetic tone will not be harmed but will be able to choose the most comfortable angle at which to maximize the benefits of therapy.
Critics of seated acupuncture may state that the use of back points is restricted by postioning patients in such a manner. However, two decades of experience by a significant number of practitioners over a wide geographical area with a broad demographic scope has indicated that successful outcomes to therapy are not hindered by this approach. Extensive use of the distal, mirroring and microsystem techniques described above has proven more than satisfactory, and can even be said to reduce the possibility of adverse events occuring during the acupuncture treatment. No distal point has yet caused puncture of vital organs. If the patient and practitioner are in agreement that some local treatment would be beneficial, there is always the possibility of simple insertion, guasha, bloodletting, or other techniques either before or after the standard seated needle retention.
When one looks at the meta-analysis by Vickers (9), one can conclude that as much as 60% of an acupuncture treatment's efficacy is due to non-specific factors - i.e. something other than the acupuncture itself. Patients' ability to relax, especially in cases of pain or stress, can be a crucial ingredient to successful results in treatment. In LA, a clinic space which has been designed to reduce patient anxiety (which can be easily provoked in a more medicalized setting - witness the phenomenon of "white coat hypertension") and increase feelings of human connection has been deemed as important a factor in treatment as needle technique or point selection.
In considering LA as a school of thought, a major challenge has been to articulate one of the most essential characteristics of an acupuncture style: the Root Treatment. As noted earlier, the proponents of CA have been trained in a variety of styles and tend to bring elements of those styles with them when transitioning into CA practice. This makes for a rather heterogenous methodology when examined with the standard assumptions of the profession. If we extend the definitions of treatment, as above, to emphasize the importance of treatment frequency and setting, the picture becomes a little more defined.
In further clarifying the most essential aspect of LA as an acupuncture style, it is worth noting the research of Professor Kazushi Nishijo of the Tsukuba College of Technology.
Briefly, in the 1990's Prof Nishijo researched effects of acupuncture on the Autonomic Nervous System (ANS). His research was followed closely by traditional acupuncturists in Japan, largely because it confirmed some of the concepts of supplementing and draining (bu-xie) found in the Nei Jing. In applying modern ideas of physiology to Yin and Yang, supplementing and draining, the two-part ANS is perhaps the most readily adaptable bridge between traditional and modern understanding of theworkingsof the human body. Prof Nishijo found the most consistently reproducible way to induce Parasympathetic activation was using SES (Sitting/ Exhalation/ Superficial) stimulation. In summary, he basically advocated treating people in chairs, and using the breath cycle and needle depth to incline the ANS in whatever direction one wanted it to go.
Some relevant passages from the NAJOM article on Prof Nishijo's research by Tim Hideaki Tanaka (10).
"Prof. Nishijo concluded that based on his research to date, stimulation applied to any part of the body surface induces a parasympathetic response. He recommended, however, that practitioners use the point distal from knees and elbows for a slightly greater response. Prof. Nishijo often uses TW5, but this is mostly for the sake of convenience. What is most important to induce a parasympathetic response is not the location of the point but rather the depth of the stimulation. "
"Stimulation in line with the somatic state of the patient is called tonification in Oriental medicine. From this perspective, Prof. Nishijo considers SES mode stimulation to be a tonification technique of root treatment. "
An aside regarding the reknowned acupuncturist, Denmei Shudo:
"In his seminar, Mr. Shudo commented that the effects of symptomatic treatment varied greatly depending on the technical skill and experience of the acupuncturist but that in general, a similar effect could be expected with root treatment. "
Shudo sensei's comment above suggests that the Root Treatment's effects are fairly well reproducible, even for novices. Community acupuncturists employing a variety of styles have reported remarkably consistent treatment outcomes, even in their beginning years of practice. Prof Nishijo's comments suggest that the Root Treatment need not be about point selection but can include (or in his case, be defined by) the patient's somatic state.
So what can we say from this discussion regarding the nature of the Root Treatment in Liberation Acupuncture, if we accept that the context, setting and somatic state of the patient are important considerations in discussing acupuncture treatment?
The Root Treatment is the Room. The main constant in LA practices, perhaps in a technical sense the most important aspect of the treatment, is that it is done in an open room, among other recipients of treatment in order to facilitate human connection and entrainment, most often seated, a quiet space with low or natural lighting. Root treatment is primarily aimed at healing the most fundamental processes of the body, and it is in this state that healing occurs most effectively. The usual confirmation that the Root treatment is effective is that the patient enters a deep parasympathetic state for a period as prolonged as the body's own wisdom deems necessary. This process, repeated with adequate frequency, is the fundamental practice that defines a course of treatment with Liberation Acupuncture.
(1) See, for example, the wrtings of Gabor Mate, M.D., especially "When The Body Says No"
(3) The Heart and Essence of Dan-Xi's Methods of Treatment, Blue Poppy Press, 1993, p 31
(4) Indeed restricted etiology is not a modern phenomenon; cf Unschuld's discussion of restricted etiology in the 4 Masters of Song-Jin-Yuan, in Medicine in China: A History of Ideas
(5) Jiang, L., Liu, B., Xie, Q., Yang, S., He, L., Zhang, R., … Liu, J. (2013). Investigation into the Influence of Physician for Treatment Based on Syndrome Differentiation. Evidence-Based Complementary and Alternative Medicine : eCAM, 2013, 587234. doi:10.1155/2013/587234
(6) or even every two or three weeks - a cursory review of the literature shows such well-known physicians as Kespi, Bensky, and Mann have all given treatments at frequencies of every two to three weeks.
(7) See MacPherson, H., Maschino, A. C., Lewith, G., Foster, N. E., Witt, C., Vickers, A. J., & on behalf of the Acupuncture Trialists’ Collaboration. (2013). Characteristics of Acupuncture Treatment Associated with Outcome: An Individual Patient Meta-Analysis of 17,922 Patients with Chronic Pain in Randomised Controlled Trials .PLoS ONE, 8(10), e77438. doi:10.1371/journal.pone.0077438
(8) Feasibility and Acceptability of Group Acupuncture in Veterans with Hepatitis C: A Pilot Study Taylor-Young Patricia, Miller Diane, Ganzini Linda, Golden Sara, and Hansen Lissi. Medical Acupuncture. August 2014, 26(4): 208-214. doi:10.1089/acu.2013.1017.
(9) Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Victor, N., … on behalf of the Acupuncture Trialists’ Collaboration, K. (2012). Acupuncture for chronic pain: individual patient data meta-analysis. Archives of Internal Medicine, 172(19), 1444–1453. doi:10.1001/archinternmed.2012.3654 http://www.ncbi.nlm.nih.gov/pubmed/22965186
(10) Professor Nishijo’s Research - Acupuncture and the Autonomic Nervous System, Tim Hideaki Tanaka, North American Journal of Oriental Medicine, Vol. 3, No. 8 November 1996