Tuesday, 28 April 2015

Acupuncturists: Looking at Different Systems and Finding Our Own Way

As practitioners of the Traditional Art of Acupuncture, each of us will have different strengths and weaknesses, different approaches and favour certain aspects of practice over others. We may all share a common base in that we may have trained in the Chinese TCM System or Worsley's 5 Elements, Kiiko Matsumoto or in Toyohari or Meridian Therapy but unless we are trained in a fixed and relatively rigid clinic setting like a TCM hospital in China or had a long apprenticeship under a particular teacher it is possible we will evolve to practice acupuncture in our own unique and distinctive way.

Not staying true to one method of acupuncture may be seen as a negative thing in the East, but to the Westerner the flexibility has several advantages. It allows for a type of further development and experimentation that would not be possible in a rigid apprenticeship or training. Mark Seems uses the expression “A New American Acupuncture” to describe essentially the development of new systems of Acupuncture that are possible. To the East, you could imagine such expressions being condemned as heresy. I believe this has a great possibility of occurring in a country where innovation and experimentation is a strong driving force.

I have come up with two ways to look at the learning of acupuncture by training in acupuncture systems. One analogy is to look at the continued tradition of orchestras playing classical music by famous composers long-since dead like Mozart, Beethoven or Bach. The compositions of beautiful music by Mozart does not need any further development. It is already complete and any further alteration would only pollute it. At most it requires a subtle interpretation or flavour, which will be given naturally by the composer and the musicians. But fundamentally, the music will remain in its original state. What matters is the talent and accuracy from the musicians to reproduce it. To feel its perfection, it must be played exactly as it was composed. If suddenly an experiential jazz musician was to hijack a section and alter it, it would ruin the piece.

I think this is comparable to the type of acupuncture systems that require strict adherence to its principles, theories and methodology. Such systems are deemed to be complete in their own right and it is considered important to preserve them in their current state and for practitioners to follow their methods accurately  without changing. For some, this is the correct way to practice acupuncture. Japanese Toyohari is a system like this although alterations to the system are gradually made.

Then there is the rock and roll approach. For example, a group of boys with a couple of electric guitars and a drum kit form a band together and learn their trade by playing the hits of their favourite singer or some other popular music. Then they reach a fairly good level of ability and gain some success playing covers. In the future, they may continue to play the same cover hits over and over again but never develop further than being an imitation band. On the other hand, they may start to absorb all that they have learnt – all the different styles and musical compositions and then develop their own unique style of music similar to the way the Rolling Stones started out as an American Blues cover band and then added their own youthful British 60’s rock vibe.

This is the way of acupuncture, whereby a person learns one system and practices it but then due to various experiences, interests and creative urges, are compelled to experiment, develop and create something different. The downside to this is that the practitioner is not always able to explain their thought processes or to adequately communicate their method in a way that can be repeated by other people in exactly the same way. Kiiko Matsumoto has a similar method to this although she has found a way to adequately train others in her system. This method is probably the kind of approach that leads to lots of different variations of acupuncture practice – the kind of thinking that existed in pre Communist China and prior to the Meiji restoration in Japan.  

So putting that aside, the consideration for practitioners is to ask which approach suits you best and on principle, which do you think is the best way to practice? For me, I know intellectually that following one system rigidly until I attain perfection (i.e. the Mozart approach) is perhaps traditionally the best way. However, in the West this approach is not really possible as the circumstances that enable it to occur do not exist and also there is my own nature - a tendency to creativity and flexibility. Actually, I don’t think there is any one way for an acupuncturist to learn – there is certainly not a right or wrong way. We all have our different journeys. I only think the most important thing is that we respect the art and always continue to improve.

I think it is common for some practitioners to start off learning one system of acupuncture and then over the course of their lifetime, they start to learn other systems. Or they may follow several different practitioners who does things a certain way and change their own practice accordingly. On the other hand, there are some practitioners who only practice the same system they originally trained in, seeking to deepen their understanding and ability in that system. Whatever system or style a practitioner follows, the goal remains the same – to reach a higher level of proficiency.

There are many benefits to staying true to one system of acupuncture. Every system is remotely complex and takes time to learn and then takes even longer to master. The benefit of staying true to one system of acupuncture takes away the temptation to keep looking at the horizon for the next best thing. Otherwise, before you know it, a typical acupuncturist then has ten different trainings in ten different acupuncture systems. ‘Jack of all trades and Master of none’ is an expression which sums up this problem because there is a risk of confusion. When faced with one problem, which solution do you choose? Humans don’t function well when given too many choices.

But then what if the acupuncturist is not happy with the choice of systems available? What if the practitioner is put off with the systematic point prescription approach of TCM? Or the Five Element practitioner tires of going through a long winded consultation process with Jack the builder with a bad back who just wants a quick fix? Or the non-insertive technique of Toyohari where you wonder if you are actually doing anything or the painful looks of patients receiving Tongs Acupuncture. What if you still haven’t found what really satisfies you? I think there are many practitioners in the West who have this feeling.

When I first learnt TCM, there were many things that excited me about the system. I respected my teachers and was impressed at their understanding and ability to explain the theories behind it. I was fascinated by the diagnostic system, which seemed to me amazingly accurate. My biggest problem came with the lack of channel palpation in the system which was something I had a strong personal interest in. When I first had an experience of the Shakajyu Japanese Acupuncture system whilst still studying TCM, it was the palpatory aspect of it that peeked my interest and I knew I was going to have to learn one of the Japanese systems to develop these skills.

For me - to enjoy practising acupuncture, I need to do it in a way that excites me and that feeds my interest so that I can continue to learn every time I practice. I tend to lose interest when I become too systematic in my treatment. However, I know there are other practitioners who feel the opposite and prefer a systematic approach. We all have different interests and biases. I think it is useful to take a look at the kind of acupuncture you enjoy practicing.

I think that finding an acupuncture style or system should have an element of passion around it. Ideally you will experience its power for yourself by having a treatment. If not you should be able to first-hand witness a practitioner of the art help deal successfully with patient’s conditions. It should not just be based on reading or on hearing what others say. You need to see or feel for yourself that there is something in it. It should be the kind of system that not only makes you think “this is it!” but also should convince you that it works by showing you results.  

I believe that traditionally acupuncture was a growing and flexible process. There may have been schools around with different methods and approaches. Some families would practice acupuncture passing their teachings and secrets in a linage onto family members or accepted students. Perhaps it was not the most efficient way of developing and training new students but at least it was diverse.

It is only when politics has gotten involved in acupuncture is when we see an end to diversity and an emphasis on standardization. The Government of the People’s Republic of China created the modern TCM system, which swallowed up all the different variations of acupuncture. A similar thing happened in Japan during the Meiji restoration, when the government attempted to severely limit the practice of acupuncture to only Western Medical physicians or Blind people during the drive to modernise the country. Fortunately, this attempt to eradicate acupuncture failed, although sadly they did manage to wipe out the last of the Samurai despite Tom Cruise’s best efforts.

Despite these big changes, there have been many benefits to this cleaning up and standardizing process of acupuncture. The way that acupuncture is taught as a subject with formalized training, clinical modules and qualifications incorporating Western anatomy, pathology and physiology means that it is now taught to a professional standard closer to Western Medical Training. Newly trained practitioners are trained to a set timetable and a set syllabus and only after qualifying can they start working as practitioners. There is also no doubt that there has been a major increase in the number of Acupuncturists Worldwide since TCM has been formulated which means that more people have benefited from receiving treatments in countries that would never have been exposed to acupuncture otherwise.

The biggest disadvantage is that the long apprenticeship under an experienced practitioner is missed out. For some acupuncturists, that is not essential. Some people find it difficult to be under the control of another. I am probably one of those kinds of practitioners. But others would prefer it. Confidence is a big issue facing new practitioners who find they are suddenly thrust out into the world to build their clinics and their skills for the most part by themselves. However, this has been the norm for Western practitioners in the last 30 years, who with the exception of a few months spent in hospitals or clinics in China or Japan have had to gain most of their experience in private practice. It has become one of the first major hurdles to cross and is a necessary step in building a practice in an industry which is predominantly in the private sector. It’s an essential first step for the western practitioner because it encompasses the development of various other skill sets, such as having a good patient centred approach – treating patients with the utmost respect (contrast that to some NHS hospitals and General practitioner) who will continue to get their high salaries paid by the state no matter how inefficient their service or how bad their bedside manner is. Developing your own skill in practice also helps develop business and salesmanship skills. These are very important because they directly impact on your ability to make a living. The following scientific equation demonstrates this:

No patients     =    have to eat tinned cat food for a while

When you are out learning on your own, there is a constant drive to improve your skills because:

Better skills   = better results =   Patients come back / More patients  = no more cat food

Though in the West we don’t have the traditional apprenticeship model, there are other ways for practitioners to develop their skills. Seminars, workshops occur throughout the year and there are various different systems to learn and many books to pick up ideas from. Without a strict level of guidance to follow, what is likely to happen is that different acupuncturists start to develop their own ideas and treatment protocols based on their own experiences? For example, if something worked, it is logical for a person to repeat it. If it didn’t work, you may try again sometimes with a small variation and if it doesn’t work again, then seek out an alternative approach. However, if you strictly follow one system of acupuncture, you are limited to only using the protocols that it teaches. I don’t believe there is any one system that is able to fix all problems. The answer to a problem may lie elsewhere. For some problems, there may be several different approaches to try out or it may be concluded that this problem will require repeated visits. Either way, there should be a constant process of evaluation going on as you scrutinise what you are doing. For example in a condition that may require a long series of treatments to resolve, there should at least be some minor improvement or good change in some aspect of their health even if it is not in an area directly related to the problem that they came to you with.

Though this process can be painful as it brings us face to face to the possibility that our treatment is not working, I believe it is by this process that we can become more effective practitioners.

And it is this constant desire to improve our skills which takes the Western acupuncturist to look at other systems of acupuncture and learn them. Actually Westerners are in a far better position than Chinese Acupuncturists because we have the choice to change our styles and to learn whereas most Chinese practitioners only have the option of TCM unless they are trained abroad. The benefit is that there are far deeper and sophisticated aspects of TCM that Chinese can learn, which is generally unavailable to Westerners.

There are other advantages to the flexibility of learning different systems. For example, it is my observation that TCM practitioners cannot see the benefit of needling superficially and some hari practitioners have trained themselves to stop needling deeply. But if you read the classic text – the Nanjing, it clearly differentiates between the necessity to needle at different depths for different people.

For example, in the Huangti Nei Ching Ling Shu (Ki Sunu Translation page 86), Huangti asks Chi Po about whether a different treatment method should be used on physical workers compared to those with more relaxed lifestyles. Chi Po answers:

“… if the way of life is different, acupuncture treatment also should be different.

For the treatment of the persons who are sensitive, one should puncture shallowly with the small needle, withdraw rapidly and should not retain the needle in position.

For the treatment of the persons who are insensitive, one should puncture deeply with the large needle, withdraw slowly and retain the needle in position.”

Drawing on my own experience, an insensitive person does not necessarily mean someone who has a fuller body or is a bit obese. Though the muscles are big, they may be very sensitive and feel drained after deep needling. And some thin people who work in office environments with central heating and sitting down a lot are not necessarily sensitive types either. If they are a Liver/Wood types of person with firm muscles and are very springy and active, they may actually be insensitive types. Nethertheless, Some problems require a stronger TCM approach to fix it and feel nothing from hari needling. Other people are in a weak condition and a gentler hari approach is more appropriate for them because TCM can be too draining. These are significant differences in technique which are sometimes passed over.

Overall, if you only needle one way or only use one approach to try to fix all problems, surely there are limitations to this. On the other hand, if you learn from various different systems and different practitioners, there is the possibility you can become a more rounded practitioner. For example, from TCM you can learn stronger techniques like deeper needling techniques and cupping. From Hari, you will develop greater sensitivity with palpation, gentler superficial needling techniques and a more diverse moxabustion usage. From Shakujyu therapy, you can get more experienced with treating the back points. With Five Elements you may be able to develop deeper insights about the make-up of the person in front of you and if you have learnt any kind of massage, your palpation skills may be enhanced ten-fold. All systems will teach you an aspect of skill that can make you a complete practitioner.

But training in different systems is expensive. Not many people have the time, inclination and money to travel to different places and learn whole new systems of acupuncture, so I think this is the value of symposiums, workshops, seminars, informal meeting groups between different practitioners and visits to other practitioners’ clinics either as an observer or as a patient. The motivation expert Brain Tracey recommends you read in your field every day. I think this advice should apply to acupuncturists to continually read up on various acupuncture books, other health related books, journals and other materials every day.  Other than from experience with patients, the next best way I find of learning is to be able to watch other practitioners in their clinic and watching their treatment. I have picked up valuable lessons and tools by doing this.

I finish this article by returning to an earlier question I posed: What if you are not satisfied with the system of acupuncture you initially trained in? I think different practitioners may have different answers to this question. For some acupuncturists, the question simply wouldn’t register. You would be met with a blank stare and not be given the answer you were hoping for. Such questions are simply not asked. It is not common practice to question your system.  From others, you may be told to have faith and trust in the system and keep practicing diligently for many years and then it will come. This is an answer similar to that sometimes found in some Oriental arts like flower arranging, calligraphy or some martial arts.

From my own Western point of view, my current answer to this question is to respect and honour the systems of acupuncture I have been privileged to learn but also to pay attention to its strengths and shortcomings. Then to practice these systems as best as I can and to gradually improve my skill and abilities. Finally to be open and constantly keep learning new things and approaches from other practitioners, teachers and books – to try out their methods out and adopt them if they are effective. I think it is important not to be judgemental of other practitioners. We all have our different ways, speeds and levels of learning and developing – the same as in life. It is better to share together so that we can help each other become better practitioners.

It is my belief that gradually, each of us makes a personal system of acupuncture that we are happy with – something that gives us the passion to have us working right up to our 60s and beyond, just like the Rolling Stones with their own brand of music. It is a way of acupuncture that incorporates all of our learning, our skills and experiences and some of our own essence. We become what we practice or as the famous acupuncturist Shudo Denmai is reported to have said “Acupuncture is the Acupuncturist”.

Wednesday, 25 June 2014

Acupuncture in Palliative and Hospice Care in the UK

In this article, I will discuss how there is a place for acupuncture and complementary therapies in palliative and hospice care and how it can benefit patients, carers and families as well as nursing staff. I will also discuss how volunteering in hospices can provide invaluable experience and confidence for all acupuncture practitioners - whether they are a new graduate or a seasoned professional.

For the past two years, I have been volunteering in St Josephs Hospice in the Whitechapel area of London. The East End of London has a curious history. If tourists ever tire of the wealth and grandiosity of Big Ben, the Houses of Parliament and Buckingham Palace, perhaps they can catch the train over to East End and have a ‘butchers’ at Brick Lane to catch a different flavour of London life. In some ways the main Whitechapel road has probably not changed much in the last 100 years. Gentrification has not set in yet (although Spitalfields market has succumbed to it) and the main high street is a mixture of local business shops and street market stalls.

The East End has a bit of a sordid history. Whitechapel was immortalised in 1888 – ‘The Autumn of Terror’ when Jack the Ripper set off a reign of murder and mutilation in the East End. The pubs along Whitechapel road were often frequented by prostitutes passing from one to the next selling their wares. The Ten Bells pub where two of his victims were seen before being brutally murdered and their organs surgically removed - still serves pints. And a mile down the road, the Blind Begger pub is open for business. This is where the famous London gangster Ronnie Kray gunned down rival gang associate George Cornell for calling him a “fat poof” in a room full of witnesses. This incident proved to be the downfall of him and his twin brother’s empire which had taken London by storm in the swinging 60’s.

The East End also has a long history of immigration and a vibrant changing population. In the 17th century, the French Huguenots made their homes in the Whitechapel area. In the 19th century, it was the turn of the Irish. In the 20th century, Ashkenazi Jews made it their home and in more recent times it is clearly a Bangladeshi area. In another hundred years, who knows which people will occupy these shops and streets? The Tower Hamlets has traditionally always been a poorer area, but it is an area with character. I should warn tourists that it does not leave any great impressions, but it is nonetheless a unique part of London.

St Joseph’s hospice is a few miles down the road and is in a modern building. It has one of the most vibrant complementary therapy departments in the UK. It was set up in 1905 by seven sisters of charity with the support and financial backing of Father Gallwey and Miss Grace Goldsmith and some anonymous donors. Their objective was to offer a place where people could die in peace away from the poverty stricken, disease ridden conditions that the poor suffered from in the East End of London at the time.

At the time, the East End was a dire place to live. It was squalid and dirty. Poverty was widespread. There was overcrowding, workhouses and many women had to turn to prostitution to survive. It had a definitive ‘Dickensian’ feel to it. It was the area where the famous American author, adventurer and social activist Jack London chose to study poverty up close and personal by being a ‘down and out’ in the East End – the details of his exploits can be found in the book ‘The People of the Abyss’. It is notable that Jack has been a hobo travelling across America which had made him strong and hardy. But even the abject poverty and hopeless desperation of the East End was too much for him both mentally and physically and at times he had to escape from his experiment – a choice that none of the locals would have ever had.

Times have changed since then. With the establishment of socialised healthcare, the NHS, the welfare state and advancements in medicine - the desperate poverty of the early 20th century has thankfully been dramatically reduced. But the hospice has grown with the times and is still as important as ever. Today the hospice can offer more than just a clean bed and warm food. Patients also have access to the best medications, access to doctors, 24 hour nurse care, counselling, community events and a variety of complementary therapies including acupuncture. The hospice relies heavily on volunteers at all levels of operation. If at any time you were to call the hospice or visit it, it is likely that some of the people you speak to or meet will be volunteers.

As a volunteer there practicing acupuncture and reflexology, I have gained invaluable experience and confidence. It has also changed my perspective on life.

Acupuncture and Complementary Therapies in Palliative Hospice Care

A major part of complementary therapies in the UK is in hospices and providing palliative care. Complementary therapies encompass many kinds of therapies such as aromatherapy, reflexology, holistic massage and many others. Among these therapies, the practice of acupuncture is becoming increasingly popular in hospice care and in hospitals in the NHS.

Patients in hospice care may suffer from a variety of health conditions, but by far the most common conditions tend to be Chronic Obstructive Pulmonary Disease (COPD), Multiple Sclerosis (MS) and Cancer. Of which, cancer is the most predominant. Patients dying from cancer experience heavy symptom burden – in particular the physiological and psychological effects of pain, which at times can be severe. Other common problems that people are affected by in palliative care are muscular skeletal pain, internal pain, breathing problems, nausea, oedema, vomiting, stress and anxiety. Family members and carers also suffer from stress, anxiety, grief and muscular pain especially if they have to lift the patient often. Stress and anxiety can also lead to sleeping problems, fatigue and depression. Complementary therapies can help people deal with all these problems and I have treated many patients and carers for these problems. This is important because it takes the strain off other medical staff – doctors and nurses and it means less suffering for the patients and their carers, which in turn creates better wellbeing.

WHO Definition of Palliative Care

The World Health Organisation (WHO) laid out a definition of what palliative care should encompass. In particular, palliative care should:

- Provide relief from pain and other distressing symptoms,

- Integrate the psychological and spiritual aspects of patient care,

- Offer a support system to help the family cope during the patient’s illness and in their own bereavement,

- Enhance quality of life.

It is my experience that acupuncture and complementary therapies can help satisfy these objectives, especially the aim to “provide relief from pain and other distressing symptoms”. To back this up, clinical research and studies have been carried out which have shown the benefits of acupuncture in hospice care and cancer treatment especially for providing relief from pain and other distressing symptoms.

Clinical Research and Studies

In one study in the American Journal of Hospice and Palliative Medicine, – ‘Acupuncture is underutilized in hospice and palliative medicine (2008)’, research showed that acupuncture was more established in the UK than in the USA. Researchers studied 27 randomized trials of acupuncture and found that in 23 of these trials; acupuncture was effective for treatment of dyspnoea, nausea, vomiting, pain and xerostomia. They also found it safe and cost effective and good value for palliative and hospice care.

In the Pub-Med Journal - ‘Acupuncture: role in comprehensive cancer care--a primer for the oncologist and review of the literature (2005), a review of acupuncture in cancer care was carried out. In this review of studies, it was found that acupuncture significantly reduced vomiting episodes for patients receiving chemotherapy and that acupuncture was observed by several researchers to be just as effective as or more effective than antidepressants. Studies on breathlessness also showed that acupuncture had a significant positive effect on chronic obstructive pulmonary disease. Patients with hot flushes due to hormonal imbalance may also benefit from the use of acupuncture. One pilot study also showed an improvement of chronic post chemotherapy fatigue following acupuncture treatment.

In another Pub-Med paper – ‘Acupuncture as palliative therapy for physical symptoms and quality of life for advanced cancer patients (2010).’ A trial was carried out to study acupuncture treatment on patients with ovarian or breast cancer.

In this pilot study, patients with advanced ovarian or breast cancer received 12 acupuncture sessions over 8 weeks with a follow-up after 12 weeks. Among all 32 assessed patients, there was self-improvement reported immediately following treatment in levels of anxiety, fatigue, pain, and depression. Psychological distress, life satisfaction, and mood states also showed improved scores during treatment with some of these benefits still being sustained after 12 weeks. This improvement in psychological distress and life satisfaction seems to indicate that acupuncture can satisfy the WHO definition of palliative care - that treatment should integrate the psychological and spiritual aspects of patient care.

The WHO definition also recommends that palliative care should ‘offer a support system to help the family cope during the patient’s illness and in their own bereavement’. It has been my experience that acupuncture treatment does offer a support system to help the family cope during the patient’s illness and in their own bereavement. This is because In St Josephs, therapies are offered to family members and their carers. It is often the case that the family member is also the carer which means they must go through the difficulty of seeing a loved one suffer but must also hold themselves together to look after their family member which includes things like dressing, preparing food, lifting them up and transporting them as well as other duties. The acupuncture session with the carer or family member provides a much needed quiet time and the opportunity to take some guilt-free ‘me-time’ for a change. Family members and carers may also have their own health problems and acupuncture provides the opportunity to address these problems and alleviate their own suffering. From treating family members and carers I have found that acupuncture is especially helpful for dealing with stress, anxiety and sleep problems. It also provides a reflective space – where they have some space to talk freely.

Enhance the Quality of Life

Aside from the fact that we are all going to die… sometime. When considering hospices, there is a misconception that patients in hospices are in an immediate terminal condition. In the U.K. this is not true. People may be referred to hospices to recover after having operations or undergoing treatments. The hospice can also serve as a drop in. Some patients will come in for a few weeks during the year and then return home. I have seen some patients return throughout the years. The hospice also has an outpatient service. St Joseph’s hospice organises many community groups for people to join as well as offering seated acupuncture groups, multi-bed sessions, free talks, tai chi lessons and even training courses to anyone who is interested. Acupuncture treatment is more than pin-sticking. Listening and counselling skills become essential and more developed. Often the session with a client becomes a much needed ‘time out’ for the patient – a chance to de-stress and release some tension.


Volunteering in a hospice I find that 80% of the patients I see have had or have various forms of cancer. There seems to be a universal fear of cancer. It can be a devastating disease. The advantage of treating many people with cancer is that the fear of treating patients with this disease can be reduced. Western science has shown us that cancer has multifactorial causes – a combination of different things. According to Cancer Research UK, Some of the factors that increase the chance of cancer are:

- Carcinogens - cancer causing substances like tobacco smoke. Also there are some indicators that diet may be a cause of cancer - particularly an excess of red or processed meat.

- Age seems to make us more susceptible. For example, a large percentage of the elderly patients in St Joseph’s hospice - particular in their 80s or 90s tend to suffer from certain types of cancer. This may indicate that resistance to disease is reduced and there is an increased susceptibility to cancer with increasing age.

- Some genetic factors, for example the BRCA1 and BRCA2 genes have a higher correlation with breast cancer.

- An impaired immune system – caused by AIDS, HIV or people who have had organ transplant and have to take drugs to suppress their immune systems

- Also some viruses may lead to certain cancers. For example, the human papilloma virus (HPV) is linked to cervical cancer. Hepatitis B & C has links to Liver cancer. The Epstein Barr virus has links to Lymphomas.

- Even some bacterial infections may lead to cancer. Research shows a connection between helicobacter pylori infection and stomach cancer.

- Environmental factors. For example, excess exposure to the sun may cause skin melanomas.

Cancer and Stagnant Qi

In TCM, cancer may be seen as an accumulation of phlegm or damp. There may also be Spleen and Stomach deficiency and the non-transforming and transporting of fluids and food. There is almost definitely a form of Liver Qi stagnation and I suspect the involvement of strong emotional factors either in the present or the past. As there are many types of cancer – it is worth looking to the area that is affected. For example, if it is lung cancer, consider firstly of course obvious environmental factors like whether the person is a long-term smoker. After that, it may be worth considering if there has been an excess of unresolved or buried grief in the past which is the emotion related to the Lung and metal element.

I have treated several women with breast cancer and have found that treating the Jueyin channel (Pericardium and Liver) seems to help open up and release past issues - hurt and anger that was especially strong before the cancer appeared. The Pericardium channel also flows through the breast area and is strongly influenced by emotions. From an oriental perspective and from my own experience, I feel that the concept of ‘Liver qi stagnation’ as used in TCM theory has some relevance. If applying a five elements point of view, emotional stress leads to excessive Liver energy which overacts on the Spleen and Stomach hindering its transforming functions and causing phlegm. Whichever way you look at it, cancer is an indicator of stagnant energy which has accumulated and solidified. It probably involves the disharmony of several organs and channels. The answer is never straightforward especially if there are other disease processes and disharmonies occurring.

With some of the people I have seen, there is some history of strong emotional stress which have been repressed. Sometimes, there is overwork in a stressful living and work environment. It can be a difficult childhood or bad relationship or bullying at school. Either way, the energy is heated up internally and then repressed causing an internal imbalance. Although, these are just my own thoughts, I have come to appreciate how important it is for us to remove stress and deep emotional hurts from ourselves in any way possible whether it is regular gym exercise, yoga, tai chi, adventure sports, shopping, drinking and talking openly with close friends, counselling, or even setting up illicit fight clubs in order to burn off all that stuck internal heat. It’s better out than in.

One final point that is important to stress. As an acupuncturist in the hospice, I see the primary role is in relieving suffering. Although I may suspect that some patients may hold strong emotional hurts within themselves, it does no good to bring these up or to try to open the patient up to this. To do so may cause more suffering. Stirring up a muddy pond only makes the pond worse until it settles down again – but the mud is still there. If you saw the hospice patient five or ten years earlier, maybe you could remove the mud, but in the hospice after they have a serious illness, it is no longer the time to remove it. Some things should be left well alone - until the next life perhaps - especially for the older patients and those in a more diseased state. However, for some of the younger patients, if they seem to want to open up more - indicated by crying during the treatment and by them openly volunteering information about their life, then the acupuncturist can become the facilitator to this process by letting them open up and let it out.

How Volunteering benefits Acupuncturists

A well structured training course, good teachers and apprenticeship (if you can find one) can set a practitioner well on his or her way to becoming a good acupuncturist. But the real lessons will always come from the patients themselves. In China and to a limited extent in Japan, it is possible to work in hospitals or pain clinics where you will be exposed to hundreds of patients and supervision. In the West, the majority of us will have to make ‘our bones’ in private practice, which in many ways is the ultimate challenge – because, unlike working in state hospitals or as salaried employees in private clinics, our income is directly correlated with our success in obtaining results with our patients. Although there are a lot of factors like how well we market and promote ourselves and our business, ultimately, the key factor is simple. If we get good results, patients come back and we earn money. If we get no results, patients don’t come back and we starve. With this motivation, we must become experienced and effective as quickly as possible and in order to achieve this level, regular patient practice will take us there. Basically the more people we see - the better acupuncturists we become. Volunteering enables you an opportunity to speed up your progress by giving you the chance to treat many people in a clinical hospital setting. However, it is not a complete substitute for private practice and practitioners must be wary of falling into the belief that it is. There will be important lessons, that volunteering cannot teach you.

Working for free

This was an issue that I had to go through. You are offering a professional service for free. Other healthcare professionals are paid, why shouldn’t complementary therapists? What is sometimes missed is that there is a trade off going on. It is not monetary. On the contrary it is far more valuable. You are providing a professional service and in return, the hospice is providing you with hands on practice, supplies, support and quick experience. There are other less obvious benefits. For example in the UK, in order to work with what are classed as ‘vulnerable’ adults or children – for example, people with serious illness or learning disabilities - you must undertake a police or ‘CRB’ check. The hospice should arrange for you to get one and once you get it, the certificate will last you for 3 years and will be looked upon favourably by other employees. A well organised hospice should also give many opportunities to develop other skills - for example to give talks, set up your own courses, give lessons or arrange any other activities. There will come the time when you will outgrow the hospice and decide to leave. Most desirable is that your own personal practice is becoming busier and you have no more time to volunteer. But, the benefit is that it is always there and you can always come back later on.

Patient Contact and Experience

In acupuncture, there is no substitute for hands on training. In Japan, the success of an acupuncturist is not based on how much money he has or how famous he is – but on how many patients he treats a week. Multi-bed clinics are not uncommon and some clinics run on a casual waiting room process where you just turn up without appointment and wait in the waiting room with other people until your turn is up. In the UK, acupuncture is not as well established and is generally more expensive so this kind of setup is quite rare.

Acupuncturists in the West must undergo training, and participate in follow up courses, seminars, workshops and read many acupuncture texts, but ultimately it is the patients that will be the greatest teachers. Think of every patient as a teacher with their own unique lesson. The more patients you see, the more teachers you have. One of the problems for all new acupuncturists is building up a practice. It is a process that can take years. It requires determination, perseverance and self-forgiveness. Some practitioners at the beginning may see only one patient a week. Gradually, that number will increase. The downside to this is that development is slower. This is one of the advantages of volunteering in a hospice for new practitioners. If the department is well developed, you may be able to see 4-8 patients a day, sometimes more – and many will have serious diseases. It can be a way of speeding up your skill development and can really help with hands on confidence.

Exposure to different people

As well as needing to get your hands on as many bodies as possible it is useful to get your hands on as many different types of people in order to develop your skills. The hospice will introduce you to a variety of people – men, women, young, middle aged, elderly, different ethnic groups, nationalities, religious backgrounds, different socio economic and professional backgrounds. You’ll notice that despite our outward differences, we all have one thing in common - we all can get sick.

You will notice that different people will often carry attitudes with them that reflect their life experiences. For example, a number of patients at Saint Joseph’s are older generation East-Enders. The elder generation were born during or after the war, and lived through periods of rationing and scarcity. They tend to have a no complaining keep it to yourself attitude and in the past may well have joked about the idea of having a massage or meditating. But in the hospice, they are curious and more open to it. Some of them will have never had any type of complementary therapy before let alone acupuncture, so it can be quite interesting to share the ‘deflowering’ process with them and provide their first acupuncture treatment - especially if they enjoy the treatment and it helps with their symptoms.

Technical skills

Pulse taking

I often take the pulse, but with some of the patients with severe diseases, I would rarely base a treatment based on the pulse. The reason is that pulses are not always clear. Regardless of the season, a patient may be thin and frail and yet the pulse will be rapid and bounding. Other times, a patient may appear healthy at first impression – they may have recovered from surgery and treatment and yet the pulse will be weak and thin. Generally, the rapid pulse and the weak pulse tend to be encountered a lot. The interaction of advanced illness, surgeries and cocktails of pharmaceutical drugs will affect the pulse in ways that were not predicted in the Huang Di Neijing. Drugs have different energetic qualities and the interaction of disease processes and surgery leads to various imbalances of Qi and blood stagnation and the Yin Yang balance in the body. Nonetheless, the hospice does provide the opportunity to feel many types of pulse qualities – albeit from people with severe disease.

Learning about strength of treatment.

Adapting treatment

Due to advanced disease states and medications, treatments need to be adapted to the patient’s condition. Sometimes treatments should be light – with few needles used and sometimes can be slightly heavier with more needles used. For some patients, I use a Chinese TCM approach and for other patients I use a more Japanese Meridian Therapy approach. At times, I feel that TCM needs to be toned down – as it can be a little too aggressive, with less needles used and Meridian therapy needs to be jacked up a level - as the focus is symptomatic treatment and I never know just how many times I will see that particular patient.

If patients are extra sensitive or have had a lot of hypodermic injections, then it may be a good idea to use thinner gauge needles and guide tube insertion. The less is more approach can be a consideration because many hospice patients are in a weak depleted state and you may not want to risk over stimulating or leaking qi. I met one acupuncturist who simply needled yintang on one patient to good effect because she deemed her condition was too weak for any further needling.

With some patients taking steroids, I prefer to keep needle insertion shallow and to not use too much needle manipulation. Steroids thin the skin and make it easier to bruise so deep massage techniques and strong needle stimulation should be limited.

But generally, I feel it is important to keep needling as painless as possible so I tend to favour the guide tube on the more sensitive patients. However, the hospice does provide an opportunity to practice and develop painless free handed needle technique but if a person is especially sensitive, than I will use the guide tube. The reason is that we want to create a positive association with acupuncture. We don’t want to give any more suffering. Most patients new to acupuncture assume needling is going to be painful. After all they have probably had numerous injections with hypodermic syringes so when acupuncture needling is painless, they are often pleasantly surprised and it helps them relax. In the Toyohari system of acupuncture, painful needling technique is said to disperse the qi. As many patients will be deficient in some way, we want to preserve the qi as much as possible.

Many patients are very immobile. Many have to lie down on their back and cannot move, which makes any form of back treatment difficult to perform. This is all the more worse when a patient has back pain – the area you want access to. Back pain can sometimes be exacerbated by lying on your back and not moving around as the energy stagnates. But with some patients it really is not possible to move around. Treating patients requires that you become inventive. Using distal points or extra channels becomes necessary.

In the Meridian therapy system of acupuncture, there is the principle of treating the healthy side of the body. This principle can be useful for patients with inaccessible body parts. For example, in one instance I treated a patient with a painful arm. Unfortunately she had bandaging over her arm and I could not treat the affected limb directly for local treatment. However, by following the principle that the channels are a mirror of each other, I treated the corresponding acupoints on her other arm. Of course, I had to explain why I was treating her opposite side.

Trying out and testing

The hospice setting is also a great place to try out new techniques that you may have been taught. For example, recently there has been some interest in a system of ear acupuncture called ‘Battlefield Acupuncture’. As the name implies it is a system of ear acupuncture designed for relieving pain presumably on the battlefield where the medical centre may be many miles away. This can be ideal for patients suffering severe pain from operations or caused by tumours in the hospice - especially when conventional painkillers are not effective.

It can be a great place to try out certain point protocols. For example, after re-reading Miriam Lee’s book – ‘Insights of a Senior Acupuncturist’, I went through a phase of trying out her standard points protocols –Liver 3, Lung 7, L.I.-4, L.I.-11, St-36 and Spleen-6, to test how effective it could be. The Mox Africa charity also had a moxa protocol for patients with tuberculosis, which involves a pattern of moxa cones around the region of BL-25 which I tried out in order to boost the immune system. Although, I had to use smokeless stick-on cones as typically most hospices will have smoke alarms – and it is highly advisable that you do not risk setting off the alarm as otherwise the entire hospice has to be evacuated, which won’t make you any friends.

As mentioned before, treating patients in a hospice requires a more flexible approach. Primarily I practice a form of meridian therapy with a great emphasis on meridian palpation as well as hara or abdominal diagnosis and evaluation of the back shu points. Unfortunately, often I may not have access to these areas. Many patients are relatively immobile. They cannot turn onto their fronts. Some may have had abdominal surgery making that area out of bounds. Some patients can be extremely sensitive especially if cancer is widespread so that even gentle palpation on the torso can cause severe pain. Sometimes, I consider myself fortunate if I am able to palpate the five phase points. You must work around all these limitations and more importantly, be light-hearted and reassure the patient. It is a great chance to sit and talk or hear about their life if they are willing to talk. Because even listening and joking becomes part of the treatment and sometimes can be more important that the acupuncture.

Other Clinical Observations

In the hospice you will encounter many kinds of clinical signs you would not often be able to see in private practice or at least not in such an extreme way. Muscle wastage can be common. If you palpate, certain muscle groups, some muscle areas may have a weak feel to them as though they are lacking qi and blood and can be an indicator of which channels are affected by the disease process. I have noticed the area around and inferior to SJ-14 to S.I.-10 can be an area prone to muscle wastage. There may be noticeable depressions or weak spots on key acupuncture points such as ST-36 or L.I.-4 and I have followed the Neijing recommendation that when depressions are found along the course of the yang channels – apply moxa. Oedema is a common occurrence and along with internal or external pain. Another finding, I have observed is the hard as a drum distended abdomen in patients with cancers of the intestines. There is a reference to the drum-like abdomen in the Neijing in respects to blood-letting treatment. Generally, the healthy abdomen should be relatively soft and pliant with some elasticity, a balance of top and below the naval, no tight or hard areas and with an even temperature – not with cold or hot patches. As the hara corresponds to the ‘dantian field’ and is effectively the power centre of the body, the health of the body can be reflected in the abdomen.

Adapting Acupuncture treatments to the Hospice Setting

Interdisciplinary working

Firstly you will work alongside other therapist of other disciplines. This is absolutely essential, because, it gives you a chance to learn new techniques or other ideas from other practitioners by exchanging treatments or attending socials. Being an acupuncturist in private practice can be very isolating and so being able to meet up with other practitioners can be beneficial. Secondly you will be working alongside conventional medicine practitioners – nurses, doctors as well as admin, cleaning, catering staff and other volunteers. You will find that having friendly relationships with all is essential. The cleaning staff will ensure the treatment rooms are cleaned and you have fresh towels and sheets. The receptionist and transport teams will be necessary for when patients are being brought in and need help to find your department. Doctors and nurses will refer patients to your therapy. At times, you may even treat nurses or other professional staff which is essential for better interdisciplinary relationships. Acupuncture is classed as a ‘complementary’ or ‘integrative therapy’. That means it complements conventional medicine – it works side by side. I don’t see any benefit to taking an antagonistic approach to conventional medicine as some practitioners do. I would prefer to see further integration and acceptance of complementary therapies especially acupuncture into mainstream medicine similar to the Chinese healthcare model, whereby hospitals would offer both conventional surgery and pharmaceutical drugs, but would also have herbal medicine departments and classical or TCM acupuncture and massage departments where patients would be referred to. And in this model, practitioners are salaried workers.

Advanced illness - death and realistic expectations

I have read and heard instances of acupuncturists who have been able to heal people completely of cancer. For example, there was an account of how the Japanese acupuncturist Kodo Fukushima healed himself of his own cancer with self treatment and after receiving regular treatments from a colleague and how later on he also had a patient come all the way from America to be treated by him for cancer. I heard also a story from a lady in London who told a compelling story of how a Vietnamese acupuncturist in England was able to clear her cancer. Such stories are not so common and have almost a mystical feel to them. The ability to heal advanced diseases like cancer is something for all of us to aspire to. Such acupuncturists clearly have powerful healing abilities but they also have a duty of care to humanity to pass on this healing knowledge to other acupuncturists.

In Veith’s translation of the Neijing, there is this passage –

“The sages did not treat those who were already ill, they instructed those who were not yet ill. To administer medicine to diseases which have already developed is comparable to the behaviour of those persons who begin to dig a well after they have become thirsty and of those who begin to cast weapons after they have already engaged in battle. Would these actions not be too late?”

This somewhat unforgiving statement emphasises the importance of preventative treatment and following a healthy balanced lifestyle in tune with nature (or the Tao). Many diseases take some time to develop and obvious symptoms may not show up until some time into the disease progression. This sums up very well – the problem of patients with advanced disease. By the time we see them, it may already be too late. The disease process is far more advanced and in many cases the best we can offer is symptomatic improvements such as reducing pain, digestive discomfort, and improving anxiety and stress or dealing with the side effects of pharmaceutical drugs like chemotherapy or post operative recovery. Perhaps, the best time would to have started treating these people at least one to five years before the cancer appeared. Of course it is easier to say this with hindsight and no guarantees that acupuncture can prevent cancer. However, acupuncture treatment and indeed many complementary therapies can enhance life, reduce stress, improve bodily function and boost the immune system and has the potential to be a good preventative measure. This is the reason why acupuncture needs be promoted more and to become more of an accepted mainstream medical system because one of acupuncture’s strengths is that it has the potential to keep a person in balanced health if taken frequently. However, proof of this is still dependent on more scientific studies being carried out.


We’re all in this together

As I mentioned before, practicing acupuncture in a hospice has changed my perspective on life. I realise that there is no difference between me, the patients, family members or carers or anyone else there. One day, I am treating a patient. Maybe sometime in the future, that patient will be me. One day, I am treating a family member who is suffering from stress as their partner is dying and I realise that it could be my mother or father or spouse that I could be treating. There is a certain awareness of the ‘fragility of life’ – of how life, dying and death are all so close together. It can be depressing, but it also makes me realise that we must try to fulfil our lives as much as possible in the time that we have.

And the final point - Why are complementary therapies effective? Healing is as much the body as the mind and the spirit. A patient can be treated with the best medicine, the best surgical procedures the best foods but if the spirit and the mind are still troubled; if the person has had enough and they don’t want to try any more, then healing is so much harder and suffering is worse. Acupuncture offers a chance to improve the physical state of the body by reducing pain, nausea, sickness and digestive function but it also improves the mind and the spirit by reducing stress and anxiety for the patients, the carers and their family members. And this is why the usage of complementary therapies is growing in palliative care in the UK.

The Future – Acupuncture and hospice care

It is my hope for the future, that complementary therapists and acupuncturists will become an integral part of hospital and hospice care and that the number of paid positions will increase in the NHS. For this to happen, it is important that complementary therapies continue to grow in popularity and become more in demand. It is vitally important that more scientific trials and research are carried out to prove their efficacy.

But there is a real humanistic reason why acupuncture should be incorporated more into hospice care:

Imagine that you are lying in a hospital bed in a weakened state and suffering from a serious disease. You have pain which keeps you awake at night and you’re feeling very tired. Your appetite is weak and you’re feeling a little distressed to see your weight dropping. You’ve got a catheter in your arm and you’re taking a cocktail of drugs which gives you an upset stomach. And even though all the nurses and doctors, cleaning and catering staff are friendly and caring and the environment is warm and comfortable, you’re still feeling anxious and depressed.

But then suddenly a friendly man or woman with a gentle manner comes into the room and after introducing themselves, offers you an acupuncture treatment. What have you got to lose? You say yes.

And then, as that person lays their warm hands on you and inserts a needle, a wave of relaxation comes over you and you are taken to another place. Suddenly you have a different awareness of your body and a feeling like a sense of tension has just been released - a tension that you never knew existed. Perhaps you feel excited that you are having something new, something mysterious for the first time in your life. Up to now, you've been poked and prodded, wheeled around, injected with drugs, had blood taken out or fluids pumped in. You’ve had your whole way of life turned around. Perhaps you feel relieved that someone is spending time with you for the express purpose of taking away your suffering.

You fall asleep during the treatment to be awoken and told that the needles have been removed and the treatment finished - but that feeling of relaxation remains with you for the rest of the day. A few hours after the treatment, the pain in your back has improved and you didn’t need to ask for that extra painkiller. The next morning, you also feel that your sleep was deeper - meaning you didn’t need to press the bell to ask the night nurse to assist you. And you may not realise it yet, but something else has been unlocked in you. That simple encounter of having needles put inside you has changed you. That is acupuncture for the hospice patient.