Issues in Implementation of Acupuncture in Depression Treatment
This post deals briefly with several issues that will arise in the context of implementing this protocol in research and/or practice. In particular we discuss the handling of acute symptoms that may arise during treatment and the integration of acupuncture with other treatment modalities for cases where clients may be receiving other treatments in addition to acupuncture.
ACUTE SYMPTOMS AND THE DELIVERY OF TREATMENT
When, in the context of working with a specific condition such as depression, an acute situation such as influenza or a cold arises, the practitioner may need to shift the strategy for that specific treatment session. The treatment of deeper imbalances may be contraindicated, especially in the case of active bacterial or viral infections (`external pernicious influences’), without addressing the presenting symptoms. If such an ailment has just begun and the client is not yet doing any-thing else to address the problem, it is advisable to tailor the treatment to address the presenting situation in the context of the ongoing treatment. It is often possible to modify the treatment while continuing with the main strategy, especially when the patient is already addressing the acute symptoms through other means (e.g. botanical remedies, homeopathy, or medications).
When the ‘acute’ symptoms are specific to depression — such as increased insomnia or anxiety, changes in appetite, digestive disturbances, or other psychiatric symptoms — the practitioner needs to review the symptoms using the diagnostic framework as outlined in previous post and modify the treatment to address these changes properly. In the event that the patient is reacting negatively to the initial strategy, care should be taken to assess whether the differentiation of signs and symptoms and the choice of treatment principles accurately match the patient’s symptom picture. A reevaluation may be indicated.
Nonpsychiatric Acute Symptoms That May Necessitate a Physician Referral
As in the course of any acupuncture treatment, clients with symptoms that require medical intervention should be promptly referred to a physician. Referral to a physician would be indicated by the presence of any of the following symptoms:
n acute abdominal symptoms
n cardiac conditions
n uncontrolled hypertension
n acute undiagnosed neurological changes
n suspected fracture or dislocation
n acute respiratory distress without previous history.
Clients should be informed before the start of treatment that the acupuncture treatment they will receive is designed to address their symptoms of depression, but that such treatment is not designed to replace the need for a physician should acute medical or psychiatric problems arise.
Acute Psychiatric Symptoms That May Necessitate a Referral
As in the case of acute medical symptoms, the emergence of acute psychiatric symptoms such as psychotic symptoms or suicidal thoughts calls for prompt referral to a mental health specialist.
Psychotic symptoms reflect serious problems with reality testing. Psychotic individuals perceive and think about the world in ways that virtually everyone else would consider ‘crazy’. Psychotic symptoms most commonly include false beliefs (delusions) and false perceptions (hallucinations). Examples of false beliefs can range from excessive guilt that is delusional (e.g. the belief that the depression is a punish-ment for sins) to severely delusional beliefs (e.g. aliens are inserting depressive thoughts into the person’s head). Hallucinations most often involve hearing voices that others would not hear. Such voices typically say negative things about a depressed person, or provide a negative running commentary on the depressed person’s actions.
Mood-congruent psychotic symptoms are delusions or hallucinations of which the content is consistent with typical depressive themes of guilt, inadequacy, death, or deserved punishment. Although many depressed patients report guilt as a symptom, a belief that the depressive illness is punishment for past mistakes is usually characterized as a psychotic feature. It is possible to overlook mood-congruent delusions or hallucinations because they can sometimes be understood in the context of depression; however, when any psychotic symptoms are present, a referral to a licenced mental health professional, such as a psychiatrist or psychologist, is necessary.
Acute Suicidal Symptoms
Clients with depression often have some suicidal thoughts. Although many times these thoughts are fleeting and do not pose a significant danger, the risk of suicide attempt for depressed clients is very real and should be assessed frequently. The practitioner needs routinely to evaluate suicidal thoughts along with other symptoms of depression. This evaluation can be done in a simple, direct, matter-of-fact manner that covers the range of symptoms described below.
Acupuncturists treating depression should become familiar and comfortable with assessing risk of suicide. Moreover, they should become familiar with the state laws that pertain to duty to report and with the limits of clients’ confidentiality, and become knowledgeable about referral sources in cases of emergency. It is a good idea to identify a mental health provider that can provide consultation when treating mental health conditions in general, and depression in particular. The risk for depression may be conceptualized in terms of the increasingly serious levels of thoughts, plan, means, and intent.
The assessment of suicide risk progresses along the distinctions shown in Box 8.1. The most natural way to begin inquiry about suicidality is to tie it in with the client’s own choice of words describing his or her depression, be it sadness, emptiness, hopelessness, or any other description. The provider can inquire: When persons feel [put the client’s descriptors here], they may think about dying or even killing themselves. Have you?’ (Endicott & Spitzer 1978). If the patient’s response is quick or defensive, the provider can attempt to put the patient at ease by explaining that these thoughts may come and go. If the client had thoughts of death, the provider’s next task is to establish whether these were passive or active thoughts, and to determine whether instruments of suicide are readily available. The third step is to consider whether the patient has ever considered a specific method of suicide and whether or not the client intends to follow through with the suicidal ideas — and why or why not. If the client had considered a specific plan in the past, it is then necessary to inquire about each specific plan, how often it has been considered, and whether the client has ever translated these thoughts into actions, however tentative.
Assessing the risk of suicide in depressed clients
Thoughts Suicidal thoughts can range from passive thoughts, such as `I wish I wouldn’t wake up’, to more active thoughts, such as ‘I wish I were dead’ or ‘The world would be better off if I just killed myself, to even more seriously active thoughts, such as `I want to kill myself’.Active thoughts typically pose a greater risk than passive thoughts.
Plan Without a plan on how suicide will be carried out, thoughts alone do not pose an imminent risk (although they may still pose a longer-term risk).The seriousness of the plan can range from a vague plan (e.g.`Maybe I’d jump off something’) to something more concrete (e.g.`I’d probably jump from a cliff) to the very specific (`rd asphyxiate myself in the car in the garage). Greater risk is associated with a more specific plan.
Means Even if a client has some level of a plan, the risk is realized only
if the person has (or can obtain) the means to carry out the plan. If a client indicates a plan (e.g. using a gun), it is important to assess whether the client possesses or could easily obtain the means to carry out the plan (e.g. the practitioner should ask: `Do you have access to, or plan to get, a gun?’). Having the means to carry out a plan increases the risk.
Intent Even given a plan and means, some individuals will have no intent to commit suicide, citing reasons such as ‘I haven’t given up all hope yee or ‘My children need me or `My family would be devastated’ or `les against my religious beliefs’. Intent can be conceptualized in three increasingly risky categories:
I. Intent not to commit suicide
- 2. Lack of intent not to commit suicide (i.e. some uncertainty)
- 3. Intent to commit suicide.
Behaviors Some suicidal behaviors can be preparatory, such as making sure that ones affairs are all in order (e.g. writing a will) or distributing precious belongings to others.These activities may indicate increased risk.
It is also important to keep in mind that some clients’ suicidal thoughts and intentions can change rather rapidly. For this reason, all clients should have a list of crisis numbers that they may call. Clients are especially likely to increase their suicidal thoughts and risk if they are under the influence of alcohol. Alcohol, in addition to being a central nervous system depressant, impairs judgement and may increase impulsivity, thereby increasing the risk for suicide. Intoxication by drugs (prescription or illegal) can also increase risk by impairing judgement, by depressing central nervous system function, or (depending on the drug) by serving as a fatal means for attempting suicide. Other important factors that increase the risk are a previous suicide attempt and living alone (or having no one else at home when the suicidal impulses occur). It is important, however, to realize that, even in absence of these risk factors, suicide risk should be taken very seriously. Moreover, even when the client’s depressive episode is ‘situational’, appearing to be an understandable reaction to a serious life condition, the patient is no less likely to die by suicide than a patient in an episode of ‘endogenous’ etiology (Fawcett et al 1990).
The practitioner is advised to consult with a mental health professional whenever any doubt about the safety of the client arises. Even if a client fails to demonstrate the risk factors listed above, but the practitioner has an intuitive feeling that risk may be present, a consultation is in order. If a client has passive suicidal thoughts and a clear plan not to commit suicide, no consultation is necessary, although it is still encouraged if the practitioner feels that any risk may exist. If more serious thoughts or intent are mentioned, a mental health professional should be contacted immediately — while the client is still in the acupuncturist’s office.
The Practitioner-Patient Relationship
In clinical research studies, such as those in which this protocol has been implemented, the practitioner—patient relationship creates unique, and at times difficult, challenges. Central to the concept of randomized control trials (RCTs) is the need to isolate the active components from the nonspecific treatment effects that result from the practitioner—patient relationship. Initially, acupuncture practitioners are skeptical and critical of this attempt, citing that the heart of Chinese Medicine resides in the practitioner’s ability to reach the spirit of the patient (Larre & Rochat de la Vallee 1991b). Any clinician knows, through experience and training, that this relationship is at the core of the process of healing, and that it is unrealistic — if not impossible — to assess the clinical effectiveness of a treatment outside of this relationship. There is, however, an invaluable opportunity in research settings to let go of our desire to heal the patient using whatever strategies are available, permitting us to do our best by focusing on the medicine itself, and not on other factors such as the relationship. Within the constraints of a study, when performing an assessment or providing a treatment, we are required to ‘stay calm and quiet without special desire’ (Larre & Rochat de la Vallée 1991b, p. 16), to do our best, and to let go. It forces us to get out of the way, and to allow the qi to flow naturally on its own, without our expectations mediating the process.
Some implementations of this protocol in research settings may involve a single practitioner conducting assessment and treatment, whereas others (e.g. Allen et al 1998) may involve the use of a separate practitioner for assessment and a separate treatment provider. Assessors and treatment providers must equally be present in themselves when coming in contact with a study participant; precisely because the work of each relies on the work of the other as a team, no one holds an exclusive relationship with the patient. Both have the opportunity to `… let the life of the spirit grow … and bring this to every part of their work’ (Larre & Rochat de la Vallée 1991b, p. 15) without expecting the comfort that this relationship usually affords practitioners in clinical settings; they must therefore rely exclusively on the medicine itself to `align the will, the purpose, and the spirit of the patient’ (Larre Rochat de la Vallée 1991b). The controlled nature of the treatment provided within a research protocol forces the practitioner to ‘needle as if looking into a deep abyss, taking care not to fall’ (Su Wen, Ch. 54; cited in Larre & Rochat de la Vallee 1991a), to ‘walk on the edge of the mystery of life’ with an authentic heart, without fear, and yet cautiously not to fall (Larre & Rochat de la Vallee 1991b, p. 48).
An acupuncturist provides a reference point for the patient to understand his or her signs and symptoms within a bodymind continuum — a framework for validating each person’s personal experience of distress or disease. The acupuncturist does not aim to replace the role of a psychotherapist or counselor, but rather strives to become a teacher, an educator, a compass. In the setting of clinical practice, once the initial reframing has been presented and some guidelines for lifestyle and diet modifications have been offered (see Schnyer Flaws 1998), the acupuncturist hopes to step aside and allow the process of healing to unfold, while continuing to offer his or her presence as guidance and support.
Nevertheless, it is not uncommon (especially when treating psychiatric or emotional conditions) for the patient to attempt to engage the acupuncturist in the role of therapist or counselor. For the acupuncture practitioner, it can be difficult at times not to rely heavily on counseling skills as a way of ‘making a signal to reach the spirit of the patient’ (Larre & Rochat de la Vallee 1991b, p. 17). Particularly when getting to an impasse in the course of treatment, it is essential for the acupuncturist to delve deeply into the foundations of the medicine in order to reevaluate and further understand the nature of the patient’s imbalance. Awakening the will to heal in a patient (Seem 1985) is the key to unfolding the healing process; as expressed by Larre & Rochat de la Vallée (1991b, p. 17): ‘Reestablishing the balance always depends on the spirit … Without the cooperation of the patient inside, you cannot do your work’. The beauty of acupuncture as a treatment, however, resides precisely in its ability to entice the patient’s innate potential to heal without the use of words; the language of acupuncture is universal, allowing us to touch the life of a patient even when they cannot talk.
When conducting a controlled treatment study, such as the one for which this manual was originally designed, both assessors and treat-ment providers were advised to refrain from engaging at a counseling level in any way. All disclosures were viewed as pieces of information that assisted in assessing the nature of the patients’ distress, both in terms of their signs and symptoms, and in terms of themselves as unique human beings. Practitioners were asked to refrain from giving advice or suggestions on how to deal with the situation, including dietary and lifestyle changes. In the case of disclosure that suggested suicidal risk, the acupuncturist was advised to follow the guidelines given above. In the research setting, where it is critical to examine the impact of acupuncture per se, and not the participants’ reframing of their situation based on discussions with the acupunturist, it is essential that the acupuncturist be warm and present without engaging in reframing or the delivery of advice. In order that participants were able ultimately to benefit from the reframing that is typically part of the acupuncture experience, educational workshops were offered to all study participants after the conclusion of the study, to present the framework and to offer recommendations for maintenance and prevention based on the principles of Chinese Medicine.
ACUPUNCTURE AS AN ADJUNCT TO OTHER TREATMENT MODALITIES
Whereas the efficacy of acupuncture as a treatment for depression is still under study, research has clearly demonstrated that antidepressant medications and specific empirically validated psychotherapies are effective treatments for depression. It is therefore ethically indicated that, when a treatment does not result in symptom reduction after an adequate trial, consultation and referrals to mental health specialists are indicated. A good practitioner knows the limit of his or her competence and should be well informed about good consultation and referral sources.
Although a good relationship between the acupuncturist and the patient is very important for the treatment as a whole, psychotherapy and counseling are outside the scope of training and license of most acupuncturists. During the course of acupuncture treatment, some patients might disclose information about difficult issues with which they are dealing. This is a good time gently to suggest adding other treatment modalities, and to provide specific referrals. At present there are no data on the interaction between acupuncture and other treatments for depression. It is not known whether the combination of acupuncture and psychotherapy or acupuncture and antidepressant medications will have a complementary effect that will improve outcome or, conversely, whether the combination treat-ment will dilute the efficacy of each of its components. It is therefore of utmost importance that treatment providers maintain close communication whenever a patient receives a combination of therapies for depression.
When this manual is used outside a research setting, the acupuncturist is advised, when possible, to work in conjunction with a psychotherapist or counselor. By involving the expertise of a mental healthcare professional, the acupuncturist is allowed to do what acupuncturists do best: engage the qi of the patient. This is not to say that the acupuncturist should avoid developing a therapeutic relation-ship with the patient that includes, among other skills, an active and caring listening; but rather, it is advised that the acupuncturist should learn to discern when an interdisciplinary effort will better serve the patient. When treating a patient who is also working with a psychotherapist, it may be useful to discuss and coordinate treatment strategies with the therapist. In working with other professionals, it is essential to obtain a written release of information from clients, authorizing the sharing of information between practitioners. Clients have a reasonable expectation of confidentiality (with exceptions in cases of clients posing a danger to self or others), and a release of information is therefore required. Such a release should be signed and dated by the client and should specifically state with whom informa-tion may be shared, specifically what information may be shared, and the timeframe covered by the release.
The Treatment Team
In our experience an interdisciplinary effort is best in the care and treatment of people experiencing depression. The treatment team in our studies included acupuncturists, psychotherapists, psychiatrists, and support staff. Study participants were first screened (to determine whether they met inclusion criteria for the study) in a phone interview conducted by psychology students trained specifically for this purpose. People who passed this preliminary screening were assessed by a clinical psychologist who conducted a structured clinical assess-ment using two widely used instruments, the Structured Clinical Interview for the DSM (SCID) to arrive at the differential diagnosis, and the Hamilton Rating Scale for Depression (HRSD) to obtain a quantitative index of depressive severity. The next step involved a medical screen to rule out medical conditions that may cause depressive symptoms (i.e. hypothyroidism), or unreported or underreported drug use. Following these screenings, participants were assigned to an acupuncture assessor for a Chinese Medicine evaluation, and for the design of an acupuncture treatment plan. The participants were then assigned to an acupuncture treatment provider who performed the treatments in his or her clinical setting. Ongoing monitoring of the care of the participants was then the responsibility of the team comprised of the acupuncture assessor, clinical psychologists, psychology graduate students, and a consulting physician. To assure the quality of assessments, regular supervision meetings took place among all assessors, both acupuncturist and psychologist assessors. Additionally, the core team met regularly to consult about clients, to discuss clinical issues including suicidality, and to make reference to the clinical context.