ACUPERCEPTIONS PROJECT: USING QUALITATIVE METHODS TO UNDERSTAND ACUPUNCTURE PRACTICE Claire M Cassidy, PhD, Dipl Ac,

1. ACUPERCEPTIONS PROJECT: USING QUALITATIVE METHODS TO UNDERSTAND ACUPUNCTURE PRACTICE Claire M Cassidy, PhD, Dipl Ac, LAc Bethesda Maryland USA

2. GOALS OF THE ACUPERCEPTIONS PROJECT • TO GIVE VOICE TO ACUPUNCTURE PRACTITIONERS • …TO HELP PROVIDE A STRONG FOUNDATION FOR CLINICAL AND SURVEY RESEARCH.

3. TWO KINDS OF SCIENTIFIC RESEARCH QUANTITATIVE o describes distributions and frequencies QUALITATIVE o examines meaning and reasoning

4. We know that distributions and frequencies are useful…we also know that they don’t deal with experiential reality. In fact, what is actually going on is often difficult to measure in numerical ways. Instead, it must be shown.

5. SHOWN IN: • WORDS • METAPHORS • IMAGES • MODELS OF REALITY • That people use to express themselves, make sense of their lives, and (for example) describe their health practices.

6. USING QUALITATIVE METHODS • The ‘product’ is word-based, thematic… • Samples are ‘small’ • Samples are ‘representative’ • Reporting employs quotations, often • misinterpreted as ‘anecdotes’ • QUOTATIONS FROM A SCIENTIFICALLY COLLECTED AND ANALYZED QUALITATIVE STUDY ARE ‘DATA POINTS’ THAT FUNCTION SIMILARLY TO STATISTICAL DATA POINTS.

7. RCT OTHER QUANTITATIVE RESEARCH METHODS QUALITATIVE RESEARCH PROVIDES A STRONG FOUNDATION

8. ACUPERCEPTIONS PROJECT • Depth interviews w/ American acupuncturists • What is ordinary practice like? • Do acupuncturists practice according • to the explanatory model of • Oriental medicine? • 3. How are their own cultural values • expressed & revealed?

9. ACUPERCEPTIONS SAMPLE • N = 20 AMERICAN-TRAINED ‘ORDINARY’ • ACUPUNCTURISTS • FROM MULTIPLE U.S. STATES & SCHOOLS • BOTH SEXES • 3 OR MORE YEARS OF CLINICAL • EXPERIENCE • WILLING TO PARTICIPATE IN PROJECT • TALKATIVE, THOUGHTFUL

10. GATHERING QUALITATIVE DATA: • INTERVIEW TECHNIQUE: • ASK OPEN-ENDED QUESTIONS • NO ANSWER IS IMPLIED • THE RESPONDENT CAN ANSWER AS S/HE • PLEASES • THE RESEARCHER MAY BE SURPRISED BY • RESULTING DATA.

11. SUPPOSE IT IS A NEW DAY. HOW DO YOU PREPARE YOURSELF FOR WORK?

12. I read notes. Two times a day I chant for my patients… ID One of the first things I do is pray to the Grandmothers & Grandfathers to do things in a good way and help me see clearly… GL My standard would be some modicum of neatness and order within the treatment room and in my own self, a sense of creating a welcoming space. Then I will…just sit…and call to my best person… KT Me being very present to my own energy…and the openness of my own heart. I guess integrity would be the word of the day for me.KD I meditate, do yoga, take a walk, eat a healthy breakfast—then I’m ready to work with others. NC I just go to work! If there are…difficult cases, I do research ahead of time. LL

13. ANALYZING QUALITATIVE DATA • IDENTIFY AND MARK THEMES • THEME: INTENTIONALITY • ‘patient-centered’ tonality • spiritual-emotional self-preparation to deliver care • Do these ideas fit an Oriental Medicine medical model? • Do these ideas fit a ‘western’ medical model?

14. PATIENT-CENTERED CARE • EMPHASIZES HORIZONTAL • PATIENT-PRACTITIONER RELATIONSHIP • ‘I’m here for patients. That’s a very conscious thought.’ • EP • IS CHARACTERISTIC OF A RELATIONAL • or HOLISTIC MEDICAL MODEL

15. SPIRITUAL-EMOTIONAL SELF- PREPARATION TO DELIVER MEDICAL CARE IS IT ORDINARILY A PART OF ORIENTAL MEDICINE THEORY or PRACTICE? Sun Si Miao (581-682 AD)  --I will strive to live in harmony with nature and teach my patients to do the same --I will above all else hold and nurture a deep feeling of compassion --I will keep an open heart.

16. GENERALLY, DOES ACUPUNCTURE PRACTICE IN THE U.S. FIT WELL WITH THE ORIENTAL MEDICAL MODEL? QI FLOWS… “In humans, in one day and one night, there are 13,500 respirations, [during which the contents of] the vessels move 50 circuits around the body….” Nan Jing 1 (Flaws 1999)

17. DOES PRACTICE FLOW? IS PRACTICE DYNAMIC? EMERGENT? ACTIVE? …OR IS IT FORMULAIC?

18. WHAT PRACTITIONERS SAY ABOUT QI • SENSING QI • SENSING THE NEEDLE AND ACUPOINT • ESTABLISHING RELATIONSHIP • DELIVERING TREATMENT

19. WHAT PRACTITIONERS SAY ABOUT QI/ENERGY • I am always working with energy, but you burn yourself out if • you use your own energy. You must channel it from other • sources…Heaven, Earth…the Universe is filled with energy • and we are working to get energy aligned and balanced • instead of in chaos, or being stagnant and stuck. NC • After 23 years of practice, I don’t think it’s possible to deliver • acupuncture without transmitting energy. DE

20. SENSING QI I’m an average pulse taker…use the tongue for reinforcement. But … my forte is…listening with everything that I have and…hearing the gap in what one is saying and what one is living. …that’s where the juice is. It’s where the Qi is, right? Qi is energy and structure. WM My hands feel as if they are turning into ears. I would like…when touching with intention, to hear what’s inside of where the hands are. I just have to wait…[and then] I’ll touch some part…and there’ll be a little ‘aha!’ that will tell me where to go. KT For me, the pulses always were my best way in…the place where I really got down to business and made the treatment choice. I saw myself as an artist…sort of plucking the right strings that created the harmonious music. DE

21. SENSING THE NEEDLE AND THE ACUPOINT I don’t move on to the next point until I know I’ve gotten the Qi at that point. [What do you feel?] Kind of—kind of—like a pressure, or a light feedback in the needle. AB When I feel like my hands are touching energy it gives me like, a chill up and down my spine. And with needles I get the same thing. …I can actually ignite an acupuncture point with my finger; I don’t need a needle to do it. … If I’m using a needle, I feel something from the needle go into my fingers, like a little charge. GP

22. ESTABLISHING A RELATIONSHIP [Acupuncture is] this ancient process of using needles… to affect the vitality of another human being in a way that helps that person become more in a homeostatic state, or more who they’re meant to be. Basically all that an acupuncturist is trying to do is help the person show up in the best possible well-being. And sometimes that means living with their pain. It may be that what they’re carrying can’t really be gotten away, but can be lifted, or heartened, or made more bearable. … What I would like to do best is to be so present to someone when they come in that I get out of the way, and…understand that they are already whole, and that all I am doing is providing a space for them finding their own wholeness. KT

23. ESTABLISHING A RELATIONSHIP HAS TWO • ASPECTS • FAMILIAR: establishing a relationship so that • treatment can be offered…all medical systems • do this • DISTINCTIVE BECAUSE SPECIFIC TO A ‘FLOW’ • MODEL • Recognizing how energy flows among • practitioner, patient, and universe…and • encouraging a healing flow.

24. DELIVERING TREATMENT IN A FLOW MODEL • DIAGNOSIS AND TREATMENT are not • sequential, BUT LINKED IN AN ACTIVE FEEDBACK LOOP which allows the • practitioner to judge if treatment is being • effective in the moment. • The PATIENT OFTEN ACTIVELY PARTICIPATES IN TREATMENT…and can feel if treatment is • being effective.

25. ACTIVE FEEDBACK LOOP AND FLOW MODEL If I’m working with pain, I want a response right away. So this morning I was working with shoulder pain. I went to the shoulder, then put two needles in lower opposite leg, move shoulder and there was [not much] change, so I put another needle down in the leg and go up and move the shoulder again. I went back down to the leg, put another needle in, went back to the shoulder and the pain was gone. So I said ‘OK, I got what I wanted here.’ Then I put one needle in her hand on the affected arm, as a guide. As a guide for the energy to move up from leg and down arm to hand. … I want to be judging what I do in the moment. KD

26. INVOLVING THE PATIENT IN THE TREATMENT • SOME STYLES EXPECT THIS • Kiiko Matsumoto: e.g., treating Oketsu • PRACTITIONERS ASSESS THEIR PATIENTS • My goal is to meet people where they’re at…then • the treatment is just right for them. Some • are sensitive, so I keep needles at the surface. Some • people have difficulty accessing their energy…so for • them Qi is hard to obtain. So for them I needle • deeply, vigorously,… KD • By asking the patient’s body, you can always • get the right answer. DE

27. EXAMPLE OF A PATIENT SPONTANEOUSLY EXPRESSING HIS EXPERIENCE “When you touch something, something else reverberates. There’s a connecting process going on….. [This is] interactive—you’re doing, I’m responding, and the two create something bigger than you and I.” JS

28. IN SUM: PRACTITIONERS DO PRACTICE AS IF THE FLOW OF QI MATTERS

29. THE EMERGENT MEDICAL MODEL • High contact, patient-centered practice • Whole body-person focus • Patients modeled as responsive and • participatory, not passive • Practitioners skilled at sensing Qi • Diagnosis and treatment linked • in a feedback loop • Healing or transformative goal

30. HOW CAN WE PUT SUCH INFORMATION TO WORK? WE CAN USE IT TO STRENGTHEN QUANTITATIVE RESEARCH Scientific research must meet quality criteria. An essential one in cross-cultural research is called model fit validity. MODEL FIT VALIDITY DEMANDS THAT THE METHODS AND TECHNIQUES USED TO STUDY SOMETHING BE APPROPRIATE TO THE TASK.

31. MODEL FIT VALIDTY • Would you assess cricket by the rules of polo? • Do you judge the quality of a sweet cake by asking if it was properly grilled? • Will you get a clear answer about the competence of acupuncture by assessing it according to the rules appropriate to the biomedical model?

32. The reason for practicing acupuncture, and for researching it, is to improve the quality of patients’ lives. …However, when it comes to research, the patients’ perspective and the subjective experience is often removed…. When this happens…research cannot answer the question of whether and how acupuncture addresses people’s health needs and improves their lives.” Paterson and Schnyer 2007:77 A …review of acupuncture research reports showed that most acupuncture research [has] been undertaken to prove the therapeutic efficacy of acupuncture, rather than generate knowledge that could be used to inform clinical decision-making. Ryan 2006: 19

33. QUALITATIVE RESEARCH CAN HELP IMPROVE THE MODEL FIT VALIDITY OF CLINICAL TRIALS… BY REFLECTING THE ACTUAL PRACTICE OF ACUPUNCTURE. “The first principle…is that the clinical evaluation should respect the integrity of the medicine.” MacPherson et al 2002

34. THE RCT--RANDOMIZED PLACEBO- CONTROLLED CLINICAL TRIAL--IS A USEFUL DESIGN FOR ASSESSING SPECIFIC ISOLABLE INTERVENTIONS, SUCH AS A DRUG, IN A LOW-CONTACT MEDICAL PRACTICE PATTERN • It aims to minimize variables, e.g., focus on one disease • and one test drug in a large sample randomly • assigned for same care within their group. • Practitioner, patient, and ‘attitudes’ are purposefully • removed as far as possible from the test.

35. IF WE ACCEPT THE ‘QI FLOW’ MODEL AS CHARACTERIZING • ORDINARY ACUPUNCTURE PRACTICE, THE RCT IS NOT A GOOD DESIGN FOR ACUPUNCTURE. • Needling is complex—not specific, not isolable • Acupuncture is a high-contact patient-centered practice • Skilled practitioners know if Qi is activated; patients often • do too, or are encouraged to notice. • Care is not ‘formulaic’ because • treatment is individualized • diagnosis and treatment on-going in feedback loop • focus of care is not on ‘cure’, but on achieving • dynamic physiological balance or homeodynamis • “Sham” cannot work if the whole body/universe is • involved in care, and energy is always transmitted.

36. “In 23 years of practice, I don’t think it’s possible to deliver acupuncture without transmitting energy.” DE “I can actually ignite an acupuncture point with my finger. I don’t need a needle to do it”. GP “Acupuncture isn’t a needle; it’s an environment.” PM

37. RCT OTHER QUANTITATIVE RESEARCH METHODS QUALITATIVE RESEARCH PROVIDES A STRONG FOUNDATION

38. WHERE CAN WE GO FROM HERE? An in-depth study of 20 ‘ordinary’ acupuncturists is a good beginning, but cannot represent all acupuncturists. What is needed now is to use qualitative data to design a survey instrument with high model fit validity that can be standardized and used to assess a large sample of acupuncturists quantitatively. Would you like to be involved in such a project?

39. OTHER QUALITATIVE QUESTIONS TO EXPLORE • How does the theory of AOM get translated into the clinic? • Is acupuncture holistic as practiced—does it treat the • Whole mind-body-spirit? Is this idea traditional? • ...a ‘western’ add-on? • Do acupuncturists follow the energy of the patient? Are • they aware of their own energy and its intersection • with that of the patients? How can this be studied? • What do practitioners aim to deliver, and what do patients • glean from acucare? • What do practitioners think they are doing and why? • What do practitioners experience themselves as doing? • Do different styles result in different clinical results? • What are favored metaphors? How do these matter? • Are there significant national/regional differences in practice?

40. REFERENCES Cassidy, C M 2004What Does It Mean To Practice an Energy Medicine? J Altern Complement Med 10(1): 79- 83. Cassidy, C M in press 2 chapters on “What does it mean to Practice an energy Medicine?” in D Major and M Micozzi, Energy Medicine East and West, Elsevier Publ MacPherson, et al, 2002, The clinical evaluation of traditional East Asian systems of medicine. ClinAcup Orient Med 3(1): 16-19. Paterson, C and R Schnyer 2007 Measuring patient-centered outcomes. Chapter 5 in: MacPherson, H et al,Acupuncture Research, strategies for establishing an evidence base, Churchill-Livingstone (Elsevier), Edinburgh, pp 77-93.  Ryan, J D 2006 The Use of Evidence in Acupuncture Clinical Practice. Aust J Acup and Chin Med 1(1):19-23.

41. THANK YOU! REACH ME AT: CLAIRE M CASSIDY, PHD, DIPL AC, LAC WINDPATH@CASSIDY.NET INFO@ACUHEALINGWORKS.COM

44. MEDICAL META-PARADIGMS PROCESSUAL/RELATIONAL REDUCTIONISTIC Focus on flow, movement, VERBS Focus on states of being, NOUNS Whole body focus Physical body focus Imbalance Disease People vary; individualize care; Diseases vary, people similar; minimize interventive protocols interventive protocols normative Diagnosis & treatment integrated Diagnosis precedes treatment Whole person responds “Placebo Effect” problematic Transformative Curative

46. “Physical symptoms are read narratively, contextually, and interpreted in cultural systems. A physician’s diagnosis is a plot summary of a socially constructed pathophysiological sequence of events.” Kathryn Montgomery How Doctors Think: Clinical Judgment and the Practice of Medicine