NADA Conference

May 1993.

Michael 0. Smith, M.D., D.Ac.

Director, Substance Abuse Division

(Lincoln Hospital)

Acupuncture is becoming to be accepted as a treatment that relieves stress, craving, and withdrawal symptoms in substance abuse patients. The same ear acupuncture point formula has been shown to be effective with many drugs including heroin1, cocaine, alcohol, and stimulants. This formula has also been used to provide stress relief in general patients, treat MICA patients, and reduce hospitalization rates in chronic psychiatric patients. Since acupuncture is not dependent on a specific drug diagnosis we can avoid the pressurized encounters about recent drug use.

First of all, we should emphasize that substance abuse acupuncture is provided in group setting. The new acupuncture patient is immediately introduced to a calm and supportive group process. Patients describe acupuncture as a unique kind of balancing experience. “I was relaxed but alert. “I was able to relax without losing control.” Patients who are depressed or tired say that they feel more energetic. This encouraging and balancing group experience becomes a critically important basis for the entire substance abuse treatment process. The perception that a person can be relaxed and alert is rather unusual in Western culture. We are used to associating relaxation with somewhat lazy or spacey behavior. We are used to associating alertness with a certain degree of anxiety. The combination of relaxation and alertness seems contradictory. In contrast, the relaxed and alert state is basic to the concept of health in all Asian culture.

We describe acupuncture as a foundation for psychosocial recovery. In the beginning of treatment, building a proper foundation is very important. If we are building on a weak “sandy” personality, work on the foundation may take many months or years before it is strong enough to support any significant psychosocial treatment efforts. However, once a foundation is established, then the focus of treatment should shift away from acupuncture toward building a “house” of psychosocial recovery on that foundation. When one of our patients testified at city council hearings, she described how important it was to attend daily NA meetings and barely mentioned acupuncture. For a patient with three months sobriety this emphasis was appropriate. Of course, during her first 2 weeks in our program, she was quite angry, ambivalent and was only able to relate to the acupuncture component of the program.

Acupuncture sets the stage for conventional substance abuse treatment. In fact, acupuncture is such an effective treatment process, those primary aspects of treatment and recovery can be transformed by including acupuncture in a program. We will refer to some of the most basic issues in the substance abuse field in order to describe this potentially transforming effect of acupuncture.

Acupuncture is a Non-Verbal Treatment

Acupuncture is a non-verbal type of therapy. Words and verbal relationships are not necessary components of this treatment. We do not mean that the therapist should not talk with the patient. However, verbal interactions can be quite flexible so that a patient who does not feel like talking can be accommodated easily and naturally. Alternatively, acupuncture will be just as effective even when the patient lies to us.

The most difficult paradox in the substance abuse field is the common reality that addicted persons usually deny their need for help. Such patients do not say anything helpful to the treatment process. Nevertheless resistant patients often find themselves in a treatment setting due to referral or other pressures. Using acupuncture can bypass much of the verbal denial and resistance that otherwise limit retention of new and relapsed patients. Substance abusers are frequently ambivalent. Acupuncture helps us reach the needy part of their psyche that wants help. Acupuncture can reduce stress and craving so that patients gradually become more ready to participate in the treatment process.

Substance abuse patients often cannot tolerate intense interpersonal relationships. Using the conventional one to one approach often creates a brittle therapeutic connection. It is easily broken by events and stress. Patients have difficulty trusting a counselor’s words when they can hardly trust themselves. Even after confiding to a counselor during an intake session, a patient may feel frightened and confused about expanding that relationship. Many of their concerns are so complex and troublesome that talking honestly about their lives could de difficult in the best of circumstances. The ambivalence typical of substance abusers makes it easy to develop misunderstandings and miscommunications. All of these factors support the usefulness of a non-verbal technique during early and critical relapse, phases of treatment.

A woman six months pregnant entered our clinic several years ago. She said, “I can’t tell you much about myself because my husband is out in the street with a baseball bat...he’ll hit me in my knees if I say too much.” We provided an emergency acupuncture treatment and conducted a simplified intake interview. Two weeks later this patient told us, “This is my husband, Herman; he doesn’t have a drug problem, but he is nervous, can you help him?” Both of them received acupuncture that day. The woman needed non-verbal access to treatment because of real physical danger. Overprotective spouses often forcefully oppose all social contacts outside the marriage. This patient was protected because there was no premature verbal bonding that would have threatened the husband. If fact, the whole process was so supportive that the husband was able to trust his wife and seek help by himself. Like many fearful people, he was literally unable to make any verbal approach on his own.

One mistake in treatment interaction should be highlighted. We should avoid “re-verbalizing” the acupuncture interaction. Anxiety and depression are common indications for acupuncture. However, it is a mistake to require that the patient admit to anxiety or depression in order to qualify for acupuncture. Substance abusers who have significant anxiety or depression will usually not admit these feelings. In fact, they will avoid anyone who asks such questions. At a later stage of sobriety and recovery, talking about these feelings will be important, but at an early stage of treatment verbalizing these feelings can lead to drop out. Likewise, it is not productive to ask patients why they have missed a previous acupuncture session. Use the advantage that acupuncture will be effective even if we don’t know the issues involved.

Many substance abuse clients are obsessed with guilt and self—deprecation. They must try to learn not to link every withdrawal symptom and craving with psychological issues. Even though substance abuse is an overall psycho—social matter, it is not helpful to psychologize every step of the detoxification process. When a detoxing client starts to cry, teach them not to ask or worry out the “cause” of the tears. Clients should expect to face the psychosocial problems gradually as they gain strength and after the basic cleansing and balancing process.

Treatment programs, without acupuncture are compelled to screen for patients who are able to talk readily with authority figures. Many verbally needy patients become quite dependent on the program and quite involved with numerous staff members. Such patients can be the focus of many conferences, but they are often too needy to remain drug-free outside the hospital. In contrast, acupuncture assisted intake can retain patients who are relatively more independent, assertive, and hostile. Noisy, troublesome patients who are frustrated with the world and with themselves may be persons who have the energy to sustain a drug free lifestyle.

Acupuncture Supports Self -Responsibility

One of the striking characteristics of the acupuncture treatment setting is that each patient seems comfortable in their own space. It is quite unusual to see so many people apparently comfortable with their own thoughts. One patient explained, “I sat and thought about things in a slow way like I did when I was ten years old.” Acupuncture treatment causes the perception of various relaxing bodily processes. Patients gradually gain confidence that their mind and body can function is a more balanced, autonomous manner. A hopeful process is developed on a private, personal basis. We are laying a foundation for the development of increasing self-awareness and self-responsibility.

Self-responsibility is one of the most overlooked aspects of substance abuse recovery. In treatment we emphasize the patient’s need for structure and a support system. Patients often become dependent on the therapeutic setting. In most conventional programs a lack of structure and authority will lead to negative behavior and chaos. Nevertheless the reality is that patients must rely on themselves to a considerable degree at all stages of treatment and recovery.

We are confronted with a paradox that is similar to that of parenting adolescents. Adolescence is nature’s version of the passage from dependency to relatively mature independence. How can the parenting authority encourage healthy independence from that same authority? How can therapeutic authorities encourage the development of a healthy self-reliance?

The use of acupuncture sets a foundation so that patients can have more autonomy in developing their own plan of treatment. A calmer, less resentful atmosphere is created. The tolerant, self-validating process helps patients find their level and type of involvement in a productive manner. Patients must choose to talk sincerely with their counselor just as they must choose to avoid temptation and return to the program each day. These choices may fluctuate widely and be mistaken at times, but such independence is the only path toward growing up. When a program properly encourages structure but ignores the patient’s own independent efforts, these actions undermine future success. Acupuncture creates a better atmosphere so that treatment staff can spend their energies helping patients make choices: rather than being fatigued by trying to impose authority on a resistant clientele.

Validating the Present

Substance abuse is about trading present experience for past and future realities. Patients hang onto the present, because the past and future seem to offer nothing but pain. Unfortunately our treatment efforts focus on assessment of past activities and planning for the future. Patients are obsessed by present sensations and problems. They often feel alienated and resentful that we cannot focus on their immediate needs. Acupuncture is one of the only ways that treatment staff can respond to a patient’s immediate needs. We can meet the patient in the present time reality-validating their needs and providing substantial relief. Once a comfortable day to day reality support is established, we can approach past and future issues with a better alliance with the patient.

The nature of recovery from addiction is that patients often have quickly changing needs for crisis relief and wellness treatment. Many persons in recovery have relatively high levels of “wellness” functioning. However, a crisis of craving or past associations may re-appear in a moment’s notice. Conventional treatment settings have trouble coping with such intense and confusing behavioral swings. Often merely the fear of a possible crisis can sabotage clinical progress.

Acupuncture provides either crisis or wellness treatment using the same ear point formula. The non-verbal, present time aspect of the treatment makes it easy to respond to a patient in whatever stage of crisis or denial that might exist. Time related contradictions are much easier to resolve using acupuncture.

The Paradox of Touch Love

Substance abusers have trouble with discipline. They need order in their lives but cannot develop internal structure. The end result is chaos or submission to a sadistic process. Substance abusers have trouble liking themselves, they are depressed and de- personalized, and cannot .accept good things. The end result is self-destruction and adherence to a masochistic life Style. AA refers to this paradox as the need for “tough love”. The ability to like one lays the foundation for internal discipline. Most substance abusers have been victims as well as victimizers. There is usually a long brutal history before today’s apparent self-centered chaos.

Acupuncture provides significant advantage in meeting the paradoxical requirement of tough love. Verbal interpersonal intensity is reduced. Patients feel that their immediate needs and their urges toward independence have been satisfied. A tolerant, flexible atmosphere exists. Acupuncture delivered in a consistent and caring manner provides the basis for the “love” side of the equation. The foundation for discipline has been set.

At Lincoln we use a system of daily toxicology as the basis for discipline. One can also use a point system that credits attendance and other items relating to compliance. The most effective systems used clear and simple data which are generated by the patient’s own behavior. Following the principles of behavior modification, this data should be frequently measured and success oriented.

Frequent urine testing provides an objective non-personalized measure of success that can be accepted equally by all parties. In this system, the counselor is the “good cop” and urine machine is the “bad cop.” The counseling process can be totally separated from the process of judgment and evaluation. According to this approach, clients will not feel a need to be friendly to their counselor in order to gain a positive evaluation. The computer printout showing a series of drug-free urines is the only documentation they will need to gain a favorable report for the court.

The counseling process at Lincoln emphasizes non-judgmental, non-invasive, supportive approach. The firm challenge of sobriety is established, but the treatment relationship is quite flexible and open ended. The therapy program cannot “hold a grudge” and put increasing pressure on the patients for previous failures to respond to treatment. Pressure and concern must be appropriate to the quality of today’s struggle and not reflect the residue of the past. The use of acupuncture makes this non-judgmental process much easier.

Our clinical staff makes a primary alliance with the criminal justice referral agency as well as with the client. This process of dual alliance with the client and the disciplinary agency is the basis for successful work in Employee Assistance Programs. The process is not at all contradictory as long as the primary focus is on sobriety and increasing the client’s integrity which can be the common goal of all parties. The Lincoln clients are very accepting of this “dual alliance” strategy. There is a lack of contradictory messages, a lack of excuses, and an abundance of interest in their daily struggle to be drug-free.

Substance abusers are the kind of people who respect the prosecuting attorney more than their own defense attorney. There is a brittle need for authority and an inability to accept kindness. Our patients are particularly intolerant to the ambivalence often created by the adversary courtroom system. Their own ambivalence is amplified by their perception of governmental ambivalence.

In our program we try to use every part of the treatment system to support the healthy internalization of discipline and authority. Discipline is based on the patient’s diary of toxicology results. Discipline is separated from the difficulties of interpersonal relationships. Within this context of discipline, leniency by the judicial authority becomes more acceptable and leads to constructive not escapist behavior. This cooperative relationship between leniency and discipline is essential to the survival of our patients and indeed for the financial survival of the judicial system itself.

Review of Beneficial characteristics of Integrated Program

Let us review the beneficial characteristics of an acupuncture-based treatment program which integrates group and individual counseling, frequent toxicology, and Narcotic Anonymous is an outpatient setting.

Barrier-free access — A wide range of patients can be accepted for the initial, stage of treatment because there is no verbal motivational requirement. Also, acupuncture is effective f or most drugs and wide range of psychological states. A low threshold, easily staffed program can be established for new patients. Ambivalent, streetwise patients find the acupuncture setting almost impossible to manipulate. The setting is so soothing and self-protective that even extremely anti-social people are able to fit in. Frequent attendance by relatively relaxed intake patients permits the gradual completion of assessment on a more accurate basis. Patients can be evaluated and triaged according to their daily response to treatment and testing rather than merely on the basis of an interview.

Retention — The tolerant, non-verbal aspect of acupuncture facilitates retention during periods when the patient would otherwise be ambivalent, fearful, or resentful within a more intense verbal interpersonal setting. Patients are often willing to give a positive toxicology and thereby show respect for the standards of the overall treatment process. Nevertheless those same patients may be unable or willing to share their crisis and failures, verbally until they have time to reach more solid ground. In: the acupuncture setting, time is on our side.

Outpatient continuum — Easy access and better retention encourage the outpatient management of difficult patients without the need for additional drugs or services. Any chronic relapsing condition should be managed primarily on an outpatient basis. Inpatient high intensity interventions only have value if they are followed by stable outpatient performance. The relatively high retention of difficult patients in an outpatient acupuncture setting lets us select the time for hospitalization more precisely and appropriately. Encouraging autonomy and self-responsibility should be essential aspects of any outpatient continuum. Such a program also facilitates primary health care management for AIDS, tuberculosis, and SDT’s. Issues such as parenting, responses to social crisis, education, and job training can be approached almost only through an outpatient continuum.

Court-related agency referrals — These patients often come to us in a total denial or with a basic conflict with the referring agency. The non-verbal aspect of acupuncture allows the intake staff to get beyond these protests and offer acupuncture for “stress relief,” instead of forcing the issue. Otherwise we are in the unfortunate position of having to value a piece of paper from the referring agency more than the patient’s own statements. This is not a good way to begin an assessment or treatment relationship. ‘Using acupuncture we are able to wait until the patient feels more comfortable and less threatened so they can admit their addiction and ask for help.

We are often asked how to persuade resistant patients to try acupuncture. Remember that addicts are intellectually conservative and behaviorally radical. Therefore you should avoid one to one “thoughtful” discussion. Our counselors show new patients the acupuncture treatment room and give only a basic suggestion that the treatment will reduce stress and craving. Stressed, needy patients are attracted by the calm atmosphere there and are welcomed by the more experienced patients. In new situations, acupuncture should be introduced to a group of patients so that a few patients might volunteer for treatment and other more skeptical patients can watch the procedure and learn to accept it.

Linkage with 12 step programs — Acupuncture has many characteristics in common with 12 step programs such as IA and NA. It uses group process in a tolerant, supportive, present time oriented manner. Participation is independent of diagnosis and level of recovery. Each interaction can be either a crisis or wellness treatment depending on the immediate needs of the participant. Both approaches are simple, repetitive, nurturing and conveniently available. The emphasis on self-responsibility is common to both systems.

In practice acupuncture provides an excellent foundation for 12 step recovery. Patients seem less fearful and more receptive when they first enter the meetings. The traditional advice: “listen to learn and learn to listen” fits our model well. There is a deeper, more sensitive quality to the NA or IA meetings. Acupuncture reduces “white knuckle sobriety” considerably. There is less guarding and a greater ability to support each other warmly.

MICA patients — Acupuncture has an obvious advantage in the treatment of MICA patients, because it can be used for a wide variety of substance abuse and psychiatric problems. MICA patients have particular difficulty with bonding and verbal relationships. Acupuncture facilitates the required lenient supportive process; but, at the same time, it provides an acute anti-craving treatment which is also necessary. The use of acupuncture can resolve the contradictory needs of MICA patients.

Retention of women Patients — These patients are often trapped in destructive and exploitative relationships. Frequently they have become the victimizer as well as a victim. Female substance abusers therefore will have special difficulty with any therapeutic relationship and the maintenance of a consistent self-esteem. Acupuncture has been a frequent component of successful programs serving women patients.

Trauma survivor support — A consistently tolerant and non-confrontational approach prepares the way to establish a trauma survivor support service for patients at an early sobriety stage of recovery. The acupuncture point formula used for substance abuse is also specific f or the kind of emotional and muscular guarding associated with early sexual trauma. These patients will suffer intermittent crises and experience profound challenges to their physical and spiritual identity. All of their relationships will be strained and transformed. Acupuncture is a very appropriate adjunct to trauma survivors support work.

Acupuncture Protects the Counselor’s Role

Virtually all of the advantages of an acupuncture based treatment system can be described as enhancing and protecting the counseling therapeutic relationship. As one colleague put it, “the patients remember what I tell them now.” ordinarily counselors have provided discipline as well as peer support. They must judge a patients progress as well as being a sympathetic listener. Using acupuncture we can develop treatment protocols which can reduce contradictory pressures on clinical staff. The reduction in verbal intensity and confrontation allow each staff member to take a consistently caring and supportive position. He or she is able to earn the patient’s trust.

The Treatment of Empty Fire

In Chinese medicine, the lack of calm inner tone is a person is described as a condition of empty fire (xu huo), because the heat of aggressiveness burns out of control when the calm inner tone is lost.

It is easy to be confused by the false fire that many addicts present and to conclude that the main goal should be sedation of excess fire or escape from its consuming attachment. The hostile paranoid, hustling climate of our inner city communities exemplify an energy depleted condition with false fire burning out of control. Our patients seek greater power and control over their lives. The empty fire condition represents the illusion of power. It is an illusion that leads to more desperate chemical abuse and senseless violence.

Imagine a foster child that has just been adopted into a new family. When the new parent gives a hug, the child is as stiff as a board. We all know what the problem is. The child is frightened and empty inside. This is another example of “empty fire.” How long will it take for the situation to change? Maybe a week, maybe a month, maybe a year, maybe this child will always be consumed by fear and emptiness. No one can know how much nurturing that this small child will require before the affection can be accepted. Treatment of empty fire involves a step by step feeding of the inner person. Acupuncture helps create this soup kitchen for the spirit.