The classic Chinese text ‘Inner Classic of Huang Di’, which is believed to lay the foundations for acupuncture, highlighted two critical principles that are of the same importance in ensuring the effectiveness of acupuncture—zhishen and deqi. According to TCM, the acupuncturist, when performing needling procedure, is required to closely attend to the emotional state of the patient. This principle is called zhishen in TCM, which aims to ‘gaining full control over the patient's spirit’. Although zhishen is so highly valued, at least no less than deqi that is well documented, by TCM as to be a prerequisite for the effectiveness of acupuncture, a lack of attention has been given to the psychological factors involved in clinical provision of acupuncture in both experimental and clinical research on acupuncture. That this principle of zhishen can hardly be found in the substantial amount of acupuncture literature just demonstrates the extent to which the importance of the psychosocial context underlying acupuncture has been overlooked.
Acupuncture is closely surrounded by a characteristic psychosocial context that essentially differentiates acupuncture from any other medical treatment in providing the patient with the unique cognitive and affective experience with this therapy. These cognitive and affective processes induced in the patient while receiving treatment include enhanced expectations and beliefs, appropriate levels of fear and anxiety and highly focused and spatially directed attention.
Elevated Expectations and Beliefs
Culture can profoundly shape medicine through shaping patients’ beliefs (4
). Embedded in unique beliefs and rituals and purported to be an ancient and natural remedy, acupuncture is especially good at inducing beliefs and expectations in patients. Theory basis underlying acupuncture is unrelated to modern science (1
), this philosophical divergence from modern science in explaining patterns and rhyme of life can always allow patients to have elevated beliefs and expectations on this therapy. Another contributing factor to higher expectations on the effectiveness of acupuncture is that most patients, for example with chronic pain conditions, turn to acupuncture only after failed experience with conventional therapies. In addition, the invasive nature of acupuncture and the sophisticated manner in which it is applied can to a great extent contribute to patients’ beliefs and expectations on the effectiveness of acupuncture. Moreover, daily practice of acupuncture treatment features comprehensive and intimate acupuncturist-patient relationship—the whole course of a particular treatment session is actually that of the mutual interaction between the acupuncturist and the patient working together as partners, which can remarkably lead to the patient's enhanced beliefs and expectations on the effectiveness of acupuncture (5
Despite the concern that laying emphasis on the importance of the role of psychological factors in the effectiveness of acupuncture will, as believed, fundamentally undermine the scientific basis of acupuncture, what actually occurs in daily practice of acupuncture is undeniable. Clinical experience shows that beliefs and expectations play a fundamental role in the effectiveness of acupuncture and the magnitude of effects of acupuncture is determined by how and to what extent the patient is involved in this psychosocial context: acupuncture seems to be more effective in the patient with stronger beliefs and higher expectations. This observation proved to be true in a recent study of acupuncture on pain that reported that patient's beliefs and expectations (determined by the perceived assignment to real acupuncture or a placebo) had a greater impact on treatment outcomes than did the actual treatment itself (6
). What underscores the importance of perceived assignment is beyond any doubt the power of patients’ beliefs and expectations. Given the important role of expectations and beliefs in the effectiveness of acupuncture, a prior study has suggested that the patient informed consent process be explained explicitly in any published report of studies assessing the effectiveness of acupuncture, because how patients are informed about the study intervention to a great extent determines the levels of their beliefs and expectations, hence treatment outcome (2
Patients’ positive beliefs and expectations are always taken for granted when they consider taking a therapy, as is the case for acupuncture. Though we never have a patient who is ‘forced’ to receive acupuncture, in daily practice of acupuncture we do occasionally treat patients who are precarious, or even suspicious, about the effectiveness of acupuncture. For these patients, acupuncture is not only ineffective but also it may cause some unexpected and clinically unexplainable effects (always unexplainable sensations at site of needling or along meridians depending on individual patients) that are always identified as adverse effects. In some patients, these effects can even last for a period of time and cannot be discontinued until the patient has been convinced that acupuncture makes no harm. It appears that patients’ beliefs and expectations determine the direction of acupuncture effects—positive beliefs and expectations induce therapeutic effects, and conversely, negative beliefs and expectations generate negative effects.
The key role of beliefs and expectations in the effectiveness of acupuncture is naturally neglected, due to their inherent involvement in clinical provision of acupuncture—acupuncture as a procedural treatment is rarely, if ever, administrated in the absence of patients’ benefit expectations. A simple but meaningful question is, nevertheless, what the outcome of needle insertion is when the patient is not made aware that it is being carried out—hidden administration of acupuncture free of any psychological contamination. Imaginably, hidden administration of acupuncture, if ethically possible, can by no means be associated with a therapeutic procedure. Inserting needles into the body, if it occurs elsewhere other than in the setting of clinical provision of acupuncture, can be nothing more than a painful injury to the body. It is the patient's beliefs and expectations that transform needle insertion—an otherwise painful injury to the body—into a therapeutic procedure.
Highly Focused and Spatially Directed Attention Ensured by Appropriate Levels of Fear and Anxiety
Acupuncture is, at any rate, an invasive procedure, and its procedural administration may look far more invasive than what it virtually is, for individuals cannot fail to know from their experience of daily life that invasive needle insertion into the body will cause inevitable pain and most likely blood shedding. In addition, to achieve the desired deqi
sensations, needle manipulations will probably cause unbearable unpleasant or painful sensations. This perceived invasiveness of needle insertion, especially when the needle in being manipulated, causes inevitable fear and anxiety in the patient while receiving treatment. It varies little across individual patients that they are subject to unconditional fear and anxiety in the anticipation and experience of needle insertion. However, during clinical provision of acupuncture, patients’ fear and anxiety are not always salient but manifest mainly as highly focused attention, because they are greatly obscured by patients’ benefit expectations. As it was suggested in a prior study that greater levels of fear and anxiety contributed to heightened somatic focus (7
). Due to this invasiveness induced fear and anxiety, any patient, even if having much experience with acupuncture, cannot fail to focus his or her attention exclusively on the local sites where needles are inserted. That is a prerequisite for the effectiveness of acupuncture: needle administration systematically directs the patient's attention to the specific areas (acupoints) selected according to TCM in different medical conditions, and these regularly located acupoints, when stimulated by different needle manipulations, can be predictive of where and what treatment effects will occur.
Fear and anxiety induced by the invasive nature of acupuncture can make great impacts on patients’ mind. A wide range of adverse effects occurring before or during needle administration can be attributable to patients’ fear and anxiety including, just list a few, severe nausea, actual fainting, severe dizziness, heavy sweating and vomiting (8
). It should be acknowledged, however, that effective acupuncture treatment necessitates an appropriate level of fear and anxiety—undue fear and anxiety will most likely lead to various adverse effects rather than therapeutic effects. It is the patient's enhanced beliefs and benefit expectations on acupuncture that remarkably balance the negative aspects of fear and anxiety and prevent them from amounting to an unduly high level. Benefit expectations and beliefs, even in the presence of fear and anxiety, ensure that he or she is enjoying and experiencing treatment happily and comfortably. Thus at the core of the psychosocial context surrounding acupuncture are the patient's enhanced beliefs and expectations. In addition to the intimate acupuncturist–patient relationship, acupuncture just depends on its invasiveness, fearful in appearance but minimum in essence, to achieve a maximum involvement of the patient successfully and necessarily. Acupuncture can only work after these psychological factors as outlined above have been brought into full play. Thus this psychosocial context is definitely an integral part of acupuncture.