Editor's Note: These first two letters refer to Bob Flaws' article, "The 50-Minute Hour" in the October 2007 issue.

On the Frequency of Acupuncture Treatment

I read with interest Bob Flaws' recent piece on the frequency of acupuncture treatment. It occurs to me that the frequency of treatment necessary to be effective will differ greatly, given the perspective from which one views treatment and the skills of the practitioner. I have practiced full time for 21 years and have found once-per-week intervals, with decreasing frequency after six to 10 treatments, to suffice for treating most conditions effectively.

When Mr. Flaws suggests that once-a-week treatment in the West reflects a historical accident, I couldn't agree more. Another word for that accident is "evolution." Chinese medicine has been able to develop in the West outside the constraints of a totalitarian, atheistic dictatorship. While China is still struggling to establish functional capitalism and isn't anywhere near what we would recognize as democracy (1860), we in the West are at the leading edge and have moved onward to holistic (1970) and integral (1990) value systems and beyond.

If the goal at hand is the quickest possible reduction of symptomatology, with no involvement from the patient, then Mr. Flaws' prescription of three times a week might be relevant. Of course, when Mr. Flaws went to China, the average citizen had few or no lifestyle options, probably didn't introspect much, would have found it nearly impossible to view themselves as individuals apart from a whole, and certainly wouldn't have felt free to express their thoughts and feelings on nearly anything of substance in a medical clinic run by the state. This is probably still true today. The Chinese still aren't close to 1967, let alone the "sensitive self" 1970s.

From the perspective of a clinical practice that emphasizes depth and seeks to engage the hearts and minds of patients as the source of healing, once-a-week treatment works perfectly well. The master practitioner has the wisdom to see the patients' unlimited and undreamt-of potential, and the care and skill to help that manifest to ever higher degrees of integration over a lifetime. At that level of subtlety, eventual treatment intervals as infrequent as every six weeks or more can still be quite effective.

Of course, when dealing with serious degenerative conditions, an increased frequency of treatment is often indicated. However, frequency is dictated as much by the patient's condition as by the core value system of the practitioner and the cultural context in which treatment is occurring. In this regard, there is no set rule.

Lonny S. Jarrett, LAc, FNAAOM
Via e-mail

Acupuncture and the 50-Minute Hour, Revisited

I agree to a certain extent with Bob Flaws' comments regarding once-a-week acupuncture treatment. I believe that his arguments make sense within the context and philosophical underpinnings of (for want of a better term) a TCM approach; however, they do not represent the perspective of the full spectrum of acupuncture styles and modalities.

Many Europeans who first explored acupuncture 30 years or more ago, went to Taiwan, Korea and Japan. What they brought back did not conform to the mainland Chinese approach. I do not know if once-a-week treatment is found in any of these areas, but even if it is a Western innovation, it is one that makes a lot of sense in the context of Five Element approach and the Western situation. And within the Five Element tradition it is a well-supported format to follow. I would be surprised if this is a purely Western development.

Within a Five Element approach, there are differing philosophical underpinnings, relative to TCM. Five Element stresses: a "least action" approach (finer and fewer needles, manipulated less forcefully and more superficially); and balancing the individual's energies, rather than explaining and/or addressing the manifest ailment directly.

The Five Element approach can be seen as rooted more in the Nan Jing. But the philosophical basis of it is also in the Su Wen. The Su Wen talks of nì (opposition, upstream, counterflow) and cóng (correspondence, downstream, flow) treatment. These principles are clearly the basis of "attack" and "support," and tonification and sedation, but actually have broader implications. To borrow from Western psychology, they suggest "non-directive" and "directive" treatment intent. Five Element is clearly more non-directive in intent.

With Five Element treatment, the emphasis on balancing and least action and non-directive treatment intent leads to different expectations from the mainstream of TCM. Patients are told not to anticipate immediate results. If this does happen, it is considered a bonus. Often, a treatment response will occur in 24 to 48 hours. This will sometimes include apparent symptom aggravation, followed by an improvement that is usually sustained as long as other factors (such as ongoing lifestyle issues or external factors) do not counteract this. The person who tries to catch up on months or years of yard work because their back is finally better, is a typical example of how nothing is set in stone. It is an intrinsic idea of Five Element that you cannot "have your cake and eat it, too." Immediate relief and long-term resolution may not be wholly compatible outcomes. Worsely stated this more categorically than I do, but it is arguable that he was often being rhetorical in his teachings because he saw how hard it was for people to follow an approach that was more idealistic.

Five Element practitioners often place relatively greater emphasis on the pulses in the evaluation of treatment frequency. The Five Element practitioner is looking for an improvement in the three cardinal qualities of the pulse: you shen (spirit), you wei (stomach/qi), you ben (root). This is called the "CF response" (but is not usually articulated in the language used here). Usually, this will not hold at first for a full week, and I have sometimes seen a patient twice in the first week. Very soon, the response process requires a certain time to run its course, and the pulses begin to "hold." Sometimes, after as little as four sessions or as many as 10 (with some variation beyond these), the pulses begin to hold, such that the patient is moved to treatment every two weeks, and again at a certain point, to every three weeks and so on (with increasing unpredictability).

One important exception that I have found in my own practice is the condition called Aggressive Energy by Worsely, that I would call "pathogenic heat in the yin organs" (I have to thank Bob Flaws for his explanations of "Yin Fire Theory" and "Law of Similar Transformation" for helping me understand this concept). I have found that a week may be too long to wait, as this often needs several sessions to clear. Greater success is achieved by clearing this on a daily basis for several sessions.

Five Element is clearly not normally addressing the acute or virulent. I would be first to agree that it should not be the first choice of approach in emergency or epidemic situations. However, it is ideally suited for the kind of persistent or chronic problems that are most common in our Western practices. Indeed (paradoxically), it often helps with many patients that the texts are beyond acupuncture; for example, when a person is severely depleted, especially in yin and blood. It is easy to see these as situations that cannot be forced, where more intensive acupuncture treatment would be contra-indicated.

It is important that we recognize that acupuncture is not one homogenous entity, and we must make sure that in our discussions we recognize that each of us may have a limited viewpoint based upon our particular approach and experience.

Andrew Prescott, BAc (UK), LAc
Via e-mail

"Wealth Seems to Be a Real Stumbling Block"

I enjoyed reading Felice Dunas' article, "Money Is Qi Is Money" (September 2007) on the business aspect of acupuncture. Wealth seems to be a real stumbling block for those engaged in our profession, and it's good to read an article by someone who grasps the business side of our profession. I'm sure you will get some very interesting mail regarding that piece.

From the medical side, we are blessed to have tools that are based historically on shamanism and shrouded in mystery, but also have access to lab testing in our modern clinical setting that can profile a patient's organic acid cycle. Needles alone will not raise public perception of who we are, but we, as physicians capable of evaluating our patients at the esoteric - as well as laboratory level - will.

Karen L. Rowe, AP, DOM
Via e-mail

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