lördag 10 mars 2012

Treating traumatic stress and PTSD with ear acupuncture and acupuncture in Chinese medicine; a look at NADA and the basics of PTSD

Sometimes in life things happen that are too far beyond what we should have to witness or go through. But these things still happen. Sometimes it affects us only in the short run, but sometimes it stays in the long run too: problems or memories we can´t quite forget as much as we want. This is an area where good chinese medicine acupuncture or ear acupuncture can help a lot.

Different levels of stress can be treated and relieved both through chinese medicine acupuncture and through the newer version of ear acupuncture that has spread in the West. In this article we are going to look at how they do this, what different levels of stress they can treat – job stress, traumatic stress and post-traumatic stress syndrome (PTSD) – and also a bit about how classical chinese medicine views this kind of treatment with shen, the mind, and how it links to our physical health. We have made this a tandem post translated into Swedish, since one of our projects is with ear acupuncture for abused women. Om du vill läsa om hur man kan behandla traumatisk stress och PTSD med akupunktur och öronakupunktur, så har du länken till vår blogpost här: http://acupractitioner21.blogspot.com/2012/03/oronakupunktur-och-akupunktur-for-att.html

I have treated women who have been beaten and abused, social services staff, and ambulance (EMT) staff fresh in from a bad shift. In all these cases I have seen how much the treatment can do to help them release and become free from the experiences they have been through. It let them find peace right now in the short run, but also to release the trauma out of their body and mind so it didn´t coagulate and affect their health – and life – in the long run.

There are moments that are made up of too much stuff for them to lived at the time they occur.”
John Le Carré, Tinker Tailor Soldier Spy

Traumatic stress, acute stress and PTSD

Stress is a normal facet of life – and the techniques mentioned here are also regularly used just to dissolve and release a week´s stress from work for many patients. But sometimes our life includes shocks, disasters, crime, or other events that are so strong that they imprint more deeply in us. Some examples of this kind of level of stress are (but not limited to): rape, physical, sexual or mental abuse, threat, bullying, severe illness, natural disaster, sexual abuse as a child, witnessing the death or injury of others etc.

All stress reactions to these kinds of events are natural for us. We should react to them. Problems only arise if the reactions stay with us too much and start shaping our everyday life.
A short-term reaction to events like these is called acute stress reaction. We can simply use the text from Wikipedia here. If the reaction stays, it then starts to become diagnosed as posttraumatic stress disorder: (http://en.wikipedia.org/wiki/Posttraumatic_stress_disorder). For those interested, there is a selected reading list for sufferers and practitioners alike at the end of this post.

Posttraumatic stress disorder is classified as an anxiety disorder, characterized by aversive anxiety-related experiences, behaviours, and physiological responses that develop after exposure to a psychologically traumatic event (sometimes months after). Its features persist for longer than 30 days, which distinguishes it from the briefer acute stress disorder. These persisting posttraumatic stress symptoms cause significant disruptions of one or more important ares of life function. It has three sub-forms: acute, chronic and delayed-onset.”

This must have involved both a) loss of ”physical integrity”, or risk of serious injury or death, to self or others, and b) response to the event that involved intense fear, horror, or helplessness (or in children, the response must involve disorganized or agitated behaviour). (The DSM IV-R criterion differs substantially from the previous DSM III-R stressor criterion, which specificed the traumatic event should be of a type that would cause ”significant symptoms of distress in almost everyone,” and that the event was ”outside the range of usual human experience.”

Typical symptoms of PTSD are flashbacks or intrusive thoughts of what happened during the event; avoidance of things related to the event or similar situations; nightmares; phobias, feeling of guilt, hypervigilance (constantly on guard), distrust that sometimes can grow into paranoia, exaggerated startle response (jumping or reacting very strongly to movements or sounds), anger, depression, numbing of reaction or feelings to other things in life, etc. Not all sufferers have all of these. For a more complete list, recommended is checking on the web or David Kinchin´s book that we talk about below.

Some people have lighter PTSD, some more severe; either way, it makes daily life dominated by an event or events. For those who have PTSD really bad, they live in hell every day, often without having keys to get out.

If the person develops PTSD, this can be of three different kinds: primary, secondary and tertiary PTSD.
  Primary PTSD is for the person it happens to. Secondary is for family of victims, who often either see things happen themselves or have to deal too much with a relative or loved one who suffers from PTSD. Tertiary PTSD can happen to witnesses of the event. Versions of these three can also happen to professionals; police, social services, aid workers, medical staff etc., the carers who might not be directly involved but face traumatized people too much, or who listen a lot to descriptions of traumatic events and see it on the people telling them until they get it too.

There are two main ways of getting PTSD. The first is the obvious one of a specific event happening, and then maybe leaving more long-term problems instead of leaving the person. The second is what used to be called PDSD: Prolonged Duress Stress Disorder, which is PTSD, just PTSD built up through smaller events but over a long time. This might be from someone living under threat, or for the social worker who seems to finally hear that one story too many – it wasn´t that story, it was many years of stories before. Often there is a seemingly smaller event that triggers the landslide of older things that were building up before. This version can often get reactions like ”Why do you react so badly to this? It´s not that bad, is it?”.

The amount of people who get PTSD after traumatic events vary a bit depending on what the event was – rape victims, 35-50%, shipwreck survivors, 75%, sexual abuse victims 50%, while the figures for bullying have been revised quite a lot over the last few years, as bullying for both children and adults can create PTSD too. (see Kinchin, 2001).

Formal diagnosis of acute stress reaction and PTSD is usually up to a psychiatrist. There are a lot of politics involved in how the diagnostic model is designed (see Ronson´s The Psychopath Test (2012) for one chapter talking about how the DSM came about and the strangely haphazard way diagnostic criteria at least could be made in it back then). You can read a discussion of the evolution of the criteria in Posttraumatic stress disorder – a comprehensive text (Edited by Saigh et al, 1999). Pages 5-8 discusses the evolution through different editions of Diagnostic and Statistical Manual of Psychiatry, the DSM III, DSM III-R och DSM IV and DSM IV-R. Recently DSM V was published, and there are other changes in that. For further information on this, you can find a lot of discussions on the Web.

The best book for those suffering from PTSD is David Kinchin´s Post Traumatic Stress Disorder – the invisible injury (2001). It is written in simple language to make it easier to read for someone who has the kind of concentration-problems PTSD can give. Kinchin, an ex-police officer, suffered from PTSD himself, and wrote the book for those who have it, with an insider´s understanding of what is needed.

Treatment of traumatic stress and PTSD in Western medicine

Most common treatment with long-term problems or PTSD in Western medicine is often limited to three options: 1) medication (often Zoloft, or similar mood-stabilisers and anti-depressants), 2) therapy, 3) CBT, Cognitive Behavioural Therapy Most sufferers would ideally need all three. There is also a technique called EMDR, Eye-movement Desensitization and reprocessing, which has been used very successfully to remove the charge in images from a traumatic event and make the person more free of them. See:

Treatment of traumatic stress and PTSD through chinese medicine acupuncture and ear acupuncture

Treatment of traumatic stress through acupuncture has been systemized and used world-wide by the aid organisation Acupuncturists Without Borders, where I am a member. For more about their work, see http://www.acuwithoutborders.org/.

The easiest version of helping someone that has been through traumatic stress is through ear acupuncture, the version that was created in the West and is called the NADA protocol.
Ear acupuncture is mentioned in the old classics, but seems to have been lost as a system over the centuries. It was researched and discovered again by Nogier, who is the father of it here in the West. (And who also, incredibly enough, was nominated for the Nobel Prize in Physiology – for acupuncture. He never got it, but was nominated in 1950). Then, in the 1980´s, a group of psychologists created what is now called the NADA protocol: five needles on the surface of each ear, inserted shallowly, and retained for 30-40 minutes.

The NADA protocol is very effective, especially for calming down and relaxing people. It seems to have a greater effect directly on the nervous system than normal acupuncture. It has less health effects than chinese medicine acupuncture, of course, but its ability to create relaxation and calm down the mind is fast, soft, and effective.

One of the very good things of using ear acupuncture to treat traumatic stress or PTSD is that it´s a completely non-verbal treatment. In many cases, the patient will either find it difficult to talk about what happened, not want to, not remember, or sometimes not be able to reach memories of the event. The ear acupuncture will work incredibly well with no communication about what happened at all. And after treatments, the patient will feel more relaxed in themselves and safer than before, which makes them more able to continue with therapy.
Another useful thing about ear acupuncture when it comes to traumatized patients is that during treatment you just sit dressed in the same clothes, on a chair. Many people who were traumatized can have a phobic fear of feeling vulnerable or even slightly powerless, and sitting on a chair fully dressed instead of half-dressed on a treatment table can make a big difference to that feeling of control as treatments start.

Here you can see volunteers from Acupuncturists Without Borders) use NADA ear acupuncture during one of their projects in New Orleans, after hurricane Katrina.

Time-frame for treatment of acupuncture for trauma and PTSD

As soon as possible. Same goes for contact with psychiatry or therapy, or simply talking things through with a good friend after a traumatic event. If it has been a very traumatic event, describing it to a friend might actually hurt them too, so remember to be careful about their health. A very traumatic event really needs contact with a professional therapist afterwards, preferably someone actually trained in dealing with PTSD. The faster the treatment, the less the shock and memory stays in the system. The longer we wait, the more risk there is for any trauma that still might be left to go deeper in us and start shaping our personality and the way we see the world.

Ear acupuncture really helps to release people´s nervous system and calm their mind, giving them peace that they can be desperate to feel. Chinese medicine acupuncture will be more complete in treating the entire system, emotions and the physical health, say if someone has had PTSD or shock for a longer time and there is more wear and tear on their body and mind. Ear acupuncture, however, has the useful ability of treating more patients at the same time, up to 10-20 or more, depending on size of room, which gives the patients a support network of others that they share that peace and healing with.

Acupuncturists Without Borders were founded on this idea: founder Diana Fried saw hurricane Katrina rip New Orleans apart, and wished she could help out – until she realized that she could, using her acupuncture skills. The aid organisation has since treated 7000 people in and around New Orleans, as well as uncountable veterans, police, and people involved in disasters all over the US, and the first responders who work in them.

Just one treatment can make a big difference if the trauma is very recent, but treating trauma or PTSD is long-term, and the standard treatment of six sessions for normal acupuncture will rarely be enough. This will of course depend on the patient and their health. The acupuncturist and their clinic will still be there as a fixpoint the sufferer can begin to trust, and if therapy gets tough or they have a bad week, they know that the treatment really helps and still is there, which in itself gives added security to their life.

An important note here is for the patient to have a stable connection with a therapist jointly with the acupuncture treatment, and ideally of course to have some kind of support network among friends and family. Sometimes this can´t be arranged, but ideally they should be in place. And ear acupuncture can be used very well in adjunct to on-going therapy for trauma or PTSD.

The intent of the practitioner when using acupuncture to treat trauma or PTSD

As practitioner, it´s important for us to have a great gentleness when approaching someone who has been through traumatic events or who has PTSD from before. We are standing before someone who has been through more bad times than anybody would want, and we have the skill to help the fragments of their being become more whole again. Even if we want to rephrase this, we stand there and have the skill to give some peace that they are desperate for, yet don´t have tools to create for themselves.

Remember that you might need to move and talk a bit differently with someone who has PTSD, as they often are much more sensitive to external triggers than other patients, due to the events they have been through. Respect this, and be gently careful while helping them heal.

The junior physician treats the disease according to the condition of the body, while the senior physician treats the disease according to the condition of the spirit.”
                - Huangdi Neijing Lingshu, Chapter 1, Nine Needles and Twelve Yuan Source Points

Classical Chinese Medicine and the view of the mind affecting the body

Chinese medicine has treated problems in the mind at least as far back as 300 BC, when the first references are found in text in the first medical textbook called the Huangdi Neijing, the Yellow Emperor´s Classic of Internal Medicine (see Wu and Wu, 1997).

For those practitioners interested in the newer TCM patterns for PTSD and trauma, an overview can be found in The Treatment of PTSD with Chinese Medicine – an integrative approach, (Chang et al., 2010). Classical Chinese Medicine (CCM) would have a slightly different approach, but both versions can be very effective in helping someone heal who has been traumatized or who have gone on to the smaller group that develops PTSD for a shorter or longer time.

Daoism, the spiritual tradition which Chinese medicine has grown from and which has shaped it in many ways, has talked about treating the mind and spirit since at leat 350 BC too (probably much longer, but those are the earliest extant sources in text). For those interested in this link and how it then is mirrored in the Neijing, Nanjing, Li Shizhen´s work on the Eight Extraordinary meridians (for a more modern view on this, see Applied Channel Therapy of Chinese Medicine, Robertson and Wang, 2008), can be recommended to start reading the oldest manuscript we have of Daoists texts, the Neiye, the Classic of Internal Cultivation (Roth, 1999).

Lighter versions of the Daoist knowledge has spread through qigong, Tai Chi and meditation here in the West. Studies and work has been done in using Tai Chi to heal PTSD, and several of these modalities can really help stabilize both the physical health and heal the mind. A personal account of dealing with severe PTSD through this kind of training can be found in Vietnam veteran Lee Burkins´s book Soldier´s Heart (2002).

Some practitioners use the so-called guixue to treat PTSD – these are the Ghost Points of Sun Simiao, a legendary acupuncture doctor who lived during the Tang dynasty (ca 700 AD). Using these would, in my experience, be inadvisable until treatment was quite advanced, but it always depends on the health and stability of the patient. The Ghost Points are used to release and free us from strong emotional or mental garbage and obsessions, and it is important that the person is stable first, which someone with PTSD usually is not until their health and life has been stabilized. Someone with severe PTSD can be very fragile, and treatments need to be gentle to build up a stable base for them to work from. For a brief look at the Ghost Points used with moxa, see Moxibustion: a modern clinical handbook, (Wilcox 2011).

Summing up

Life sometimes contains experiences that mark us too hard. This can be healed, we can become more whole again; not like we were before what happened, because whatever it was will stay happened whether we like it or not. But we can become healed in that it doesn´t affect our everyday life or control our thoughts: instead we can make it a strength that we build on and move forward from. Alloys are often stronger than iron.

Ear acupuncture and acupuncture is one way of helping someone who is traumatized, or someone who has developed PTSD. It is practical, concrete, and requires no verbalization of events or feelings. With ear acupuncture, it can also be given while just sitting on a chair dressed in our regular clothes. The practitioner gently inserts five needles along each ear, very shallowly, and then we sit there for half an hour. Then we get up, with a whole new peace and relaxation inside.

If you have any questions on this article or about treating PTSD and trauma with acupuncture or ear acupuncture, you can contact me at acu@smallchange.se. For sources, links and bibliography, see below. For the brilliant work done by Acupuncturists Without Borders in this field, see http://www.acuwithoutborders.org/.

For every needling, the method is above all not to miss the rooting in the spirit.”
            - Rooted in Spirit, Chapter 8 of the Neijing, the Heart of Chinese Medicine, Larre and Rochat de la Vallée, Station Hill press 1995

Articles and links:

Acupuncturists Without Borders work with nation-wide programs in the US to heal and dissolve traumatic stress in patients, veterans and people who have been through natural disasters. They also regularly treat the first responders who go in to help out in the disaster zones. Their website is http://www.acuwithoutborders.org/

Bibliography and selected reading

A very interesting paper on the subject of NGO security, security for aid workers. I believe that good Acceptance will decrease the risk for PTSD in aid workers.

Activist sustainability – hållbar hälsa för aktivister och frivilliga, Daniel Skyle, 2011, Swedish version http://www.smallchange.se/activistsustainabilitydanielskyle, english version at
Paper on activist sustainability, with some comparisons and guidelines.

Applied Channel Theory in Chinese Medicine, Robertson and Wang, Eastland Press, 2008
Brilliant book, and comments on the use of the Eight Extraordinary meridians in treating emotions and the nervous system.

A war of nerves – soldiers and psychiatrists 1914-1994, Ben Shephard, Jonathan Cape, 2000
Historical overview of the concept of PTSD and how the military has treated (or ignored) it since the 1800´s.

CARE International Safety and Security Handbook, CARE, 2004

Choke – the secret to performing under pressure, Sian Beilock, Constable&Robinson 2010

Episodes in Traditional Chinese Medicine, Bai Jingfeng, Panda Books, 1998
Good biography of Sun Simiao, re his Ghost Points.

Extreme Fear – the science of your mind in danger, Jeff Wise, Palgrave Macmillan, 2010

Laughing Saints and Righteous Heroes: emotional rythm in social movement groups, Erika Effler, Morality and Science Series, 2010
One of the first and only books on how emotional rythms move and change groups of volunteers, along with the pressure this puts on their health, what is called activist sustainability.

NGO Security Conference 2010, with interview with anti-kidnapping specialist Suzanne Williams, Daniel Skyle, www.smallchangengosecurityblog.blogspot.com
Re PTSD in kidnapped aid workers. For ideas of treatment, besides this blogpost, see also Activist sustainability – hållbar hälsa för aktivister och frivilliga, Daniel Skyle, 2011, Swedish version http://www.smallchange.se/activistsustainabilitydanielskyle,

Moxibustion: a modern clinical handbook, Lorraine Wilcox, Blue Poppy Press, 2011

Nan-Ching, the Classic of Difficult Issues, Unschuld, University of California University Press, 1986

Neiye – Original Tao, Inward Training and the Foundations of Taoist Mysticism, Harold Roth, Columbia University Press, 1999.

NLP and Health, McDermott and O´Connor, Thorsons, 1996
Good book on how we can use our language and phrasing to ease healing in patients and with ourselves. This is especially important in PTSD-patients, as they often are very sensitive to external triggers.

On Combat – the psychology and physiology of deadly conflict in war and in peace, Dave Grossman, PPCT Research Publications, 2004

Operational Security Management in Violent Environments, Brabant et al, Good Practice Review 8 Revised (GPR 8 R), 2011
NGO security handbook, chapter discussing signs of stress and stress-injuries due to external events in conflict zones or disaster areas.

Perplexities to Acupuncture and Moxibustion – English- Chinese edition, Li Ding, Shanghai University of TCM Press, 2007
Includes chapter on treating the mind, shen, in Chinese medicine.

Posttraumatic stress disorder – a comprehensive text, Edited by Saigh, Bremner, Allyn and Bacon, 1999

Post traumatic stress disorder – the invisible injury, David Kinchin, Unlimited Success, new edition 2005
Best book on the market for people who have been through trauma or who suffer from PTSD.

Soldier´s Heart, Lee Burkins, 2002
Personal memoir of someone who suffered from extremly grave PTSD, and his way of healing that.

Sunzi´s Art of War and Health Care, Wu et al, New World Press, 1997
Several chapters on treating the mind and emotions, linked to Sunzi´s teaching on conflict and war.

Supporting Children with Post Traumatic Stress Disorder – a practical guide for teachers and professionals, Brown and Kinchin, David Fulton Publisher, 2001
A simple yet very effective book for those working with children, including how to spot trauma and PTSD in children. Includes advice on how to deal with it and help them too.

Synopsis of Prescriptions of the Golden Chamber, Jingui Yaloue, Zhang Zhongjing, Chinese-English edition, New World Press 2007

Talking to the Enemy, Scott Atran, HarperCollins, 2010

The Beautiful Tree, James Tooley, Cato Institute, 2009
The Gift of Fear, Gavin de Becker, Random House, 1997

The Psychological Health of Relief Workers: some practical suggestions, Salama, Humanitarian Exchange Magazine, 1999, http://www.odihpn.org/report.asp?id=1043

The Psychopath Test, Jon Ronson, Picador, 2011
Includes chapter on how the DSM was created, with some worrying information on the (at least early) haphazardness of diagnostic criteria.

The Seven Emotions – psychology and health in ancient China, Larre and Rochat de la Vallée, Monkey Press, 1996

The Treatment of PTSD with Chinese Medicine – an integrative approach, Chang et al., People´s Medical Publishing House, 2010.
First and only book so far specifically on treating PTSD with modalities within Chinese medicine. Joe Chang works at Fort Bliss Restoration & Resilience Center William Beaumont Army Medical Center, US, Wang wei Dong is chief physican and professor, Department of TCM psychology, Guang´anmen Hospital of China Academy of Chinese Medical Sciences, Beijing, China and Jiang Yong is Associate professor of chinese medcine, Chengdu University of TCM, Chengdu, China.
Interestingly, it includes case-studies of PTSD-treatment in Chinese hospitals from the Sichuan earthquake in 2006.

The Yellow Emperor´s Canon of Internal Medicine, Chinese-English edition, Wu and Wu, China Science and Technology Press, 1997

Understanding post-traumatic stress – a psychosocial perspective on PTSD and treatment, Joseph et al, Wiley, 1997

Daniel Skyle © 2012. Copyrighted material.