Can use of acupuncture delay proper medical treatment?


Even though there is room for more thorough adverse effect reporting in acupuncture trials and a need for more studies about acupuncture safety (Ng et al. 2016; Turner at al. 2011), there already exists evidence concerning the safety of acupuncture. Based on the studies (Witt et al. 2009; Kim et al. 2016; McCulloch et al. 2015; Park et al. 2014; Houzé et al. 2017), we can conclude that generally acupuncture can be seen as a relatively safe practice. The adverse effects from acupuncture are extremely rare compared to reported adverse effects from conventional medicine. The FDA Adverse Event Reporting System (FAERS) Public Dashboard reveals 906,773 serious side effect reports and 164,154 deaths from side effects or malpractice in 2017 alone. This is an unfair comparison as the patient base and seriousness of the conditions treated are often very different, but it gives us a perspective to the safety of acupuncture in comparison with many other medical treatments. And even the most serious side effects like pneumothorax from acupuncture seem to be preventable with sufficient training in acupuncture education (Kim et al. 2016).

In the acupuncture studies about patient safety, the subject has been approached from the point of safety of the treatment itself. There seems to be a lack of studies about the possibility of delayed medical treatment in cancer or other severe medical conditions due to the use of acupuncture. This essay approaches the subject with reflection on a patient case.

Case background

The author first met the patient in 2011. The patient had suffered from recurring, almost constant uveitis for 15 years. Known causes of uveitis had been previously excluded by medical doctors. The only treatment offered to the patient was ophthalmic steroids. Prolonged use of the steroids had increased her intraocular pressure causing glaucoma that threatened her diminishing vision. The ophthalmologist wanted to start a more robust and constant medication for glaucoma with a drug having the side effect of flaring of uveitis. The patient wanted to try acupuncture as an alternative.

After five sessions of acupuncture, the symptoms of uveitis had clearly decreased and she had reduced the use of corticosteroids. She had permission from the ophthalmologist to dose corticosteroids based on need. During the following months, she used them only twice when she felt any peculiar feelings in her eyes. Five months later she visited her ophthalmologist who could not see any signs of uveitis. Due to increased intraocular pressure, they had agreed for regular follow-ups. Beside one occasion in 2012, she has been without corticosteroids and free from uveitis.

In addition to uveitis, she had a medical history of back and joint pains, and Ménière’s disease.

During her initial visits to author’s clinic, she expressed her growing frustration with medicine and how she felt like a test subject. The doctors could not give a reason for her symptoms, and to her it seemed illogical to use medication causing uveitis to treat problems caused by the medication for uveitis. She also felt that some doctors she had met had been unprofessional in their behaviour. Side effects and dissatisfaction to conventional health care are among common reasons for trying acupuncture (Jakes et al., 2014).

Radical change in patient’s health

In 2015, the patient wanted to try acupuncture for fatigue. She had already visited a medical doctor through occupational health care who didn’t find anything alarming. The author performed acupuncture based partly on her previous background information and her current symptoms. Afterwards, she reported a slight initial improvement, but the exhaustion soon returned and was non-responsive to further attempts with acupuncture.

After a third acupuncture treatment she caught a flu and visited another doctor who took a chest X-ray that revealed a cancerous growth in her lungs. The patient was treated with surgical removal of the tumour. Because of inappropriate joking by the operating doctor just before the surgery, she felt mistreated again even though the surgery was successful. Soon after the surgery she contracted pneumonia. During follow-ups later on, her papers were not read properly leading to surgical marks visible in the X-ray to be mistaken as a sign of pulmonary embolism. Two months of unnecessary subcutaneous injections added to her mistrust of the whole medical profession even though the surgery itself had been successful.

During these events the patient contacted the author and told him about the correct diagnosis. She didn’t blame the author for misdiagnosis. But for the author this caused concerns and a need for reflection. How could something this serious be missed even when the cancer was advanced enough to cause serious fatigue? Could this be prevented from happening again?

Meeting in 2017

In 2017, the patient reserved time from the author because of vertigo caused by Ménière’s disease. The prescribed medication was no longer effective. During the meeting she gave a detailed account of her experience with surgery and how she felt afterwards. She was angry and frustrated and said she had little faith left for the health care system even though she had been saved by the medical procedure. During the session she gave permission for using her case as a case study. After giving the permission, she was told that the treatments would be free of charge.

Meeting her after the incident produced conflicting thoughts. Because of her past, the current condition felt more alarming. Why did her medication suddenly stop working? Was the dizziness caused by Ménière’s disease, a simple benign positional vertigo or was it something more severe? What if this was somehow connected to her previous condition? There was also curiosity and a need to ask questions about her previous health concerns that might shed some light to the author’s wrong diagnosis.

She had already seen her physician to screen out anything serious but still the situation stirred some insecurity in the author. During the discussion and diagnosis she revealed that she had recently lost her job and was now unemployed. So she was particularly happy to receive free treatments. Lack of money combined with free treatments might also increase the possibility of an already vulnerable patient to feel more dependent on the acupuncturist or it could produce a feeling of groundless gratitude. Having less money might also mean that she might be less willing to see a doctor in case the acupuncture treatment did not work, especially with her experiences with the public health care.

While describing her experiences and expressing her mistrust with the medical profession, she didn’t seem to consider the author to be part of the medical profession. In Finland, the author is a registered health care professional due to being a licensed masseur, but an acupuncturist is not an accepted health care professional nor is there any legal regulation about the profession. The professional associations are working to self-regulate the field, set educational criteria, enforce the following of ethical guidelines, and ensure that the professionals have proper insurances.

For the author, it was important to meet the patient face to face after making a wrong diagnosis. There were no signs of blaming or mistrust from the patient. Her patient records had been reviewed in 2015 and again before the appointment. There was no evidence of neglecting of symptoms, and she had already visited a medical doctor beforehand. It was crucial for the improvement of practice for the author to become more aware of possible consequences. It made the author question his own responsibilities and also the boundaries of his practice.

Analysing the case

During 2015, the author had failed to recognize lung cancer. The examination and questions asked during the visit could have been more thorough. Owing to the fact that the patient was previously known, there was a possibility of using information gathered during earlier visits. This combined with the shorter time reserved for returning patients might have made it harder to be cautious enough. The TCM diagnosis based on the discussion, pulse, and tongue during the visit revealed what is known in Chinese medicine as a deficiency of blood and a weakness of lung qi. Relying on the patient history while formulating a picture of the current situation might have affected the understanding of the real reason for exhaustion and how serious her case was. The medical expertise of the author did not enable him to recognise the underlying reason. A similar mistake was probably made by the medical doctor in occupational health care who failed to see cause for further tests. Given the patient’s earlier bad experiences with health care, she probably might not easily go back for a second opinion. In this case, it was pure luck that the patient caught the flu and was sent to x-ray.

The seriousness of the situation also raises other concerns. What if the patient had gotten better results from the acupuncture treatment? In that case, could the better results have delayed a proper diagnosis and medical treatment? And what role does the therapeutic relationship play in a possible delay of proper treatment?

There exists some evidence that acupuncture is effective in treating cancer-related fatigue (Duong et al. 2017; Zhang et al. 2018; Zick et al. 2016). These studies focus on fatigue in connection with conventional cancer treatments, but acupuncture might also diminish the fatigue caused by cancer itself. Definite scientific evidence for the effectiveness of acupuncture for cancer pain is still lacking (Wu et al. 2015), but there is reason to believe that acupuncture might provide some relief from cancer pain (Hu et al. 2016; Chiu et al. 2017). So there is a possibility that acupuncture might prolong the time before the patient goes to see a doctor. An acupuncturist might see diminished fatigue and/or pain as evidence of successful treatment, which might in reality delay proper medical treatment. However, in case of pain, the same could easily happen with self-administered and commonly available pain killers. The fatigue might also diminish with energy drinks (Warnock et al. 2017), but the effects wouldn’t probably last for long. However, it could also be possible that by visiting an acupuncturist frequently, the acupuncturist could notice if there was no response to treatment or that the results were not as long-lasting as they should be. At least the acupuncturist would notice if the condition of the patient seemed to deteriorate despite the treatments. This could easily alarm a professional acupuncturist so, in this way, the acupuncturist would provide an extra pair of eyes watching for the patient’s health. In Finland, the acupuncture associations require the signing of ethical conduct which states that all acupuncturists refer cases to medical doctors when medical treatment is needed.

A study by Shorofi and Arbon (2017) offered some reasons why patients are opting to use CAM therapies instead of medical therapies. In the study, in all the people opting for CAM therapies, the most relevant reasons for this case study were that the problem was not seen serious enough to see a doctor (21.4%), a belief that these alternative treatments have fewer side effects than conventional ones (16.9%), and dissatisfaction with conventional treatments (6.8%). Combining these percentages with those of people who felt that CAM therapies were more fitting to their personal lifestyle or philosophy (37.7%), there is some evidence of a group of people who might not prefer to see a medical doctor in the first place. The study was done among hospitalised patients in Australia, but the author is in agreement over these patient groups and confirms similar numbers based on his own patient records and experience.

In serious diseases, like cancer in this case, medical diagnosis and intervention as early as possible is paramount. The symptoms, however, can begin with only minor health complaints. The 21.4% of population who use complementary modalities consider their problems not serious enough (Shorofi and Arbon 2017), but they might still find their way to the acupuncturist who, with adequate training, could be able to recognise the severity of the symptoms and could advise the patient to see a doctor.

The example patient in this essay had a medical diagnosis from her ophthalmologist for her previous condition. But in Finnish acupuncture clinics, it is very common to meet patients with medically unexplained physical symptoms (MUPS). These patients do not have a diagnosis and often feel that in conventional medical care they are misunderstood and their symptoms are not always taken seriously (Lipsitt et al. 2015). This same patient group generally obtains poor clinical outcomes from medical practice (Lipsitt et al. 2015), which might lead them to further avoid medical doctors. Some of these patients might feel more understood by CAM practitioners in general. Depending on the type of therapy, this could partly be due to the duration of initial interview and time used during the treatment, or more cosy clinical settings. It might be the CAM practitioner who first notices that their symptoms start to change or become worse, signalling that there might be a need to see a doctor. However, if the CAM therapist fails to see the alarming signs, the patient might get non-optimal treatment and believe that he gets all the treatment he needs. This could be preventable with proper education and further cooperation with medical doctors.

An even more alarming group than the MUPS patients who often burden health care with their constant visits (Lipsitt et al. 2015), are those who feel very dissatisfied with their medical care and are avoiding seeing doctors. This group is easily left without treatment by their own choice. Some of these patients might still be willing to see an acupuncturist. In that case, more serious and easily recognised problems might become apparent and they could be referred to health care, if they can be persuaded to make an appointment. Within these patient groups, there are people who feel vulnerable and, sometimes, they do not know where they should go and which symptoms they should tell their doctors. In their case, even one bad experience with a medical doctor can lead to further aversion of medical procedures and tests. For them an acupuncturist might be seen as a neutral bridge for communication to conventional health care.

CAM modalities are also often selected because of recommendations or wanting self-control over an illness (Shorofi and Arbon 2017). Many patients from the group who feel CAM therapies are more fitting to their personal way of life may not easily visit a doctor for any minor complaints. Based on the author’s experience, the people from these groups are generally willing to see a doctor when faced with any serious conditions or when told so by an acupuncturist. The problem for these patients is to recognise what is relevant and what is serious enough. Those seeing an acupuncturist with at least a basic education of medicine, could then be told by the acupuncturist to see a doctor if needed.


The failure to recognise lung cancer by the author and by a medical doctor in occupational health care was a human error. The proper acupuncture studies in Finland include a minimum of 14 to 30 ECTS of medicine, depending on the year of graduation, and lung cancer is one of the most difficult forms of cancer to diagnose even for general practitioners (Rankin et al. 2017). Mistakes can happen for any medical professional and CAM practitioner alike, but delays in treatment can lead to disease progression and missed opportunities for cure in a significant subset of patients (Rankin et al. 2017). In conventional care, it is customary to refer the patient to a specialist for diagnosis in case the general practitioner suspects cancer or another more serious disease. A similar attitude is crucial for patient safety among all CAM modalities. Wide cooperation with medical doctors would ensure patient safety and could also encourage some vulnerable patient groups to visit a doctor in time. It might also provide a bridge for communication to patients with MUPS or other patient groups who may feel more understood by CAM practitioners.

Based on these reflections, the author claims that there exists a possibility for certain groups of people to be left without early recognition of serious diseases in conventional health care and in clinics offering CAM modalities. In developed Western countries, most patients already go to a medical doctor in case they suspect anything serious. Those coming to see an acupuncturist or another CAM practitioner have often already visited a medical doctor (Eisenberg et al., 2001). Those who have considered their problems too minor for needing a doctor may still try acupuncture. In case the acupuncturists suspect any more serious health concerns, the professional acupuncturists always ask the patient to visit a doctor. In Chinese medicine education, it is necessary to teach acupuncturists to become aware of their own limitations. In acupuncture education, the students need to be taught to communicate with the patients honestly, if they cannot understand the symptoms or they have any suspicions.

The ability of an acupuncturist to recognise important clues about serious health issues depends on education and clinical experience. Even though Chinese medicine courses are not meant to produce medical doctors or to teach how to make a conventional medical diagnosis, they aim at providing enough understanding when it is necessary to refer the patient to medical care. As the popularity and acceptance of acupuncture is growing fast and more and more research about its effectiveness is emerging, the acupuncturists will receive more and more patients seeking alternatives. With growing public awareness of acupuncture, there will be more and more patients coming with grave illnesses that require conventional medical treatments. The need for basic medical education and continuous education for acupuncturists cannot therefore be stressed enough.

It is also crucial for acupuncturists, and other CAM practitioners, to network themselves with medical doctors whom they can refer the patients to or ask for an opinion. Awareness of these critical situations can also be improved with open discussion and sharing experiences with other acupuncturists or practitioners of other CAM modalities.

Some patients have withheld information from their doctors about their nutraceuticals recommended by their nutritional therapists or herbs recommended by CAM practitioners. In the study by Eisenberg et al. (2001), three fifths of CAM therapy used was not disclosed to doctors. The common reason is that the doctor didn’t ask and some patients were also afraid that the doctors would not agree or understand (Eisenberg et al., 2001). This can be very dangerous considering the potential interactions (Salminen, 2018) with drugs used in cancer treatment, for example. The possibility that the patient uses some CAM modality is ever increasing. According to Eardley et al. (2012) “the prevalence of CAM use varied widely within and across the EU countries” and could be even as high as 86% of the population in some countries. The most commonly used modality is herbal medicines. If the patients sense a strong dichotomy between CAM practitioners and medical professionals, it can cause the patients to withhold vital information. It is important that acupuncturists also recognize these dangers and are able to inform their patients and form patient relationships based on trust. They need to tell their patients to inform their doctors or practitioners of other CAM modalities about any treatments they give, especially if they prescribe any medicinal herbs or products.

The acupuncturists and Chinese medicine practitioners might also hear about the use of falsified medicines that can endanger the patients (Hamilton et al. 2016) or other unregulated and possibly harmful products. The acupuncturists can report these potentially harmful products to local authorities and inform their patients about possible dangers in their use. The author believes that information about the use of unregulated or falsified medicines might be left out during visit to a doctor just as easily as the patients withheld information, such as using CAM modalities, and an acupuncturist can instruct their patients to disclose this information.

With patients having any previous dissatisfaction with medical care, extra caution should be taken. In case of any suspicious symptoms, the patients should be instructed to see a doctor, if they have not already done so, to avoid a late diagnosis of serious medical conditions. Making patients agree to see a doctor probably requires building a good therapeutic relationship. The practitioner of any CAM modality also needs to be aware in his therapeutic relationships that a patient might also easily get a wrong idea of the effectiveness. The patient in this case reserved time to check if acupuncture could help with Ménière’s disease when medicine failed. She had already had made the assumption that vertigo was because of Ménière’s disease and that acupuncture might help. Currently, there is preliminary evidence that acupuncture might work for Ménière’s disease (He et al. 2016) but her expectations were high because of the previous success with uveitis. It is sometimes almost impossible to avoid giving false hope by just agreeing to treat any less commonly treated symptoms. Not treating or overly explaining that the treatment might not work might harm the therapeutic relationship and even prevent the referral to a doctor in case it is needed.

Reflecting upon therapeutic relationships and clinical skills after this incident, the author became more aware of possible consequences of his therapeutic practice. It would be unrealistic to think that these mistakes couldn’t ever happen in the future, but there are always ways to improve the practice. He will now reserve extra time for returning patients if a few years have passed from the last session. With this he tries to ensure that he has enough time to collect information. Even in cases of seemingly minor complaints that do not respond to acupuncture treatments, the patients will from now on be routinely encouraged to see a doctor upon termination of the course of treatment. Before, the patients have already been asked to see doctor if there have been any alarming symptoms, but minor health concerns might have been previously overlooked. The author himself sees the work of an acupuncturist very tightly interwoven with the medical profession and sees further cooperation between different medical modalities as a requirement for patient safety. The author also concludes that it is unlikely that offering acupuncture would generally cause delays in diagnosis and treatment of a serious disease like cancer, but there is definitely a lack of proper studies in this area.



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Āyurveda, Modernity, and Time

Moderator’s note: Many practitioners of Asian medicine and Asian-based health modalities are grappling with questions concerning the historical roots and cultural status of their disciplines today as never before. In response, Asian Medicine Zone is launching a new series of practitioner essays exploring how changing conceptions of “tradition” and “modernity” are impacting their practice and field in the 21st century (these are organized under the tag “tradition/modernity”). If you’re interested in contributing to this seriesplease email a short description of your proposed essay to the moderators. Here, we’re pleased to share our third offering, a poetic reflection on the paradoxes involved in being an Ayurvedic educator/practitioner who’s well aware of the culturally contingent and politically contested nature of the practice.

On the morning I sat down to write this, the Nobel Foundation announced it had awarded the 2017 Prize for Biology or Physiology to the American scientists Jeffrey C. Hall, Michael Rosbash, and Michael W. Young for their work in the field of chronobiology. Over decades of meticulous lab work, the trio isolated the “period gene”, and described how the protein it encodes regulates each cell’s rhythm of vitality and rest in relation to cycles of light and dark.

The news made me smile.

After nearly 15 years of studying and practicing the narrow stream of Āyurveda to which I’ve had access – modernized, Anglicized, commodified, and merged with reconstructed European naturopathies – I’ve come to the personal conclusion that the most general gift this art form offers is insight into how human beings can heal our relationship to time.

My first Ayurvedic mentor said, “We are living in the most vāta-aggravated period in history, but we can take great comfort in the faithful stability of the solar cycle.” Using the mathematics of Jyotiṣa, he taught us the daily calculations for finding solar noon, and the precise transitions between the kapha, pitta, and vāta periods of day and night. He taught us how the stress of sundowning could be eased by meditation at dusk, about why we should avoid staying awake past the “pitta threshold” – that tripwire that gives us a second nocturnal wind, better applied to dreaming than internet browsing. He taught us how to calculate the pre-dawn moment of brahma muhurta, when the fluctuations of air and space seem to relax, and groundless anxiety can yield to expansive possibility.

The lessons communicated both primal dependability and existential maturity to an uncertain, insomniac, gaseous world. I began to feel that the “knowledge of longevity” for which Āyurveda is named is not so much about personal wellness goals as it is about making peace with time, which means making peace with change, which means making peace with death, the pole star of stress.

This core idea, fleshed out in the broad principles of dinacharya (“to follow the sun”, according to my teacher’s nirukta) has remained as stable for me as the solar cycle itself. It has survived the numerous waves of disillusionment I now see as natural to the interrogation of an unconsciously adopted religion.

My resonance with dinacharya has survived realizing that my exposure to Āyurveda has come through an alchemy of the neo-colonialism that wants to commodify it for export and the Hindutva ideology that wants to claim it as part of a saffronized patrimony. The former thinks it can be packaged and sold. The latter wants to deny that Buddhists played an essential role in its early formulation.

It has survived realizing that Āyurveda’s gender essentialism and heteronormativity – whether authentic to its historical roots or not – can be subtly oppressive to the women’s consumer market it claims to serve. (Not to mention wondering whether its obsession with human fertility is coherent in a world racing past its carrying capacity.)

It has survived realizing that modern global Āyurveda can provide sanctimonious cover for neoliberal propaganda, and contribute to the anxiety of privatized, aspirational responsibilism. Āyurveda in current practice can reinforce the punishing belief that self-care is the only care we can rely on, or that oil massage makes the world a better place, or that health is assured through kitchari and memorizing the doshic implications of red grapes versus green grapes.

It has survived watching friends from the country of the Nobel-winners use Āyurveda to faithfully but unsuccessfully manage cancer because they either distrust public medicine, don’t have health insurance, or both.

It has survived realizing the hypocrisy of Āyurveda’s marketing as a common sense, low cost, local economy wellness modality, whilst outside of low-income India it mainly flourishes as a lifestyle brand and leisure activity for the wealthy, consumable through long-distance spa vacations and carbon-heavy importation. Globalization popularizes and sells the notion of local authenticity through the process of destroying it.

It has survived realizing that Āyurveda’s premodern somatic poetry is elliptical enough to help contemplatives interrogate their internal sensations, but also vague enough to serve as a platform for Deepak Chopra to authenticate pseudoscience.

It has survived watching the rise of Baba Ramdev use Āyurveda as a tool of blood-and-soil purification: selling spiritually-inflected skin-lightening creams, or researching herbs that will cure homosexuality.

And today, it will survive both the grandiosity of biologists who have “discovered” that life has rhythm, and the patriotic fantasies of those who will claim that the “period gene” is described in the Vedas.

“Āyurveda is said to be eternally continuing because it has no beginning,” says Charaka (via Sharma). “Our understanding of Āyurveda has arisen a posteriori to Āyurveda’s eternal laws.”

I have only a dim understanding of where the cultures of Āyurveda have come from, and no real clue as to where they’re going, or how much trouble and joy they will foster. But between these mysteries lies a present, palpable phenomenon that points to the notion of “eternal law”. Even a deconstructionist such as myself can get behind it, and treasure it.

Through these histories of colonial, capitalistic and epistemological violence – histories that may cause more disease than the bacteria and viruses that Āyurveda cannot treat – the earth still turns in its measure. It faces the sun, and then faces away. The body radiates and grows dark. The identity extroverts and introverts. We wake and sleep. Dinacharya does not solve capitalism, climate crisis, or death. But it looks clearly at the rhythms of change, and perhaps relieves us of the suspicion that time is meaningless.

Modernity, Identity, and Contemporary (Non-) Buddhism

Moderator’s note: Many practitioners of Asian medicine and Asian-based health modalities are grappling with questions concerning the historical roots and cultural status of their disciplines today as never before. In response, Asian Medicine Zone is launching a new series of practitioner essays exploring how changing conceptions of “tradition” and “modernity” are impacting their practice and field in the 21st century (these are organized under the tag “tradition/modernity”). If you’re interested in contributing to this seriesplease email a short description of your proposed essay to the moderators. Here, we’re pleased to share our second offering in the series, which focuses on a reassessment of the therapeutic practices of mindfulness meditation and lifestyle coaching in light of recent scholarship and critiques of Buddhism.

I grew up firmly attached to my mother, a hippie and follower of the White Eagle Lodge, a self-described “Wisdom School for the New Age,” in the UK during the 1980s. By the time I reached adolescence, I had mediated, journeyed to power spots, been healed energetically and blessed by Indian Gurus, and taught all manner of transcendental spiritual truth. 

Buddhism caught my interest in my early teens. After several exploratory years, I joined a Tibetan Buddhist group just after turning 19. Like many other young Brits in the 1990s, my relationship with Buddhism was informed by New Age ideals, unreflective romantic orientalism, a desire to experience mysticism and escape from materialism, and a warped view of Asian Buddhists as being in possession of something inherently special. Although I didn’t recognize it then, I was clearly a product of the historical and cultural influences of the time.

Coming to understand the significance my own cultural formation as a modern Buddhist-based practitioner, psychological counselor, and life coach – and then deciding how best to respond to this – has been a lengthy process. Over time, it has revolutionized how I understand, experience, and engage with my self, my work, and my practice, both personally and professionally.  

The shift began when I first started to seriously question the cultural direction that the Western Buddhist world was heading. When I found that such inquiry was mostly met with resistance within Buddhist circles, I turned toward a wide range of scholarly and critical literatures – religious studies, Buddhist studies, cultural history, and postmodern theory – for answers. As I explored these materials, I found myself most powerfully drawn to the question of how subjectivity and selfhood in contemporary Western Buddhism is developed and maintained. 

Diving deeper into this inquiry eventually led to the conclusion that the ideas and practices that dominate Western convert Buddhist communities help shape and support identities that conform to the ideological super-structure of the larger society. Seeing this process of socially conformist identity formation more clearly shifted my personal identity as a Buddhist-based spiritual practitioner. At the same time, it generated ethical tensions for me in my professional work as a counselor and life coach who utilizes Buddhist-based to including mindfulness and meditation. As I came to see such practices as embedded in a cultural matrix that I found problematic, the question of how to resituate the therapeutic encounter in an alternative framework of meaning became paramount. 

Currently, I am exploring whether a “metamodern turn” might help resolve the philosophical and practical tensions that run between more traditional Buddhism, modern Buddhism, and the relatively unexplored terrain of post-modern Buddhism. Most pivotally, I am interested in whether some sort of metamodern reframing might serve to reinvigorate the second purpose that Buddhism has historically served: that is, the alleviation of suffering through the reduction of ignorance. 

Emergent dissonance

During my teens and early 20s, it was perfectly normal for me and my companions to carry out traditional deity practice in a Gompa one weekend and study with a New Age teacher from the States the next. We got high on the positive vibes in the process. Powerful feelings were sought, as well as mystical insights and revelatory truths. 

Although I would spend time with other Buddhist traditions such as Goenka’s Vispassana and Soto Zen, Tibetan Buddhism held the greatest appeal. I spent 15 years following the Gelugpa and Kagyu traditions intensely, as well as a neo-Shamanic group from the States on the side. During that period, I also trained as a Person-Centered Counselor, Life Coach, and Core Shamanic Counselor. All of these activities were connected by a sense of meaning and purpose that would be best defined as spiritual and salvational. 

The cracks that would eventually emerge in this identity came from my father’s influence. He was a Marxist, an intellectual and history buff, and an avowed atheist. My parents had divorced when I was one. Weekend visits to Dad’s home involved him taking me along to political protests whilst boring me with the truths of anti-capitalism. But his imprinting had an important, if delayed effect. 

As Tibetan Buddhist groups began to grow in the UK and the States, many appeared to be moving towards commercialization. At the same time, many New Age teachers were appropriating aspects of Buddhism. Fake Lamas and Gurus were discrediting themselves and their groups through inappropriate behavior. Their money-making was becoming grosser and more evident. My paternal history meant that I could not help but notice this emerging alignment with capitalist goals. 

These observations began to chip away at my romantic readings of Buddhism and the New Age. Eventually, I realized that the spiritual practices and groups I had been engaged with were not separate from the wider society, as I had believed. It seems ridiculous to say now, but I had previously seen the meditation cushion, sweat lodge, or retreat center as direct routes for escaping from the illusory material world and entering into something authentic, powerful, and more real. 

By the early 2000s, I had stopped frequenting New Age teachers entirely. As the decade rolled on, I began to slowly withdraw from Tibetan Buddhist groups, while only intermittently engaging with others. Eventually, I began working with a European Shingon teacher who I discovered via the “Buddhist Geeks” podcast. 

With the benefit of hindsight, I realized that I had come to Buddhism for a variety of reasons, many of which were simply romantic. Some, however, were less problematic. In particular, I was fascinated by the possibility of learning to better understand and address my own ignorance, and its general role in creating suffering. My pursuit of this foundationally Buddhist aspiration, however, took a nontraditional route. 

Modernism, Texts and Disruption

The first years I spent within traditional Buddhist convert groups in the UK (mainly Tibetan but also Southeast Asian and Japanese) had been marked by a lack of access to other voices that resonated with my personal concerns. I searched for, but failed to find some sort of informed, intelligent, and critical engagement with Buddhism as it was developing in the West. It seemed that my intuitions and observations were mine alone. This increasingly distanced me from Buddhist groups, as well as the materials they relied on to validate their practices. 

Were it not for the Internet, which enabled me to engage with Buddhism more critically, I would likely have abandoned it all together. Instead, I started exploring relevant academic literatures and related work online. Initially, I focused on academic books that crossed over to a general audience. Notable titles included Donald S. Lopez’s Prisoners of Shangri-La; David Loy’s The Great Awakening: a Social Theory and Non-Duality: A Study in Comparative Philosophy; Geofffrey Samuel’s Civilised Shaman; and Sam Van Sheik’s, Tibet: A History. I also perused books, articles, and podcasts by religious studies scholars such as Rita Gross and John D. Dunne, as well as non-academic writers and thinkers including Stephen Batchelor and John Peacock. 

Scholarly works that contextualized modern Buddhism, neo-shamanism, and other spiritual practices in an overarching cultural-historical framework enabled me to see how my own private, personal practice was actually, in great part, the product of Western history and the forces of modernity. David L. McMahan’s The Making of Buddhist Modernism was particularly pivotal in this regard. For me, reading this and other texts was a form of practice, as enlightening as any experience I’d had sitting on a meditation cushion or in retreat. Engaging with them burst my ideological bubble and challenged many of my remaining beliefs about Buddhism. It disrupted my sense of what it meant to be a Buddhist and spiritual person, and changed my clinical practice. 

By and large, I felt quite alone in this process. As far as I could see, there were no Buddhist teachers offering signposts for where to go next. All were firmly committed to the narratives of their traditions, or uncritically embedded in Buddhist Modernism. The prioritization of unreflectively visceral “experience” from teachers and practitioners alike seemed to be part of a more general anti-intellectualism in Dharma centers. Among those who had engaged with works detailing the historical particularity of modern Buddhism, the dominant reactions were either: 1) defending their own particular tradition, which was seen as not having fallen for such delusion; 2) rejecting Buddhism as a whole; or 3) searching for a more “authentic” form of Buddhism. 

For me, no such options were available. I wanted to engage critically with contemporary Buddhism, but not abandon it altogether. 

At this point, I wondered if a further possibility existed: Perhaps some sort of Buddhist postmodern turn? I had found the work of Heidegger, Merleau-Ponty, and other precursors of postmodern philosophy helpful in attempting to make sense of being and embodied practice from a non-Buddhist viewpoint. Now, I was motivated to explore postmodern theory more thoroughly in light of my shifting understanding of contemporary Western Buddhism and its relationship to modernity, identity, and culture. 

Here again, having access to the Internet proved invaluable in terms of researching and accessing relevant materials. That said, finding direct connections between Buddhism and postmodern thought was not easy.  By and large, I continued to grapple with the implications of my ongoing intellectual explorations for my Buddhist-based identity, thought, work, and practice on my own.  


Gaining an understanding of the historical formation of Western Buddhism led me to radically rethink my relationship with contemporary Western spirituality as a whole. I also became deeply uncomfortable with how I used to understand therapy and my role as a therapist. I realized that I had long held a salvational vision of therapy, and had been transmitting the myths of the Buddhist modernist project unwittingly. 

I recognized that Buddhist groups have a tendency to form particular types of identities whilst inculcating specific codes of behavior, linguistic habits, and taboo areas of discussion. I also saw that these directives were almost never made explicit. If brought up in discussion, they evoked defensiveness and avoidance on the part of students and teachers alike. I came to view this phenomenon as intimately related to the creation of an ideologically shaped Buddhist identity. 

I began to frame meditation within different conceptual and perceptual frames. I stopped using Western Buddhist jargon and spiritual tropes. I came to believe that recognizing the role of modernity in forming Western Buddhism and shaping the experiences, beliefs, practices, and concepts of its practitioners was itself a powerful form of practice. Moreover, I now saw it as necessary one if Western Buddhism is to act as a genuinely liberating force.

Western Buddhist, being blind to its own influences, does not see that the language and practices of Buddhist modernism are part of an ideological apparatus that creates subjects within a discourse of pseudo-liberation. In fact, Buddhism is incapable of providing an adequate response to the complexities and implications of modernity on its own. This should not be surprising, as Buddhism was never designed for such a purpose. Tools from the Western intellectual tradition are required to respond to the challenges that Buddhist modernism presents, both for individuals and for those groups committed to a therapeutic approach to practice.

Uncovering the historical roots and cultural formation of modern Buddhism within one’s own work, life, and practice can be liberating and transformative. It can also be highly disruptive and difficult to navigate. Within Buddhist discourse, concepts such as Enlightenment, the Bodhisattva, and the Four Noble Truths act as grand narratives. In contradiction to the Buddhist notion of no-self, they provide a solid foundation for the creation of religious or spiritual identities. 

Challenging the solidity of such perceived final truths by means of cultural history and postmodern theory destabilizes sustaining ideological norms. This undermines not only the certainty of dependable, pre-existing identities, but also the pay-offs that are implicit in the promise of an end to suffering, awakening, or whatever else is currently on offer in Dharma halls or therapeutic encounters. 

The problem is that while subjectivity comes under attack in the work of postmodern thinkers such as Derrida and Foucault, postmodern theory offers no real replacement for the modernist subject. The resulting lacuna is particularly problematic for the spiritually inclined, who are drawn to practices such as Buddhism. Postmodernism provides no clear basis for new models of selfhood that are sufficiently robust to sustain any sort of meaningful practice. 

It’s no surprise that many Buddhists resist exploring the more potent insights of postmodernism. They rightly intuit that it conflicts the therapeutic, religious, and/or mystical aspirations that most commonly motivate engagement with Buddhism in the first place. Glynn (2002) goes as far as saying that subjectivity is “denatured” by postmodern thought and thus incapable of “self-actualization.” To the extent this is true (and I think it essentially is), it also undercuts the commonly made marriage between Buddhism and self-help/self-development. 

As a therapist utilizing Buddhist tools and concepts, this necessarily presents a challenge. I don’t want to encourage salvational fantasies by directing clients deeper into a culture that promulgates them via the language of True Nature, Buddha Nature, Awakened One, and so on. On the other hand, if the carrot of enlightenment is not held out, whether explicitly or implicitly, what final vision of the individual is to be held? What is the purpose of engaging in this, or any other sort of therapeutic and/or spiritual practice? 

Undermining the modernist project presents a profound challenge to Buddhist-based clinical practice. It raises questions about the use of meditation to bolster well-being, and as a tool for the development of a psychologically robust individual. Ethically, it raises questions about the purposes that Buddhist practices are being put, and their true compatibility with the liberationist aims found in much traditional Buddhism. 

Non-philosophy, non-Buddhism

I continued to explore relevant work on the Internet as such questions simmered. Eventually, I discovered the Speculative non-Buddhism (SNB) website, which had been founded in 2011 by Glenn Wallis, a former professor of religion at the University of Georgia. SNB provided precisely the sort of critical engagement with Western Buddhism, informed by a vast array of modern and postmodern theory, that I’d long been looking for. My discovery of this online hub of critical thought was extremely important for my developing relationship with Buddhism. It also further disrupted whatever certainties I had formerly held around the role of therapist. 

My initial encounter with SNB was marked by reading Tom Pepper’s 2001 essay, Buddhist Anti-Intellectualism, which hit me like an intellectual bomb. Pepper’s critique of Buddhism went well beyond anything I had heard before. His description of how Dharma centers in the West resisted Western philosophy and engaged in “spiritual snobbery” captured my own sentiments, and reinvigorated my relationship with Buddhism as a site of critique. 

Pepper argues that Western Buddhism’s anti-intellectualism is rooted in and nourished by its over-focus on “experience,” which effectively serves as a retreat from thought. While this is an understandable “reaction to the desolate landscape of post-modern thought,” Pepper argues “a more useful . . . response is to escape up, into the limits of philosophical rigor.” 

Wallis’s experimental text, Nascent Speculative Non-Buddhism (2013), leveraged another pivotal turn in my evolving relationship with Buddhism and clinical practice.  This work develops a heuristic that combines a variety of thinking tools, many of which come from Continental philosophy. Here, Wallis’s core influence is the work of François Laurelle and his concept of “non-philosophy.” By adapting it to create the concept of “non-Buddhism,” Wallis generated what is perhaps the most intriguing critique of Buddhism to emerge in this century. 

Non-philosophy is not a postmodernist concept per se. Rather, it emerges from an attempt to rethink philosophy, drawing on ideas found in Derrida and Heidegger. Laruelle posits a number of relatively simple concepts, but presents them in very complex ways. In part, this is because he is attempting to build a conversation about philosophy that does not fall into the “decisional matrix” that he identifies as being at the heart of all philosophical theory and practice. 

Laurelle’s  foundational concept is what he defines as decision: an unconditional, non-reflexive commitment to an ideology or thought-world. Laurelle notes that out of decision the world becomes the subject of philosophy, in the sense that the world is remade in the image of said philosophy through a dialectical splitting of the world, with the philosopher confusing the philosophizing image of the world for the world itself.

In transferring this concept to Buddhism, Wallis defines decision as a commitment to Buddhism as the source of truth. Buddhism provides a totalizing means of understanding the world and our selves in it, one that encompasses the whole person and their most intimate spaces of selfhood. Buddhist metaphysics provides a lens through which the world is seen and experienced. Despite Buddhist teachers’ claims to the contrary, it provides a perceptual filer. This is an important insight as it means that descriptions of experience within Buddhism are in part ideological and not pure, perfect reflections of reality. 

While drawing on postmodern thought and evidencing an acute awareness of the limits of modernity, Nascent Speculative Non-Buddhism does not embrace postmodern irony. True, it is playful and creative in its style, mirroring much of the rhetorical strategy of postmodern thinkers. But hidden within this ostensibly destructive prose is an aspiration for Buddhism to do more. There is a clear desire, dare I say hope, to find a way forward that incorporates relevant insights across ideational and geographical boundaries, and historical and cultural phases. Wallis describes today’s unprecedented opportunity to draw from this vast array as “the great feast of knowledge.”

Just as non-philosophy drags philosophy out of its own rarified sphere, robbing it of its specialness in the process, so does non-Buddhism demand that Buddhism test out its axiomatic claims in the world, beyond the gates of Buddhist ideology. This requires a meeting of minds across intellectual boundaries, a cross-cultural, cross-discipline explorative endeavor. 

Both Laruelle’s and Wallis’ work is radically democratic in that it seeks to liberate the subject from its dependency upon any totalizing system. Adapting non-philosophy to the practice of non-Buddhism supplies a creative ground for a democratized exploration of practices and thought beyond the rules, taboos and persuasive rhetoric of lineage holders and orthodoxy. 

I want to make clear that I am not arguing for the superiority of such an approach. I would simply argue that Wallis provides a novel Dharma door through his work on Buddhism by means of Laurellian thought. Seeing Buddhism as culture through the lens of non-philosophy, which itself is informed by and in conversation with the Western intellectual tradition, enables the development of form of meta-knowledge that remains tethered to Buddhist insights while dismantling Buddhist orthodoxies. 

Therapeutic Implications

Speculative non-Buddhism provided a vast array of conceptual tools for thinking about my coaching business and how it might best serve people who found mainstream Buddhism problematic and didn’t want to suspend their critical thinking skills at the Gompa door, but had no sense of where to go next. Increasingly, my clinical work specialized in critically engaging with Buddhist materials in conjunction with a similarly critical utilization concepts and practices associated with self-help, change work, maturation, personal development, waking up, gaining insight, training the mind, working with the body, and becoming more intellectually capable. 

Rather than seeing meditation as a means of connecting to the true nature of things, I viewed it one tool among others for grappling with the fact that ideological filters and decisional matrices necessarily structure and influence our understanding and experience. This perspective allowed me to reframe the therapeutic relationship as a creative dialog that allowed for a conceptual reframing not only of Buddhism, but also of the person engaging with practices such as mindfulness. 

In this sense, the Buddhist-based tool of mindfulness practice becomes a means of synergistically exploring and addressing the shared nature of subjectivity and the ideological currents that run through all spiritual practices. Therapy provides a dynamic space for thinking and experiencing beyond the decisional matrix of a given Buddhist tradition, as well as the overall cultural climate and its ideological thrust. If well realized, this process is not a means of liberation per se, but rather an act of liberation from the delusion of transcendence: In other words, a practice of immanence. 

Any system of thought and practice can steer its practitioners into a decisional matrix, and prescriptive forms of being and perceiving. From this perspective, a counseling intervention can be put into the service of liberating a client from the decisional matrix (e.g., traditional Tibetan Buddhism), whilst rendering the materials of Buddhism available as democratized resources that cease to hail the practitioner into conformist identities. This supports the client/practitioner in exiting the modernist-self and moving towards thought and insight that draw from the wider knowledge community. It offers an alternative to the more common subjective frames that encourage either retreating into pre-modernist desires and irrationality, or spinning off into postmodern cynicism and fragmentation. 

Metamodern Buddhists?

Recently, I’ve begun exploring the emerging body of work on “metamodernism” as a means of further developing and articulating my understanding of Western Buddhism(s), the purposes that meditation and mindfulness can serve, and the therapeutic act. 

Metamodernism is one among many labels that attempt to describe emergent cultural shifts that are moving beyond postmodernity in the arts and culture more widely. Vermeulen & Van den Akker and Abramson characterized it as capturing the desire to resolve the conflict between modernity and postmodernity. As a term, it has begun to appear tentatively in academic discourse, but is very much in its infancy and may never truly take off as a new marker for the current cultural zeitgeist. Nonetheless, its emergence is evidence of the need to respond to the diminished cultural status of postmodern theory, which is increasingly understood to have a very limited ability to respond helpfully to either our current cultural and artistic climate, or the religious and therapeutic landscape we inhabit. 

Metamodernism can be understood in a variety of ways. Vermeulen & Van den Akker describe it as a structure of feeling incorporating principles of multiplicity and paradox, as well as the loss of distance. Abramson sees metamodernism as the cultural milieu of the internet age, with characteristics such as collaboration and simultaneity that mirror aspects of internet culture. 

In terms of the individual, metamodernism offers a creative response to the certainties of modernity, which are no longer psychologically compelling, and the fragmented postmodern self, which undercuts purpose and meaning. Metamodernism recognizes that if the nature of the self is fluid, it still requires stable foundations in history. In contrast to postmodernism, there is a preference for the reconstruction and realignment of cultural resources, rather than purely deconstructive relationship with them. 

I believe that a metamodern paradigm might provide a means for religions to refind themselves in an appropriate relationship with the contemporary world due to its embrace of multiplicity and paradox. This is the framework that I have adopted in my therapeutic role with regard to both teaching meditation and reconfiguring spiritual concepts in interrelationship with a larger ecology of ideas, theories, and practices. Resources and relationships that I am particularly drawn to include Western psychotherapy and self-actualization, Shamanistic worldviews and their compatibility with process-relational ontology, and Buddhist concepts of emptiness, Buddha nature, and interdependence. 

All these concepts and many more can be explored critically within different systems of thought, and applied as practices within each framework for different ends. This encompassing of possibilities rooted in the material world of historic contingency and finitude reinvigorates the field of spirituality in terms of thought and practice without leaving aside intellectual engagement. 

In this context, a practice like meditation can serve multiple ends. Many people who come to my coaching practice would like to be able to embrace the irrational aspects of ceremony or deeper meditational insight without having to sign on to a preset belief system or identity. Exploring the complexity of selfhood within the context of the therapeutic relationship enables us to better understand and experience how we are individuals and collectively formed beings that are finite and rooted in history. We also gain better insight into how we are enmeshed in both individual and collective forms of ignorance, suffering and selfhood. Together, we unpack each line of inquiry that arises while drawing on a wide variety of materials and practices. 

Many of my clients might be loosely defined as a new category of practitioner, one that comes after that of “spiritual-but-not-religious.” They are basically secular. Yet, they find the rationalism, empiricism, and scientism of both atheism and secular Buddhism to be less than satisfying. And, they understand that all of these “-isms” are products of modernity. They desire a spiritual path of sorts. But, they want to remain fully aware of the problems of both religion and spirituality. They recognize that an affective practice is needed and that the term “spirituality” serves signify something of value. At the same time, they recognize that it is bogged down by a great deal of baggage. 

It could be said that we carry within us the seeds and consequences of both premodernity, modernity and postmodernity. Banishing the cultural legacy associated with one or more of these epochs can be seen as a form of denial, or an ostracism in which part of our shared selfhood is bypassed or alienated. The macro-cultural, historical phases that each of these terms designates is part of our shared human selves and history. They reference the diverse array of ideas, practices, and opportunities available as our identities and experiences of self become more fluid, yet necessarily remain rooted in our material existence and indebted to our collective past. 



Batchelor, Stephen. Buddhism without beliefs: a contemporary guide to awakening. Bloomsbury, 1997. 

Batchelor, Stephen. Confession of a Buddhist Athiest. Spiegel & Grau, 2010. 

Boon, Marcus and Eric Cazdyn and Timothy Morton Nothing: Three Inquiries in Buddhism (TRIOS Series) University of Chicago Press 2015.

Laruelle, François. Dictionary of Non-Philosophy. Translated by Taylor Adkins Univocal Publishing, 2013. 

Lopez, Donald S. Jr. Prisoners of Shangri-La: Tibetan Buddhism and the West. Chicago University Press, 1998. 

Loy, David. Nonduality: A study in comparative philosophy. Humanity Books, 1988.

Loy, David. The Great Awakening: A Buddhist Social Theory. Wisdom Publications, 2003. 

Lyotard, Jean-François. The Postmodern Condition: A Report on Knowledge, Manchester: University Press, 1989.

McLeod, Ken. Wake Up To Your Life. HarperOne, 2001.

McMahan, David L. The making of Buddhist Modernism. Oxford University Press, 2008.

Polt, Richard. Heidegger: an introduction. Cornell University Press, 1999.

Samuel, Geoffrey. Civilized Shamans: Buddhism in Tibetan Societies. Smithsonian University Press, 1993.

Van Schaik, Sam. Tibet: a history. Yale University Press, 2011. 

Wallis, Glenn. A Critique of Western Buddhism: Ruins of the Buddhist Real. Bloomsbury, September, 2018. 

Wallis, Glenn, and Tom Pepper and Matthias Steingass. Cruel Theory|Sublime Practice: Towards a Revaluation of Buddhism. EyeCorner Press, 2012.

Wallis, Robert J. Shamans/Neo-Shamans: Ecstasy, alternative archaeologies and contemporary pagans. Routledge, 2003.

Znamenski, Andrei, A. The Beauty of the Primitive: Shamanism and the Western Imagination. Oxford University Press, 2007. 


Abramson, Seth. “What Is Metamodernism?” Huffington Post (01/05/2017, Updated Jan 09, 2017)

Abramson, Seth. “Metamodernism: The Basics” Huffington Post (10/13/2014, Updated Dec 12, 2014)

Abramson, Seth. “Ten Basic Principles of Metamodernism” Huffington Post (04/27/2015, Updated Dec 06, 2017)

Chapman, David. “A bridge to meta-rationality vs. civilizational collapse” Meaningness (Last viewed 07/29/2018) 

Damico, Philip. “An Introduction to Metamodernism” The Metamodernist (February 18, 2017) introduction-to-metamodernism/ 

Gross, Rita M. “Buddhist History for Buddhist Practitioners” Tricycle (Fall, 2010)

Ivakhiv,  Adrian J. “Žižek and his Others” Immanence: ecoculture, geophilosophy, mediapolitics (UVM Blog) (November 24, 2009, last viewed 29/07/2018) 

McLeod, Ken. Unfettered Mind: Pragmatic Buddhism.

O’Connell, Matthew. “Post-Traditional Buddhism: The Quiet Revolution?” elephant journal (November 21, 2012)

Pepper, Tom. “On Buddhist Anti-Intellectualism and the Limits of Conceptual Thought” Speculative non-Buddhism (blog) (October 2011, last viewed on 01/03/2018) /2011/10/25/buddhist-anti-intellectualism.

“Postmodernism” Apologetics Index (Last viewed July 30, 2018)

Sobol, Hokai. Personal website.

Žižek, Slavoj. “From Western Marxism to Western Buddhism” Cabinet Magazine, Issue 2 Mapping Conversations (Spring 2001)

Journal articles

Brassier, Ray. “Axiomatic heresy: the non-philosophy of François Laruelle.” Radical Philosophy 121 (2003): 24-35.

Clasquin-Johnson, Michel. “Towards a metamodern academic study of religion and a more religiously informed .” HTS Teologiese Studies/Theological Studies, Vol 73, No. 3 (2017). 

Glynn, Simon. “The Freedom of the Deconstructed Postmodern Subject.” Continental Philosophy Review 35: P.61-76 (2002)

Laruelle, François. “A Summary of Non-Philosophy.” The Warwick Journal of Philosophy, Pli 8 (1999): 138-148.

Vermeulen, Timotheus, and Robin van den Akker. “Notes on metamodernism.” Journal of Aesthetics & Culture Volume 2, 2010, no.1 (Published online: 25 Jan 2017).

Wallis, Glenn.Nascent Speculative Non-Buddhism.” Journal for the Study of Religions and Ideology, vol. 12, issue 35, (Summer 2013).

Yousef, Tawfiq. “Modernism, Postmodernism, and Metamodernism: A Critique.”
International Journal of Language and Literature, Vol. 5, No. 1 (June 2017): 33-43


Paul Smith, Anthony. “History of Non-Philosophy: From Philosophy I to Philosophy IV, Or What’s Behind the Move from the First Non-Philosophy to the Second” A Symposium on Non-Philosophy, University of Warwick, UK, (March 5th 2010, last viewed 07/29/2018)


Peacock, John. “Buddhism Before the Theravada.” Insight Meditation Center Audiodharama. (Septemer 3rd/4th 2011)

Buddhist Geeks Podcast,

Chapman, David. “18. On stages of maturation, Dzogchen & the future of Buddhism.” Interview by Matthew O’Connell on January 6, 2017. Imperfect Buddha Podcast: 

Dunne, J. “Awakening to Buddha Nature.” Upaya Zen Center (January, 2012)

Freinacht, Hanzi. “Metamoderna” Interview by Tom Amarque Podcast on February, 17, 2018. Audio:

Ivakhiv, Adrian. “11. On Immanence & a world after enlightenment.” Interview by Matthew O’Connell on May, 30, 2016. Imperfect Buddha Podcast: 

Sobol, Hokai. “On Buddhism.” Interview by Matthew O’Connell on May 26, 2007. Imperfect Buddha Podcast:

The Dharma Overground

Wallis,  Glenn. “16. On non-Buddhism.” Interview by Matthew O’Connell on September 16, 2016.  Imperfect Buddha Podcast:


Žižek, Slavoj. “The Irony of Buddhism.” Zizekian Studies Channel, Youtube (Published, August 14, 2015)

Zen training in the U.S.: tradition, modernity, and trauma

Mushim and son at Green Gulch Farm Zen Center in 1990 when she was a penniless single mother, following six years of monastic practice under a vow of poverty. (Photo credit: Jack Van Allen)

Moderator’s note: Many practitioners of Asian medicine and Asian-based health modalities are grappling with questions concerning the historical roots and cultural status of their disciplines today as never before. In response, Asian Medicine Zone is launching a new series of practitioner essays exploring how changing conceptions of “tradition” and “modernity” are impacting their practice and field in the 21st century (these are organized under the tag “tradition/modernity”). If you’re interested in contributing to this seriesplease email a short description of your proposed essay to the moderators. Here, we’re pleased to share our first offering, which artfully explores the encounter between traditional patriarchal authority and contemporary social justice commitments in the author’s life, practice, and community.

Having spent over 30 years of my adult life as a Buddhist practitioner in the U.S., I’m certain of only one thing, which is this: in the process of spiritual maturation, the path is not always clear and straightforward. In my personal experience as a practitioner, there’s been a lot of both/and – a particular experience can be abusive and traumatic, and it can lead to insight and breakthrough. Necessary spiritual surrender can mix potently with what Western psychology calls poor boundaries. And, it seems to me, some people will always be drawn to take paths of greater risk in varying degrees, up to so-called crazy wisdom. Others will develop by staying true to conventional mores with quiet patience.

In 1984, I was living as a renunciant under a vow of complete poverty in a Buddhist community in the United States. Our teacher, a strong-willed Asian man, resided most of the time in Canada, with periodic visits to our startup temple in the Midwest. Probably like most of our convert Buddhist community, I had moved into the temple full-time with a great deal of hope and projection that the teacher, who was described by his senior students as a Zen master and enlightened being, would be my major role model of elevated qualities of compassion and wisdom as I somehow imagined them to be.

I had immediately been appointed office manager and treasurer when I moved into the temple. I started the office with a landline phone, a cardboard box for petty cash and receipts, a checkbook, and a small wooden bench that could be used as a tiny desk if one sat cross-legged on the wooden floor. There wasn’t enough money in the bank to pay our utility bills and mortgage when I moved in, so we cut every corner and pinched every penny.

It was under these pressured circumstances that I was quietly working in the office when the “Zen master” suddenly walked in and began screaming at the top of his lungs at me for making a long- distance phone call for business reasons during a time when rates were higher. As Zen students, we were taught to “eat the blame,” so I did, and simply apologized until he went away. A few days later, having complained to the temple director who told him that the reduced rate times for calling were different in the U.S. than in Canada, he sheepishly reappeared in the office and said he hadn’t had full information. This was somewhat short of an “I’m sorry I unfairly vented my rage on you.” But it was the best I could get under the circumstances.

I couldn’t talk to anyone outside our temple system about such incidents because they would immediately say, “Why don’t you leave?” And the fact was, I was also learning a great deal. There were so many beautiful aspects of our communal temple life of meditating together and manual work, cooking and cleaning and eating together. The teacher was also immensely talented and caring in many ways. It was confusing, and in the Buddhist practice we were doing, it was okay not to know everything at once.

Traditional Zen stories and Zen lore are full of anecdotes that involve hitting and yelling and enduring unfair accusations. By the time I became a renunciant, I was an adult woman with a master’s degree. I’d been married and divorced. I had worked various jobs in the secular world. And I’d been exposed to the women’s movement and lived through the civil rights era in the U.S. I was open to going through some strong, and even traumatizing experiences for the sake of spiritual training.

Things continued to be a dynamic mess. I ended up in an Asian monastery for 8 months in 1987-88. There, my life and identity as I had known them continued to be blown up. As I said some time after I returned, I felt as though I got completely chewed up by the patriarchy.

It is also completely possible that if I had been smarter and had better boundaries, I wouldn’t have ended up as badly as I did.

But I survived. I got back to California, and, struggling continuously with extreme poverty, raised a Buddhist child, and continued my practice. I promised my son and myself that I would find a way to live in Buddhist community where power was more equally distributed, and codes of ethics and democratic structures were in place. Buddhist life might continue to be a mess. But I wanted, at minimum, a more workable mess that aligned with my cultural values. I distinctly remember thinking, upon returning to the U.S. from the Asian monastic system, “I don’t have to get my way, but I will be damned if I don’t at least get to vote. I am an American, and I want my vote!”

I didn’t want to overthink any of this. All systems and forms have limitations, and attachment creates suffering – this is a universal principle of Buddhism which I personally have never found to be untrue. That being said, the reason I began Zen meditation in the first place was because I wanted to find a situation in which I could live with other people with forms of practice that encourage well-being, kindness and justice, while at the same time providing support for Awakening. And I’ve been fortunate, because I’ve spent the last eleven years working with others to create a diverse and social justice-centered urban meditation center in Oakland, California, where I live. For me, and for many others, East Bay Meditation Center has been the intersection of Dharma practice and community-based social justice activism and awareness where I can constantly explore Liberation in ways that don’t separate the spiritual world from the real experiences of structural violence that I experience or witness every day.

As a Buddhist teacher at East Bay Meditation Center, I teach in trauma-informed ways that I have learned as a yoga student from the social justice-based Niroga Institute in Oakland, California. The traditional forms of spiritual training that require students to withstand humiliation and abuse from those above them in a hierarchical model are, I’m convinced, not essential to a 21st century Eightfold Path. Why? Because for most people, especially those in communities targeted for oppression, life is already full of traumatic humiliation and abuse. What we need are ways to become resilient, whole, and wise in seeking environmentally sustainable ways to coexist nonviolently and joyfully.

My Bodhisattva vows, the same as millions of others who have taken these vows, are “to save the many beings.” Where the rubber meets the road is that we are different from one another, love is not always the answer, and conflict is inevitable. I’m fine with this particular dynamic mess of imperfection, as long as it’s worked with in the service of systemic justice and equity.

Water Blog, Part Three: Li Shizhen on Terrestrial Waters

The first part of my blog on the Therapeutic Use of Water in the Bencao gangmu (click here to read it) contained an introduction and brief survey of the content of the whole text, and the second part (see here) covered the first section of Li Shizhen’s volume on Water: the thirteen entries on “celestial waters” 天水, or in other words, on the various kinds of water that fall from the sky. The following information concerns the second, and considerably bigger section, namely the thirty entries on “terrestrial waters” 地水. As in the previous post on celestial waters, the historical illustrations below come from Vivienne Lo’s wonderful collection of images from the Shiwu bencao (Materia dietetica), a dietetic herbal in four volumes dating from the Ming period (1368-1644) found here ( For other illustrations relevant to medical history, visit the Wellcome collection here and type in your search terms.  If you are more interested in my personal thoughts and a less nerdy approach, you might enjoy my personal blog here.

After covering the thirteen types of water that come out of the sky (rain water, downpour water, dew, sweet dew, sweet dew honey, brightness water, winter frost, snow from the dead of winter, hail, summer ice, divine water, half sky river, and leaky roof water; for explanations and details, read my earlier blog post), let us now look at the waters that come from, pool on, or run over the earth. Given that this section is more than twice as long as the section on celestial waters, I will not cover each entry, nor completely translate the ones I do discuss, but pick and choose based on entertainment value, clinical applicability, historical relevance, or my personal whim. If I have omitted a type of water that you urgently need to know about or additional explanations, indications, or attached formulas, post your question as a comment to this blog, and I promise to answer it. I may eventually publish a complete translation in book form….

Terrestrial Waters

Running Water


The explanations found in this entry offer valuable insights into Li Shizhen’s understanding of medicinal efficacy and the way in which a substance is affected by its surroundings. I believe that most of us modern people, used to eating lifeless greenhouse strawberries in February and heavily processed food from distant continents out of plastic containers, cannot even begin to comprehend the reasoning expressed here. It is just one more expression of this notion of “resonance” (ying 應) that strikes me as the foundation of the classical Chinese way of living in harmony with the universe. In the initial general explanation to this section, Li Shizhen himself comments that flowing water refers to rivers, streams, creeks, and brooks, which all share the characteristics of moving on the outside but being still by their inner nature, and of being soft in substance but hard in Qi. He then emphasizes the importance of distinguishing running water from the stopped water of lakes, marshes, ponds, and reservoirs. In addition, the muddy waters in the larger rivers differ from the clear waters in smaller streams. As proof for the importance of these differences, Li reminds us of the drastic difference in the nature and color of fish living in each, in the outcome of tempering swords or dying cloth with each, and in the flavor of rice porridge or tea cooked with each. So how could we not take this into consideration when preparing medicinals!

Known to traditional medical practitioners and contemporary translators by the technical terms “thousand-mile water” 千里水, “east-flowing water” 東流水, and “sweet-billowing water” 甘爛水,” Li claims that these substances are the most efficacious for decocting medicinals and keeping spirits at bay. They are indicated for the Five Taxations and Seven Damages–a common term referring to debilitating conditions of emptiness taxation, with the seven damages explained in the Zhubing yuanhou lun 《諸病源候論》 as food damage, anxiety damage, drinking damage (i.e., due to alcohol), bedchamber damage (i.e., due to sexual intercourse), hunger damage, taxation damage, and damage from taxation of the channel and network vessels and ying wei 營衛 provision and defense Qi damage)–; for kidney vacuity and spleen weakness; for Yang exuberance and Yin vacuity; for inability to close the eyes; as well as for dysentery, vomiting and diarrhea and for threatened bentun Bolting Piglet syndrome after cold damage. Water that is moving countercurrent, on the other hand, is indicated for wind strike, sudden reversal, head wind, malaria, all sorts of throat conditions, and vomiting of phlegm rheum.


In the following “Elaboration” section of the entry on Running Water, Li Shizhen quotes various authorities to make sense of the above indications: Thousand-Mile Water and East-Flowing Water flush out and rinse away evil and filth and hence are good for restraining and exorcising spirits and ghosts. According to our friend Sun Simiao, river water has journeyed far from its spring and thus homes to the sea with the force of its current instead of flowing upward. Thus it is perfect for treating conditions like headache by inducing a downward movement. “Sweet-Billowing Water” is explained as water that has been whipped up a thousand times with a ladle until it appears frothy. This process changes the nature of the water from being salty and heavy to being sweet and light. As a result, it no longer assists the kidney Qi but instead boosts the spleen and stomach. Water that moves in the direction of the current flows downward by its nature and therefore treats patterns in the Lower Jiao and lumbus and knees, while also promoting defecation and urination. Rapidly flowing water with its fierce urgency and downward pull can treat conditions like stopped urination and defecation or wind Bi syndrome. Water that is moving countercurrent, such as in eddies, is by its nature upward-moving contrary to its regular flow and is therefore indicated for promoting the ejection of phlegm rheum. As the greatest proof for the efficacy of running water, Li cites a story about Zhang Congzheng 張從正 successfully treating a patient suffering from urinary block that other practitioners were unable to cure. After decocting the same medicinals in urgently flowing water from long rivers, one drink restored urination!

Well and Spring Water, Well Blossom Water, and Freshly Drawn Water

As anybody who works with historical formulas knows and as Li Shizhen demonstrates with the 29 new and old formulas he has attached to this topic, well and spring waters are important ingredients for a wide range of conditions. Indications range from cleaning dog and insect bites or infected wounds with it, to inducing vomiting and diarrhea to treat arsenic poisoning by drinking freshly drawn well water; consuming large amounts of plain water to counteract alcohol poisoning or sudden retching from taking excessive doses of medicine; drinking a bowl of water with honey mixed in for heart oppression with sweating and loss of consciousness; using the first water drawn from a well at dawn to treat bad breath by holding it in the mouth and then spitting it out in the outhouse or to induce childbirth by having the woman drink it; and making newborn babies cry out by sprinkling them with cold water. 

The information in the introduction to Well and Spring Water and the two following entries on Well Blossom Water 井華水 and Freshly Drawn Water 新汲水 explains the reasoning behind these usages: First off, Li cites Wang Ying 汪穎, author of  the Shiwu bencao 《食物本草》 (“Materia Dietetia”), as his authority: “Freshly drawn well water treats illness and benefits people, and the first water drawn at dawn, called Well Blossom Water,  is extremely broad in its applications and different from all other water. Well water that comes from far away in the earth’s veins is best; water that has seeped in from nearby rivers and lakes is second. Water in the cities that is close to ditches and canals and has sewage mixed in forms must be boiled vigorously….” Li Shizhen continues: All water under heaven functions identically in extinguishing fire and irrigating withered plants. And yet, its nature is transformed by the earth and its material quality changed by things, until it is no longer identical. For example, brocade is brilliant in color when washed in Sichuan water; spring water from the mountains in Shanxi cure abscesses because of the alum; and bathing in the sulfurous hot springs in the foothills of Western China cures pestilence. 

Even the water coming out of a single well is different in effect and must be chosen carefully: For example, Well Blossom Water, drawn at dawn, is indicated for alcohol-induced heat dysentery while Freshly Drawn Water is indicated for heat dysentery and strangury, and red and inhibited urination. Well Blossom Water is used for treating bleeding in the extremities and all orifices due to extreme fright, for settling the heart and calming the spirit, for fermenting alcohol and vinegar to avoid spoilage, and for decocting Yin-supplementing medicinals and for medicinals for phlegm, fire, Qi, and blood. Freshly Drawn Water, on the other hand, dispels evil and attunes the center, brings down heat Qi, disperses welling abscesses, and resolves various toxins.


The “Elaboration” section (fa ming 發明) on Well and Spring Water provides fascinating background for Li Shizhen’s thinking, mostly supported by other textual authorities: Always use freshly drawn clear spring water when using water to treat illness, and avoid stagnant, muddy, warm water. Freshly Drawn Water and Well Blossom Water contain the One Genuine Qi of Heaven 天一真氣 floating on the water’s surface and are therefore used to decoct Yin-supplementing medicinals and to prepare alchemical substances. They are equal in their quality and flavor to snow water. Wells and springs are the veins of the earth 地脈, and the blood in human veins resembles this. So you must use deep water from dense earth, from distant sources and of pure quality. Humans are produced from the earth and their natural endowments are mutually linked with and affected by the Qi of the mountains and rivers. Thus their beauty or ugliness, longevity or premature death are all mutually affected. Metals and stones, herbs and trees, all adapt to the inherent nature of the water and soil, so how could this not be true for humans, as the most divine of the ten thousand things, as well? Each region and soil create humans of its type: Mountain Qi means more males and Marsh Qi more females; water Qi more muteness and wind Qi more deafness; forest Qi more infirmity and tree Qi more hunchback; Qi below cliffs means more swelling, stone Qi more strength, and Qi in dangerous and obstructed places more goiters; summerheat Qi means shorter life and winter-cold Qi means longer life; valley Qi more bi Impediment Syndrome and hill Qi more mania; and so on and on.


After all this evidence to show the intimate relationship between humans and their environment and the resulting importance of choosing water for medicinal uses carefully, Li Shizhen abruptly changes the topic to discuss hydrotherapy. He tells the following story: A woman had been suffering for years from a chronic illness identified as an “influx of cold and heat” 寒熱注病. At the height of winter, the famous Han dynasty physician Hua Tuo instructed her to sit in a stone trough, and at dawn began a treatment of pouring cold water over her, stating that this treatment must be repeated a hundred times. After receiving seventy cold showers in this manner, the woman was shivering and close to death. The person pouring the water was scared and wanted to stop, but Hua Tuo would not permit this. When she had received eighty pourings, the hot Qi finally exited with great noise from the top of her head in a cloud of steam two to three feet high. When she had received the full treatment of a hundred pourings, Hua Tuo made her lie down on a warm bed over a burning fire, covered with a thick quilt. After a good long while, cold sweat came out, and she was dusted with powder and was cured.

In a similar story, a general had taken too many preparations of “Five Stone Powder” 五石散, an addictive and toxic mind-altering mineral-based drug popular in medieval China that purportedly consisted of five minerals like fluorite, quartz, red clay, stalactite, and sulfur. As a result, he was suffering from cold, forcing him to wear warm clothing even in summer. Diagnosing this condition as “latent heat,” the physician Xu Sibo 徐嗣伯 insisted that it could only be treated by effusing it through hydrotherapy in winter. So he waited until a time of abundant snow and ice at the height of winter and then made the general sit naked on a stone. He had a total of twenty bushels of freshly drawn cold water poured over his head until his patient’s mouth clenched shut and his Qi expired. The general’s relatives wailed and cried, asking the doctor to stop, but he seized and struck the person who had criticized him. After he had used a hundred bushels of water, the general began being able to move, with a great display of Qi on his back. After a while, he sat up, complained of unbearable heat, and begged for a cold beverage. The physician gave him a pint of water to drink, and his illness was cured. Thereafter he often felt hot, only wore thin clothing in winter, and was generally stout and strong. 

Li Shizhen explains that both of these treatments are cases of latent fire, which was effused by dousing the patient with cold water at dawn around the time of the solstice, when Yang Qi is inside but just starting to break out. Breaking the fire by cold causes it to be stimulated and released through the sweat.

Miscellaneous Other Waters

 Pig trough and urine ditch water

Pig trough and urine ditch water

In the following entries, Li Shizhen covers a range of waters to be found on the earth, from waters drawn during specific seasons to water from special springs, caves, seawater, or springs in cliffs. Lastly, he discusses various poisonous waters and their medical applications. Without going into details here, it makes sense, as Li states, that the specific Qi in each of the 24 seasonal nodes 節氣 affects the quality of the water drawn at this time. In a universe where everything is related to everything else and where Heaven and Earth resonate with each other, not only the time of day when the water is collected but also the time of year affects its Qi and therefore its potential effect as a medicinal. Thus, water drawn on the first day of spring or during the “tomb-sweeping” (Qingming) festival two weeks after the spring equinox is indicated for all sorts of wind conditions, for the spleen and stomach, for deficiency, and for alchemical preparations and medicinal liquors. Water drawn in the seasonal nodes of winter is best for supplementing the five Zang organs and treating phlegm fire, accumulations, and worms and toxins. Drinking just one cup of water drawn before noon on the first day of autumn can treat malaria and dysentery and the “hundred diseases in both old and young people.”


Following this section are a number of entries of water from special springs. For example, water from springs in mountains that contain jade will make the body hair black and increase longevity, just as the vegetation in these mountains is luxurious because it is exposed to this treasure. Water from caves with stalactites is greatly beneficial. It is concentrated and heavier than normal water. Consuming this water will make the person fat and healthy and stave off aging, just like the effect of consuming stalactites (shizhongru 石鐘乳) directly. Concerning hotspring water, the sulfur deep down makes the water hot and causes it to have a foul-smelling odor. Sulfur is indicated for all sorts of sores, so this water has the same effect. Bathing in it causes the Qi of sulfur to enter the skin. Arsenic hotsprings, however, are poisonous to bathe in. In general, bathing in hotsprings is indicated for spasms and contractions in sinews and bones due to wind, for bi Impediment in the flesh and skin, paralyzed limbs, lack of eyebrows and hair on the head, for scabies and for problems in the skin, joints, and bones. When done with the bath, one is greatly deficient and fatigued and can take medicine in accordance with the condition or supplement and nourish health with food and drink. Healthy people should not lightly enter hotsprings.


Next there is a fascinating line that might actually refer to the phenomenon of bioluminescence, which I myself got to experience last summer while swimming under a new moon in the Puget Sound: The entry for “Jade-green Sea Water” 碧海水 explains that when one stirs the water while moving in the sea at night and there are fiery stars, this is saltwater. Because its color is jade-green, it is called “jade-green sea.” Reinforcing my own love of the sea and practice of immersing myself in it almost daily, Li Shizhen comments: “The sea is the meeting of the hundred rivers. Heaven and Earth and the four directions are all connected with each other by the waters of the sea, with Earth in its center.” Bathing in it gets rid of wind-related itchy and scabby skin conditions. 

 dish washing water

dish washing water

Let me finish this blog with a few curiosities: Water from old burial mounds is toxic and will the person if drunk, but can treat all sorts of sores by washing them in it. Water in earthen grain jars from old tombs is good for treating ghost Qi, being struck by malignity, and demonic infixation, for heart and abdominal pain, nightmares of ghosts and spirits, and for killing roundworm. In the interest of scientific objectivity, Li notes that rinsing the eyes with it will cause one to see ghosts, but that he has not personally tried this. It is, however, divinely effective for treating hiccup. Drinking one bowl of pig trough water may be disgusting but will treat gu poisoning! It can also be used for washing out snake bites. For serious cases of dispersion thirst, you can make a patient drink a small bowl of city latrine water, but do not let them know (for obvious reasons). Lastly, this volume concludes with some general rules that are good to know: Water houses the palaces of dragons, and you must be cautious not to offend them. Washing the face with old cooking liquid, as I have personally done in the steppes of Mongolia when fresh water was too precious a commodity to waste on bathing, will cause one to lose color. Washing the head with cold or hot water creates wind in the head, which is particularly dangerous for women. Here I may add that this warning is still heeded by traditionally minded women in Asia and elsewhere who avoid swimming in cold water or washing their hair during menstruation and the postpartum recovery period. Bathing in cold water after a seasonal disease injures the pericardium, bathing in it in exuberant summer-heat causes cold damage. Entering cold water after sweating causes bi Impediment Syndrome in the bones. Bathing after childbirth causes convulsions and often death. Drinking cold water when intoxicated causes tremor in the hands. Drinking tea after drinking alcohol causes liquor aggregations. Drinking water and then going right to sleep causes water aggregations. Finally, when walking long distances in the summer months, do not immerse the feet in cold water, and when walking far in the winter months, do not immerse them in hot water. So much for dipping your feet in an icy mountain stream or cool ocean while playing at the beach this month…




Water Blog, Part Two: Li Shizhen on Celestial Water


The first part of my blog on the Therapeutic Use of Water in the Bencao gangmu (found here) contained an introduction and brief survey of the content of Li Shizhen’s grand opus in general. Now we are finally ready to jump into the blue stuff itself! The pictures below come from Vivienne Lo’s wonderful collection of illustrations from Shiwu bencao (Materia dietetica), a dietetic herbal in four volumes dating from the Ming period (1368-1644) found here. For other illustrations, visit the Wellcome collection here and type in your search terms.

The section on Waters is the first of 16 major parts (bu 部) in this text, and the second shortest section, about twice as big as the one on Fires and just a bit shorter than the one on Earths, which are the next two sections in the text. After these three innovative sections, the main body of the Bencao gangmu follows a more traditional format with sections on Metals and Stones, Herbs, Grains, Vegetables, Fruits, Trees, Clothes and Utensils, Bugs, Scaly Creatures, Shelled Creatures, Birds, Quadrupeds, and, last but most definitely not least, Humans. The section on Water is divided into two large categories (lei 類): Celestial Water 天水 and Terrestrial Water 地水, which are further subdivided into 13 and 30 “types” (zhong 種) respectively. Because this text is just so much fun to read, I couldn’t help translating or excerpting much of it here. Let us first look at Part One, namely water that comes from Heaven, or in less poetic terms, falls out of the sky:

Celestial Water 天水

The category of Celestial Water is comprised of various types of natural precipitation that fall from the sky, from different kinds of rain to dew, hail, snow, frost, condensation gained by exposing a large clam shell or copper and tin vessel to the moon (mingshui 明水 or fangzhushui 方諸水), and even “leaky roof water,” which refers to water that comes dripping through a leaky roof in a rainstorm.

 Plum rain water (aka rainy season rain)

Plum rain water (aka rainy season rain)

  1. Rain Water: As a general introduction to Celestial Water in the first entry on “Rain Water” 雨水, Li Shizhen cites a famous Suwen 5 line and relates it to human sweat: “Earth Qi ascending constitutes clouds; Heaven Qi descending constitutes rain. Hence the sweat of humans is named the rain of Heaven and Earth.” 地氣升為雲,天氣降為雨,故人之汗,以天地之雨名之。Classified as salty, balanced (between cold and heat), and non-toxic, rain is then further subdivided into three varieties with different properties:
    1. Rain at the beginning of spring has the two main indications of being “divinely efficacious” for making babies when husband and wife each drink a cup and then retire to the bedroom, and of being suitable for decocting dispersing medicines and those that supplement the center and boost Qi. Because it is imbued with the uplifting, generative, and effusing Qi of spring, another quote states in the paragraph marked as “Explanations,”, it can be used to decoct medicine for insufficiency of center qi and for failure of clear Qi to ascend. The reason why It was used for fertility in ancient times, this text explains, is because it provides for the initiation and development of the myriad things.
    2. Rainy season rain is good for washing scabs and making scars disappear. But Li Shizhen comments that this substance comes from warm-damp places in the south and makes people sick. 
    3. Early winter rain is indicated for killing the hundred bugs and is thus an appropriate substance to use for decocting medicinals that kill bugs and disperse accumulations. When the hundred bugs drink this sort of rain, the text explains, they go into hibernation underground until they hear the thunder of the next spring.

2.     Downpour Water: This substance is classified as sweet, balanced, and non-toxic. It is indicated for decocting medicines to attune the spleen and stomach and get rid of damp heat. To explain this effect, Li Shizhen quotes the famous hereditary physician Cheng Wuji 成無己 (1063-1156): “The reason why Zhang Zhongjing uses Downpour Water for decocting the ingredients in Mahuang Lianqiao Chixiaodou Tang 麻黃連翹赤小豆湯 to treat cold damage from static heat in the interior with generalized yellowing is that its flavor is thin and it therefore does not assist the damp Qi.”

 Autumn dew water

Autumn dew water

3.     Dew: Being sweet, balanced, and non-toxic, dew is the fluid of Yin Qi. It is the Qi of the night that adheres to things and moistens them. Collected in a bowl in autumn and simmered down to a syrupy consistency, it extends people’s years and alleviates hunger. Because it is “endowed with the Qi of austere killing” (due to its association with the season of autumn), it is suitable for decocting lung-moistening and evil-killing medicinals and for mixing into the various powders for treating scabies, ringworm, bugs, and leprosy. Collected in autumn from the tips of herbs before the sun has started shining on them, it cures the hundred diseases, stops dispersion thirst, and makes the person’s body light and without hunger and the flesh glistening. Collected on the first day of the eighth lunar month, used to grind up ink, and painted on the Taiyang points, it stops headaches. Painting a spot on Gaohuang treats taxation sickness. This is called Heavenly Moxibustion. Dew from on top of the hundred flowers gives the person a beautiful complexion.

 Profuse dew water

Profuse dew water

4.     Sweet Dew: Listed as a separate category, this auspicious substance is also known as “heavenly liquor” or “spirit sauce” and is described as “the essence of divinity, sheen of humane auspiciousness, congealed like lard, and sweet like syrup.” According to one text, it descends onto pine and cypress trees when the king reveres and nurtures the elderly, and onto bamboo and reeds when he reveres the paragons of virtues and treats the masses with magnanimity. According to other sources, it descends when the star Tianru 天乳 (Heaven’s Nipple) shines with bright luster or is found in special locations such as on Mount Kunlun 崑崙. Either way, it is an auspicious omen and is indicated, when eaten, for “moistening the five Zang organs, lengthening years, avoiding hunger, and turning the person into a spirit immortal.”


5.     Sweet Dew Honey: This is another rare syrup-like substance. It is a sugary “frost” that is purportedly produced in Arabia in autumn by collecting dew and exposing it to the sun. It is indicated for all sorts of heat in the chest and diaphragm, brightening the eyes, and quenching thirst.

 Fangzhu water, aka "brightness water"

Fangzhu water, aka “brightness water”

6.     Brightness Water: An alchemical substance with different explanations in various textual sources, it is a fluid of a Yin essence that is gained by exposing a mineral, a large clamshell, or a metal (copper or tin) object to the moon. It brightens the eyes, settles the heart, gets rid of vexing heat in small children, and quenches thirst.


7.     Winter Frost: Being “congealed dew when Yin is exuberant,” it kills things, as opposed to dew, which moistens and thereby enriches things. Sweet, cold, and non-toxic, you can consume it to resolve the heat from liquor, cold damage nasal congestion, and generalized heat and a red face after drinking.


 snow from the dead of winter

snow from the dead of winter

8.     Snow from the Dead of Winter: Related to the fact that snow is cleansing, this substance “washes away miasms, epidemics, bugs, and locusts.” It is indicated for resolving all poisons and treating medical conditions like seasonal warm epidemics, small children’s heat seizures with manic crying, adult people stirring due to cinnabar and mineral [poisoning], fulminant heat after drinking alcohol, and jaundice. It can also be used to prepare tea or cook porridge to resolve heat and stop thirst. It treats all the diseases mentioned above because it is the water of great cold.


 hail water

hail water

9.     Hail is the Qi of Yin and Yang struggling with each other and therefore categorized as poisonous. Alternately, it is described as Yin wrapped around Yang, as opposed to sleet, which is Yang wrapped around Yin. Eating it will make you sick.


 summer ice

summer ice

10.  Summer Ice: Li Shizhen explains that ice (bing 冰) is the essence of Taiyin and, as the extreme state of water, resembles earth in that the transformation of softness becomes hardness, which is a case of the extremes of things changing entirely into their opposites. Hence the Chinese character for ice consists of water plus two ice crystals. It is indicated for getting rid of heat vexation, for effusing heat and swelling from “stones” in the breast, and for resolving vexing thirst, summer-heat toxin, yang poison in cold damage, and heat stroke, which you treat by placing a piece of ice on the center of the chest.  It also resolves alcohol poisoning. In the Explanation section of the entry on Summer Ice, we find the stern warning that eating ice in the abundant heat of summer is the opposite of the season and not recommended because heat and cold strike each other as they enter the abdomen, causing all sorts of illness. Li Zhizhen offers a story about Song emperor Huizong eating too much ice and contracting spleen disease that numerous physicians were unable to cure as a warning example. Finally, Yang Jie cured the condition by giving Da Lizhong Wan, which he prepared by decocting the ingredients with ice, to treat the source of the illness by using the cause of the illness.

11.  Divine Water: This ingredient is collected by catching the drops trickling out of the center of a bamboo pole cut quickly when it rains at noon on the fifth day of the fifth month. Citing no secondary source, Li Shizhen states that it treats masses in the heart and abdomen and worm disease and should be taken by mixing it with otter liver into pills. Alternatively, you can drink it to clear heat, transform phlegm, settle fright, and calm the spirit.

12.  Half Sky River: According to a citation from the illustrious alchemist and commentator on the Shennong bencao jing Tao Hongjing, this substance, which is also called “upper pool water,” refers to water found on top of bamboo fences or in tree hollows. Li Shizhen then cites a story that Bian Que gained his X-ray vision, allowing him to see patients’ internal organs after drinking this substance. It is indicated for ghost infixation, mania, malign poisons, Gu toxin, killing spectral entities, and insanity, and should be drunk in secret, without telling others about it.

 leaky roof water

leaky roof water

13.  Leaky Roof Water: Even though this substance is classified as toxic and inedible, it is suitable for washing out dog bites, spreading on warts, and for rubbing on cinnabar toxin.


The third part of this blog on Water will cover the second half of Li Zhizhen’s information, on Terrestrial Water, 地水.

The Therapeutic Use of Water in the Bencao gangmu, Part One: Introduction to the Text




This post is written in preparation for a lecture I will be giving while soaking in the hot springs at Ojo Caliente in New Mexico, in the framework of a retreat on Chinese herbs and the Chinese medicine classics taught by Z’ev Rosenberg and myself in Taos on August 19-23, 2018. For more information on that retreat, see here. My interest in water is obviously also inspired by my current life on the Puget Sound on Whidbey Island where I go wade, swim, and play in the blue stuff almost every day.

 Thanks to my daughter for modeling as a mermaid.

Thanks to my daughter for modeling as a mermaid.

While late Imperial China is not my specific area of expertise, I have always been intrigued by Li Shizhen 李時珍 and his grand masterpiece, the Bencao gangmu 本草綱目 “Classified Materia Medica,” and consult it frequently in my research in medical history. Anybody interested in the natural sciences in Chinese history needs to read Carla Nappi’s wonderful book on the subject, titled The Monkey and the Inkpot: Natural History and Its Transformations in Early Modern China! If you haven’t, the following information is meant to give you a little taster.

To provide a bit of historical background, this text was composed in the late Ming 明 dynasty and was perhaps influenced by three developments relevant to natural history in China:

1.     The Ming dynasty (1368-1644) was a return to indigenous Chinese rule that followed after the Yuan 元 dynasty (1279-1368) when China was under Mongol control. While undoubtedly traumatic and associated with a horrendous loss of Chinese lives and cultural treasures, China’s incorporation into the Mongol empire also resulted in the creation of a multicultural, multiethnic society with a vibrant exchange of knowledge, substances, languages, religions, artefacts, and peoples all over central Asia, connecting Europe to India to China. As part of this diverse culture, medicine in China became more exposed than ever to the theories, clinical techniques, and medicinal substances of Greek, Arabic, Tibetan, Mongolian, and Indian medicine. In addition, the Mongols eventually succeeded in reunifying the north of China with a much more developed south.


2.     The cultural openness, confidence, and dynamism of the early Ming dynasty, exemplified by the famous seven voyages of Admiral Zheng He in his fleet of “treasure boats” between 1405 and 1433 was abruptly replaced with xenophobia and isolationism, especially after a humiliating defeat of the imperial army at the hands of the Mongols in 1449. Rather than collecting tributes in the Indian Ocean and bringing home giraffes from Africa, the Ming rulers turned their focus to defending against Northern invaders by fortifying what would become known as the Great Wall.

3.     The cultural and economic development of the Jiangnan region south of the Yangzi from the Song period on introduced different diseases into mainstream Chinese medicine. Consequently, both medical theory and clinical therapy expanded, as exemplified by the School of Warm Diseases 溫病 and an emphasis on supplementation of weak deficient Southern bodies. From the Ming dynasty forward, famous literati physicians tended to come from medical lineages in the Jiangnan area.

Against this backdrop, Li Shizhen 李時珍 lived and worked in the late Ming dynasty (1511-1593). Descended from a medical family, he ended up becoming a doctor like his father after he failed the highest level of the civil service examination. Besides being an accomplished physician and compiling one of the greatest books of Chinese natural history and eleven other medical texts, he was a voracious reader, skillful poet, and dedicated scientist and naturalist who spent decades traveling throughout China for his textual, oral, and clinical research. In his relentless pursuit of knowledge, he interviewed countless local sources and interacted with people from all backgrounds. He is reported to have poisoned himself repeatedly by experimenting on his own body and investigating the objects of his research directly by dissection, close observation, and even smelling and tasting. The reader should be warned that Li’s passion for research in his subject matter may be contagious and that it is easy to get lost in the plethora of mind-bending stories in his book.


The Bencao gangmu is undoubtedly one of the greatest books ever written in Chinese history, published posthumously by Li’s sons in 1603. Based on 27 years of research, it summarizes 40 bencao (materia medica) texts and 361 other medical sources, consulting a total of 932 texts, as listed in the bibliography! In the spirit of the Neo-Confucian “investigation of things” 格物, Li Shizhen embraced direct empirical research in combination with thorough studies of all relevant literature, to examine all sorts of natural phenomena and their effect on humans. In 53 volumes, almost 2 million characters, and 1892 main entries or categories (綱 gāng), which are further subdivided into specific entries (目 ), it classifies 1892 substances (plants, animals, “stones,” and objects employed, derived from, or otherwise related to humans) and offers 11,000 formulas for their medical use. The entries include clearly marked subsections identified as

·      “Elucidation of names” 釋名: Including sometimes lengthy lists of alternate names and discussion thereof, this philological preoccupation with naming can be traced back to the Confucian emphasis on “rectifying names” 正名 as an important aspect of scholarly activity.

·      “Collected explanations” 集解: A collection of quotations from a wide range of literature and contemporaneous local informants, with a critical discussion by Li Shizhen himself, on the object and its natural history, lifecycle, varieties and distinguishing features, myths and stories, and other general information. This is a goldmine of facts and fiction for any natural historian;

·      Separate entries on the specific parts used and their preparation and processing as a medicinal substance 修治;

·      Qi (i.e., thermodynamic quality) and flavor 氣味, including information on toxicity and substances to avoid while taking it, also faithfully quoting disagreements in the literature;

·      Indications 主治: The clinical uses of the substances, as traced through the bencao literature up to Li Shizhen’s time;

·      Elaboration 發明: Perhaps the most useful part for clinically inclined readers, this section elaborates on the reasons why the substances has the effect on the body described in the “Indications” section.

·      “Attached formulas”: This section not only cites earlier sources, written and oral, but also includes Li’s personal experience, thereby providing great insight into the actual clinical use of the substance in the late Ming period.




Probably the most innovative feature of the Bencao gangmu is the classification of substances: In the earliest edition of the earliest transmitted bencao text, the Shennong bencao jing 神農本草經 (“Divine Farmer’s Classic of Materia Medica,” translated and published by yours truly here), contains 365 substances categorized into three levels associated with Heaven, Humanity, and Earth in that order, based on their effect on the body and with generally increasing levels of toxicity. This text does employ the system of the Five Dynamic Agents 五行 to classify the substances according to flavor, but not as an organizing principle for the text itself. In his later edition from 492 CE, Tao Hongjing uses the distinction between minerals, plants, and animals, in that order as his main organizing principle, and then subdivides each of these categories into the three classes of Heaven, Humanity, and Earth. Subsequent materia medica text followed this general organization but changed the order to start with plants, followed by minerals, then animals, and ending with human substances.


In sharp contrast to his predecessors, Li Shizhen used the Five Dynamic Agents wuxing 五行 as the overarching paradigm for organizing all substances that affect the human body and therefore created the following major “parts” 部: Waters, Fires, Earths, Metals and Stones, Herbs, Grains, Vegetables, Fruits, Trees, Clothes and Utensils, Bugs, Scaly Creatures, Shelled Creatures, Birds, Quadrupeds, and Humans. Of these major parts, the first three (waters, fires, and earths) are a radical departure from previous bencao literature! The order of the wuxing here does not follow either the cycle of creation or the cycle of control, but instead is subordinated to what Carla Nappi describes as progressing “from the most fundamental to the most exalted.” These large “Parts” 部 are then subdivided further and further into “Categories” 類 and individual Entries 種. For example, we go from “bugs” to “egg-born bugs” to “bees,” or from “herbs” to “mountain herbs” to “gancao.” Besides this emphasis on correct classification and rectification of names, the organization of substances in this text also reflects the Confucian preoccupation with hierarchical ordering of the natural world, especially in the progression from plants to animals (and therein from bugs to scaly to shelled creatures to birds and then quadrupeds) and lastly to humans.

Among the main parts, the section on Fires is the shortest, with no separate “Categories” and only twelve Entries. The first of these is titled “Yin Fire and Yang Fire” and offers an introduction to the topic of fires. Here, Li states that Fire can be categorized into three “Guiding Principles” 綱 , namely Heaven Fire, Earth Fire, and Human Fire, and 12 “Entries” 目, perhaps because it “has Qi but no substance.” Part Two of this blog on the therapeutic uses of water in the Bencao gangmu will discuss the section on Waters in this text in greater detail. Stay tuned….. because right now the tide is high and it’s time for a swim…


Curing Illness with Meditation in Sixth Century China

This is a syndicated post that first appeared on BuddhistDoor
By C. Pierce Salguero

Buddhistdoor Global | 2018-06-29 |


Though he lived in the sixth century, Zhiyi (538–597) has a lot to teach the modern practitioner of meditation, whether Buddhist or secular. He is best known as the founding patriarch of the Tiantai school of Buddhism, widely considered to be the first native East Asian school, and thus a precursor to Chan and other later developments. Among the foundational writings of Tiantai are several treatises on meditation composed by Zhiyi.

Although it is popular to think of meditation as a solution for all kinds of illness, Zhiyi knew it was more complicated. In his Shorter Treatise on Samatha and Vipasyana (in Chinese, Xiao zhiguan), Zhiyi suggests not only that not all illnesses can or should be treated with meditation, but that meditation itself can be a cause of illness: one might be unskillful in harmonizing the mind, body, and breath, and thus fall ill. But he does advise eight different healing meditation practices.

These eight practices are divided into two categories. First are the calming meditations, or, as he calls them, employing the Chinese translation of the Sanskrit samatha, “stopping” meditations:

1. Settle the mind on the location of the illness.
2. Settle the mind on the dantian,* one inch below the navel.
3. Settle the mind on the soles of the feet.
4. Abiding calmly, remain aware that all phenomena (including the illness) are empty.

Next, Zhiyi introduces what he calls “seeing” meditations. Here he uses the Chinese translation of the Sanskrit vipashyana, although most are quite different from what contemporary meditators mean by the term vipassana. There are four practices in this category:

1. The Six Breaths, a Chinese exercise in which the practitioner makes the sounds “chui,” “hu,” “xi,” “he,” “xu,” or “si,” while exhaling in order to regulate internal processes.
2. The Twelve Respirations, which are different types of Indian breathing exercises (pranayamas) intended to regulate various symptoms of illness.
3. Visualization techniques in which one concentrates on one type of qi in order to counteract ailments caused by others. (He gives the example of concentrating on fire-like qi to cure cold in the body.)
4. Finally, Zhiyi mentions using both samatha and vipasyana together to “analyze the non-existent nature” of physical and mental illnesses, resulting in their spontaneous healing.

painting of Sramana Zhiyi, founder of the Tiantai school of Buddhism. From
Painting of Master Zhiyi, founder of the Tiantai school
of Buddhism. From

Lamentably, Zhiyi does not give us much detail on specifically how to practice the techniques mentioned in this particular chapter. (Zhiyi did write instructions on samatha and vipasyanameditation, much of which has been translated into English. [Chih-i 1997; Zhiyi 2009]) The most detailed descriptions he gives concern the specific medical applications of the Six Breaths and for the Twelve Resiprations.

For example, each of the Six Breaths should be used as follows:

Imagine each of the Six Breaths revolving around inside your mouth and between your lips, and then make [the sounds]. If you are in meditation, use chui when you are cold and hu when you are hot. In the treatment of illnesses, chui is for eliminating cold, hu is for eliminating heat, xi is for eliminating pain and treating wind, he is for eliminating mental troubles and also flatulence, xu is for breaking up phlegm and relieving congestion, and si is for replenishing exhaustion. If you are treating the Five Viscera, the two breaths of hu and chui can treat the heart, xu is for treating the liver, he is for treating the lungs, xi is for treating the spleen, and siis for treating the kidneys.

For the Twelve Respirations, he instructs:

Now, to explain how the Twelve Respirations relate to the treatment of symptoms: the upward respiration cures weight gain, the downward respiration cures feeling spent, the falling respiration cures emaciation, the scorching respiration cures bloating, the increasing respiration cures depletion [of the Four Elements], the dissipating respiration cures [their] excess, the warming respiration cures cold, the cooling respiration cures heat, the forceful respiration cures blockages, the retained respiration cures trembling, the harmonizing respiration completely cures disharmony of the Four Elements, and the nourishing respiration nourishes the Four Elements. One who is good at using these respirations can cure any and all afflictions—but, as you can infer from this, doing them wrong can cause even more afflictions to arise.

In closing the chapter, Zhiyi offers general reflections on the practice of healing using meditation. Advising the practitioner to become skilled in all of the eight techniques, he notes that he has only provided an overview, and that we should seek out more complete instruction. Above all, Zhiyi is emphatic that healing meditations help us cultivate various good qualities. He explicitly states that if one follows 10 “dharmas,” then one’s “treatments are guaranteed to be effective and will not be in vain:”

1. Faith in the effectiveness of the methods outlined in the text.
2. Regular practice.
3. Sustained effort.
4. Staying entirely focused on the object of the meditation one chooses.
5. Clearly discriminating the causes of illness (presumably in order to apply the correct meditation).
6. Using skill in choosing the right practice for the ailment in question.
7. Maintaining a long-term perspective and not giving up when results come slowly.
8. Knowing when to continue with a beneficial practice and when to abandon a non-beneficial one.
9. Avoiding mental distractions and moral transgressions.
10. Avoiding hindrances to practice such as pride and frustration.

Zhiyi lived in a very different religious and medical culture than we do today. Throughout the essay, we see that his notion of illness revolves around traditional Asian medical concepts, such as qi and the “five viscera” from Chinese medicine and the “four elements” from Indian classical medicine. However, it is quite possible that Zhiyi’s essay is describing contemplative techniques that can be proven to be efficacious in the modern context. At the very least, he is pointing out avenues beyond the current fixation on mindfulness meditation that merit further medical research and exploration.

* Qi or energy center.

C. Pierce Salguero is an interdisciplinary humanities scholar interested in the role of Buddhism in the cross-cultural exchange of medical ideas. He has a PhD in the history of medicine from the Johns Hopkins School of Medicine, and teaches Asian history, religion, and culture at Penn State University’s Abington College. He is the author of numerous books and articles on Buddhism and medicine, including Buddhism and Medicine: An Anthology of Premodern Sources.


Chih-i. 1997. Stopping and Seeing: A Comprehensive Course in Buddhist Meditation. Translated by Thomas Cleary. Boulder, CO: Shambhala Publications.

Zhiyi, Shramana. 2009. The Essentials of Buddhist Meditation. Translated by Bhikshu Dharmamitra. Seattle: Kalavinka Press.

Salguero, C. Pierce, ed. 2017. Buddhism and Medicine: An Anthology of Premodern Sources. New York City: Columbia University Press.

See more

Pierce Salguero

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The Seminal Suwen Chapters: A Blueprint for Human and Ecological Health


Given the fact that I am really busy right now finishing up my forthcoming book Humming with Elephants: The Great Treatise on the Resonant Manifestations of Yīn and Yáng (a discussion of the Yellow Emperor’s Inner Classic, Plain Questions 5 黃帝內經素問:陰陽應象大論) and getting ready for a busy spring lecturing season, my esteemed colleague Z’ev Rosenberg, professor emeritus and former chair of the Department of Herbal Medicine at the Pacific College of Oriental Medicine in San Diego, has kindly offered to help out. Incidentally, Z’ev and I will be teaching a “medical classics study and herb expedition summer retreat” in Taos, New Mexico, in August of this year, which will incorporate material from both of our books. For more information on that, see here. To read more about Z’ev and his ongoing projects, visit his website here. In the guest blog below, he is providing a brief excerpt from his long awaited brand-new book Returning to the Source: Han Dynasty Medical Classics in Modern Clinical Practice, which has just been released by Singing Dragon and promises to be a real gem. Here is a little taste:

The essential first three chapters of the Huang di nei jing Su wen set the stage for the core principles of Chinese medicine. These opening chapters contain the compass of life and medicine; the text reveals the equations that allow us to see how far we’ve deviated from the principles of life. As Wang Bing explains in his commentary of Chapter 3 in the Su wen:

“If one’s desires cannot fatigue one’s eyes, if the evil of lewdness cannot confuse one’s heart, if no recklessness causes fatigue, this is ‘clarity and purity.’ Because of one’s clarity and purity, the flesh and interstice [structures] are closed and the skin is sealed tightly. The true and proper qi guards the interior and no depletion evil intrudes… Those that are ‘clear and pure’ follow the order/sequence of the four seasons, …they do not cause fatigue through reckless behavior, and rising and resting follow certain rules. As a result, their generative qi is never exhausted and they are able to preserve their strength forever.”

Many modern practitioners of Chinese medicine criticize the seminal first three chapters of the Su wen as ‘fantasy’, about a world that no longer exists, of sages living in perfect harmony with the way (dào 道). The Su wen describes it as an ideal, as a way of living that even at the time of the Huang Di nei jing was long past. In Chapter 1 of the Su wen Huang Di asked Qi Bo:

“The people of high antiquity, in [the sequence of] spring and autumn, all exceeded one hundred years. But it their movements and activities there was no weakening. As for the people of today, after one half of a hundred years, the movements and activities of all of them weaken. Is this because the times are different? Or that the people have lost this [ability]?”

Qi Bo responded:

“The people of high antiquity, those who knew the Way, they modeled [their behavior] on yin and yang…. [Their] eating and drinking was moderate. [Their] risings and resting had regularity. They did not tax [themselves]) with meaningless work. Hence, they were able to keep physical appearance and spirit together, and to exhaust the years [allotted by] heaven. Their life span exceeded one hundred years before they departed.”

What many people don’t glean from the passage is that the Su wen presents the principles for the practice of ecological medicine, based on living in harmony with natural law and its influences on the intricacies of human health. This has been known since ancient times, first mentioned in the Mawangdui manuscripts, as nourishing life (yǎng shēng 養生). The ideal way of life attributed to the sages is based on the intrinsic harmony of heaven (sky) and earth, and the human being as an intermediary between these poles of existence. So right at the beginning of Chinese history, we are seeing that the human being has a profound influence on the world around us.

In modern times, the predominating dogma(s) in modern science, on the one hand, are that nature is unconscious, working according to Darwinian mechanisms that push survival and adaption forward. On the other hand, are the religious fundamentalists who believe that such phenomena as climate change are a hoax, and free-market evangelists who believe that energy companies should be deregulated and be allowed to despoil the environment in the name of economic need and job growth? Nowhere is this problem more acute than in mainland China, as we discussed above. The closest modern theory I could find from a scientist is James Lovelock and Lynn Margulis’ “Gaia Principle,” which states that the Earth is a living being that responds to our activities. One of the great sea changes of the scientific revolution in the West was the complete repudiation of what is called the vitalist principle, the concept of a life force in creation that animates all living and sentient beings, replaced by a more mechanistic view of life. In my opinion, this is the biggest rift between Western and Chinese medicine. And to the degree that Chinese medicine abandons so-called vitalism, it moves far from its Han dynasty sources.

According to the evidence, of course doctors should recommend acupuncture for pain

Last week, the BMJ published an invited head to head debate as to whether doctors should recommend acupuncture for the treatment of pain. Below is my rapid response:

What’s most interesting about this discussion of whether or not doctors should recommend acupuncture for pain is a total lack of discussion of the other available treatment options that doctors and patients decide amongst and how acupuncture compares in terms of efficacy, effectiveness, safety and cost-effectiveness. Surely this is the only reasonable starting point for any intelligent discussion about how healthcare resources should be utilized to best help this patient population.

If we continue for a moment to look at acupuncture in an artificial vacuum, as Ernst and Hrobjartsson have done here, there are a few things to note. First, the small effect size that they note of acupuncture over sham needling for pain, which given that the review in question discarded the most positive studies constitutes an underestimation,1 both demonstrates specific effects of acupuncture and at the same time, is a completely irrelevant comparison to determine ‘clinical effects.’2 Doctors and patients are not choosing between acupuncture and sham acupuncture needling control; they are choosing between acupuncture, paracetomol, NSAIDs, opioids, surgery, off-label, poorly tolerated, experimental medication in the case of migraines and fibromyalgia, and physiotherapy, all of which are limited in their ability to effectively treat pain whilst introducing considerable and measurable harm. Sham controlled acupuncture trials merely assess two different types of acupuncture needling. Both are often superior to conventional care in terms of pain reduction and improved quality of life, with the highest-quality evidence demonstrating a statistically significant benefit of acupuncture over sham needling, with an effect size greater than that of paracetomol compared to placebo for many types of pain.3

If we look at sham controlled studies of orthopedic surgery, we find not a small difference between surgery and the sham procedure but no difference at all.4 Clearly surgery and acupuncture have similar methodological challenges to being studied using the double-blind RCT study design held as the gold-standard for pharmaceuticals. If lack of practitioner blinding is such a powerful force as the authors suggest, surely this should have a much stronger effect in the case of surgery, which is more invasive and more expensive (factors that we’re told influence acupuncture outcomes), and yet there’s no difference between fake surgery and the real thing when it comes to reducing patients’ pain. It seems odd to argue against something with at least small specific effects and large non-specific effects (in other words, large proven clinical effects in helping patients reduce their pain) rather than something that’s ineffective, invasive and expensive to boot.

It’s also helpful to note that studies of placebo, including Hrobjartsson’s own research, repeatedly and consistently demonstrate that placebos are ineffective and while they can bring short-term benefits for subjective outcome measures such as pain, they don’t work in the long-term at all.56 This is diametrically opposed to what we see in acupuncture research. Acupuncture brings meaningful reduction in pain symptoms that persists at 12 months,7 as Dr Cummings has pointed out. No placebo has been demonstrated to do this so I’m curious if the authors are arguing that acupuncture is a particularly special placebo unlike any other that has ever been studied before. Of course, this would be special pleading, which is an argument firmly rooted in the authors’ own bias rather than faithfully interpreting the evidence in a consistent and objective way in order to best help patients.

If the authors’ reading of the acupuncture mechanism literature stops at the gate control theory as they have stated, I’m confused as to why they feel qualified to comment as subject experts. Specific mechanisms for acupuncture in pain control are numerous and well-documented, involving but not limited to peripheral effects mediated by purinergic signalling and nitric oxide release, spinal reflexes, modulation of endogenous analgesic biochemicals (including endorphins i.e. endogenous morphine, very effective for pain relief!), improved functional connectivity in the brain, modulation of parasympathetic activity and modulation of inflammatory signaling.8

Of course, the ability to articulate how a treatment works has zero relevance for clinical effectiveness, which is what we’re actually discussing. On the other hand, a recent review in this journal that found that paracetamol is even more harmful than generally appreciated, notes that the ‘mechanism of paracetamol’s analgesic action remains largely unknown.’9

This comes after another recent review of paracetamol for spinal pain and osteoarthritis, also published in this journal, that finds that “paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis” 10. In short, paracetamol is widely used and prescribed, increases the risk heart attack, stroke, kidney damage, GI bleeding and death, and we don’t know how it works which is moot because it doesn’t work anyways. In that light, doesn’t it seem a bit silly to debate whether or not to recommend a treatment that is repeatedly demonstrated to be efficacious, effective, cost-effective, and safe, where the only question is exactly how much of its sizable clinical effect is down to the specific effects through analgesia induced through mechano-transduction and how much is due to the ambiance of the acupuncture clinic or the caring disposition of the clinician?

Another mainstay of pain treatment in the NHS are NSAIDs. This class of drugs suffers from a paucity of long-term clinical data but are frequently prescribed indefinitely, despite serious risks. A recent review looking at over 400,000 patients, also published in this journal, found that “All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction” (which is fancy medical speak for ‘heart attack’) when taken for any time period, including as little as one week.11 A now out-dated and absurdly conservative estimate shows that the adverse effects of NSAIDs costs the NHS a median estimate of £251 million pounds a year.12 This figure is only based on the cost of treating GI perforation and doesn’t take into account any of the heart attacks and strokes caused by NSAIDs when taken as directed.

Of course, the harms caused by NSAID and paracetamol consumption pale in comparison to those of opioids, which are extremely addictive, frequently debilitating and often lethal (in the UK, deaths related to prescription opioids doubled between 2005 and 200913), which is why until a successful albeit illegal marketing campaign by their manufacturer in the 1990’s, oral opioids were only available as part of end-of life pain management for terminal cancer patients. In this light, it’s interesting to note that the first and only study ever performed on long-term effectiveness of opioids for pain-relief found that those taking opioids were actually in more pain than their non-opioid popping counter-parts.14 Talk about a poor benefit to harm ratio! While NICE guidelines for various pain conditions urge doctors to use these drugs sparingly and as a last resort, recommending against using acupuncture as a treatment for pain directly increases the usage of these drugs, which is clearly in no one’s best interest and makes the recommendations seem disingenuous.

As acupuncture has been repeatedly demonstrated to reduce the consumption of pain medication, including opioids and NSAIDs, surely a discussion of the cost of acupuncture should take this into account, given how much treating the harms of these drugs costs the NHS each year. Indeed, if we look at the cost-benefit ratio of what’s typically offered for pain, it would be more germane to discuss the cost to the NHS and harms to patients of not recommending acupuncture.

Compared to physiotherapy, acupuncture has a much stronger evidence base. As one point of reference, there are over 10,000 trials on Cochrane’s Central Register for acupuncture compared to under 7,000 for physio (ironically, this latter number includes studies of physios doing acupuncture). With this in mind, it’s interesting to note that physios frequently add acupuncture to their practice (the UK’s Acupuncture Association of Chartered Physios boasts over 6,000 members), often after very minimal training, contrary to World Health Organisation safety recommendations. It’s difficult to reconcile why physios would increasingly start using acupuncture if it didn’t work and their own tools that they learned in their training yielded satisfactory results in practice. Are you suggesting that physiotherapy techniques are so ineffective at treating pain that thousands of physios are offering a placebo to their patients instead?

Any discussion about which treatments should be recommended for pain that center on patients’ wellbeing and the allocation of precious healthcare resources should be based on a comparison of the benefits versus the harms of available treatments. This is self-evident. Such an approach, no matter how you slice the evidence-base, leaves acupuncture amongst first-line treatment options for pain, if not a clear winner. If Hrobjartsson and Ernst insist on banging the disproven placebo drum despite repeated demonstration of specific effects, clinical superiority over treatments that themselves are shown to be superior to placebo and despite the scientific community’s clear understanding of specific mechanisms of how acupuncture is able to achieve these results, then the discussion we should be having is not about the ethics of recommending placebos. Rather the discussion would need to be about the ethics of recommending treatments that fail to outperform or in some cases are inferior to a treatment that you claim is s placebo, all while exposing patients to considerable and avoidable harm. That’s the only logically consistent reading of your suggested interpretation. So let’s have a discussion about the ethics of that.

In the interest of patients and the responsible provision of healthcare resources, I sincerely invite the authors to explain: if not acupuncture for pain, then what do they recommend instead and based on what evidence? If they are unable to provide evidence of a more effective treatment, one with stronger evidence of positive effect, one that does not unacceptably harm patients, then perhaps a reconsideration of providing such a respectable platform for such outdated and un-evidenced opinions is appropriate, as it directly puts patients at risk while impeding access to a proven and effective treatment for a poorly treated affliction.

The post According to the evidence, of course doctors should recommend acupuncture for pain appeared first on A Better Way To Health.