Substance Abuse

CASE
SUBST
STANCE
A CASE STUDY OF SUBSTANCE ABUSE
DEPRESSION
AND DEPRESSION by Damian Carey

The author, engaged in the pursuit of Mental Health

CONTENTS
Page
Introduction
Introduction
History
Case Histor y
Aetiology
Pathogenesis
Oriental Medicine Diagnosis, Aetiology and Pathogenesis
Treatment
Oriental Medicine Treatment
Aetiology
Treatment
Western Medicine Aetiology and Treatment
Research
Discussion
Conclusion
References

1
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2
2
4
6
7
8
9

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INTRODUCTION
The purpose of this paper is to demonstrate the application of an Oriental Medicine approach to psychotherapy* in clinical practice. This case study of substance abuse and depression is a good example of a single acupuncture treatment applied in confluence
with
specific psychotherapeutic counselling, yielding successful results.
This case is then placed in the context of: 1) current research on acupuncture as a treatment for substance abuse and depression and 2) the current status of mental health service in Australia.
The paper concludes by 1) questioning the research methodology which is crucial to formulating public and professional perception of the value of Oriental Medicine in the treatment of mental health disorders; and 2) underscoring the value of psychotherapy in confluence with acupuncture treatment.
* “Psychotherapy: The treatment of mental and emotional disorders through the use of psychological techniques designed to encourage communication of conflicts and insight into problems, with the goal being relief of symptoms, changes in behaviour leading to improved social and vocational functioning, and personality growth.” The American Heritage Dictionary of the English Language, Fourth Edition

CASE HISTORY
Tom, 27 year old male, musician/teacher.
Presenting Complaint
Tom was struggling to overcome an long term pattern of prolific, daily smoking of marijuana. He had smoked marijuana for eleven years and had been a heavy user for the past seven years.
Pr
Associated Problems
Depression, pessimism and melancholy; loss of motivation; suicidal thoughts; poor memory and concentration; fatigue; cold hands and feet; red facial rash.
P ulse
The general pulse quality was flooding, slippery and slightly rapid. In the Spleen and
Lung positions the pulse was swelling at the superficial levels, but lacked intrinsic strength.
Tongue
Swollen tongue body with red sides and tip; thin phlegmy coat
Abdomen
Tender in the lower lateral abdomen and along the Kidney channel.
General Health
Good; fit and active. Tom appeared to have a bright and cheery personality.
History
Family Histor y
Tom’s father was diagnosed with depression. His grandmother had exhibited signs of depression. Several of Tom’s extended family have been regular marijuana smokers.
Treatment
Previous Medical Diagnosis or Treatment
None.

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ORIENTAL MEDICINE
ORIENT
DIAGNOSIS, AETIOLOGY AND PATHOGENESIS
Diagnosis
Spleen Qi deficiency with Stagnation of Qi and Blood in the Lower Jiao and Phlegm
Fire disrupting the Heart.

Aetiology and Pathogenesis
Pathogenesis
The dominant signs in this case are of excess: Stagnation of Qi and Blood, Liver and
Heart Fire and accumulation of Phlegm. But underlying all of these is a pattern of Spleen
Qi deficiency. This is demonstrated by the swollen tongue with the thin, phlegmy coat.
The Spleen Qi deficiency has led directly to an accumulation of Phlegm and a Stagnation of Qi and Blood in the lower abdomen, the presence of which further weakens Spleen.
The long term drug use has damaged Yin, leading to Empty Heat, compounded by the actual inhalation of heat, regarded as Exogenous Pathogenic Fire. This Heat has affected the Liver and Heart and combined with Phlegm to disrupt Heart Shen, hence the depression and melancholy.

Analysis of Signs and Symptoms
Sign / Symptom
Swollen tongue body with a thin, phlegmy tongue coat

Indication
Phlegm/Damp from Spleen Qi deficiency

White tongue coat

Cold in Spleen

Red sides and tip of tongue

Liver and Heart Fire

Flooding pulse in the Spleen and
Lung positions, lacking intrinsic strength Deficiency of Spleen and Lung Yin with
Empty Heat

Slightly rapid pulse

Heat

Slippery pulse

Pathogenic Factor (Phlegm/Damp)

Abdominal pain

Stagnation of Qi and Blood

Depression and Melancholy

.

Spleen Qi deficiency;
Phlegm Heat disrupting Heart Shen

(Wiseman & Ellis, 1996; Maciocia, 1994; McLean & Taylor, 2003; Xinnong, 1980)

ORIENTAL MEDICINE TREATMENT
Principle
Treatment Principle
The primary aims of treatment were to strengthen Spleen while simultaneously moving Qi and Blood in the lower abdomen in order to break the cycle of Phlegm accumulation. In addition, treatment was directed towards: 1) resolving the Phlegm
Heat disruption of Heart Shen; and strengthening Kidney Zhi, or will.

Points
Acupuncture Points and Methodology
The pre-eminent pattern for moving Stagnant Qi and Blood in the Lower Jiao is the
Chong Mai, particularly relevant in this case because of it’s association with releasing stagnant emotion. (Carey, 2005) The following points were used:

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Point
Gongsun (Sp 4)

Function/Action
Master point for Chong Mai
Fortifies Spleen
Resolves Phlegm and Dampness
Calms the spirit
Benefits the Heart and chest

Neiguan (Pe 6)

Couple point for Chong Mai
Loosens the chest and regulates qi
Regulates the Heart and calms the spirit
Clears Heat and Phlegm

Zusanli (St 36)

Harmonises the Stomach
Fortifies the Spleen and resolves dampness
Tonifies qi and nourishes blood and yin
Clears fire and calms the spirit

Qichong (St 30)

Regulates qi in the lower jiao
Regulates the Chong Mai

Guanyuan (CV 4)

Fortifies the original qi and benefits essence
Tonifies and nourishes Kidney
Warms and fortifies Spleen
Regulates the lower jiao

Shanzhong (CV 17)

Regulates qi and unbinds the chest
Meeting point for Qi/influential point for breathing

Zhongzhu (Kid 15)

Regulates the lower jiao

Zhishi (Bl 52)

Residence of the Will
Tonifies Kidney and benefits the essence

Pishu (Bl 20)

Tonifies Spleen Qi
Resolves dampness

Xinshu (Bl 15)

Tonifies and nourishes Heart
Regulates Heart Qi
Calms the spirit
Unbinds the chest and resolves blood stasis
Clears Heart Fire

Feishu (Bl 13)

.

Tonifies Lung Qi and nourishes Lung Yin
Clears Heat from Lung

(Deadman & Al-Kafaji, 2000; Ellis, Wiseman & Boss, 1991; Maciocia, 1994)
These needles were applied with even method in two stages. Gongsun, Neiguan and Zusanli were applied unilaterally with bilateral application of the abdominal points.
These needles were retained for forty minutes. The patient then turned face down and the Bladder channel points were applied and retained for a further thirty minutes.

Counselling/Psychotherapy
Counselling/Psychotherapy
Several specific ideas were discussed with Tom prior to the acupuncture treatment and re-emphasised after the treatment. First of all, characteristics of the Chong Mai were explained along the following lines:

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“ The Chong Mai treatment challenges the patient to re-assert themselves and to take affirmative action to re-claim their emotional integrity. A Chong Mai treatment will often include a sense of emotional release which will commonly occur within two days of the treatment. A Chong Mai treatment is purgative; it expels pathogens and moves
Stagnant Qi and Blood; psycho-emotionally it has the effect of expelling unresolved emotion. A Chong Mai treatment is appropriate for anyone experiencing an intense emotional state which is being denied or unexpressed; it allows the patient to re-define their emotional priorities.” (Carey, 2005)
This explanation focused Tom’s mind on the process and supported his expectation of imminent change. The action of several points was also explained, particular the action of Gongsun, Neiguan, Shanzhong and Zhishi. Tom was thereby given a vision of a treatment targeted towards removing blockages and supporting his will, which is the stated functions of the individual points utilised. Emphasis was given to the fact these points were used in confluence, so that an effect greater than the sum of the individual points was being triggered.
Tom was then counselled to focus his intention on making a decision to cease his marijuana addiction independent of its available supply.
Finally we discussed Tom’s future plans to generate an independent business based on his music teaching abilities. This placed the focus of the immediate treatment into the context of Tom’s unfolding life path.

Assessment of Outcomes
Nine weeks after the treatment Tom has not used marijuana and is adamant he will never again be a regular smoker. This is what he reported to me:
“The day after the treatment I felt distinctly unsettled. I had told myself I would have one last fling, which I did that evening. The next day I felt seriously depressed. I spent the whole day in bed, stressing about my situation and talking with my girlfriend.
By that evening I faced the decision squarely and ‘click’ it all fell into place. A great weight immediately lifted from me and I climbed out of my depression. It felt like a final fight between two parts of myself. Until the acupuncture treatment I hadn’t ever been able to make a clear decision. I could feel a strong sensation in my lower back all weekend [around Zhishi]. Since that treatment life has turned on its head. I feel fabulous and very positive.”
It is evident that Tom has overcome his addiction, at least for the moment. Time will tell if this sustains over the months and years, though there is a strong indication that, at the least, Tom has gained a new perspective on his previous habit. Tom’s own will, the acupuncture and the counselling, all working in confluence, have contributed to this outcome. WESTERN MEDICINE AETIOLOGY AND TREATMENT
Substance Abuse
Substance abuse, dependence or addiction are very common, affecting one in five people at some point in their life. Substance abuse is characterised by compulsive, continued use of a drug despite negative consequences. (Greene, 1996, pages 756-757)
Marijuana is the most commonly abused of the illicit drugs. Marijuana intoxication leads to feelings of euphoria, increased appetite and distortion of time and space perception; some individuals can experience hallucinations, palpitations and panic attacks.
Marijuana is known to reduce motivation. (Greene, 1996, pages 758)

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“Chronic use of ... marijuana can ... result in persistent, typically depressive, mood changes.” (Flaws, 2004, page. 324)
Treatment for Marijuana Abuse
There is no physical dependence with marijuana, so complete cessation does not induce withdrawal symptoms. The primary requirement for treatment is for the patient to acknowledge the addiction. Treatment consists of education, social support and psychotherapy. (Greene, 1996, pages 759-760)

Depression
“Psychiatrists refer to the entire constellation of problems known to accompany depressed mood as the depressive syndrome.” (Greene, 1996, pages 730-731) The central feature of depressive syndrome is a mood of sadness, hopelessness or despair. This may be accompanied by additional signs such as diurnal mood variation, psychomotor retardation or agitation, lack of interest and withdrawal from friends and family, fatigue, depressed libido, poor concentration, memory loss, disturbances of appetite and sleep and reduced motivation and productivity. Depressed individuals usually suffer from low self esteem and regularly contemplate death and suicide. Researchers estimate as many as
15% of individuals with major depression succeed in killing themselves. Major depression is defined when an individual experiences at least five of the above listed signs for at least two weeks continuously. (Greene, 1996, page 732)
Aetiology of Depression
“The etiology of mood disorders is not clearly established within conventional Western medicine” though “... studies have demonstrated consistent associations between abnormal levels of specific neuro-transmitters and depressed mood.” (Flaws, 2004, page
325)
Depression may be linked to a variety of organic origins, including:
- medication;
- endocrine disorders;
- neurologic disorders;
- infectious diseases;
- cancer;
- auto-immune disorders;
- nutritional deficiencies;
- blood electrolyte disturbance; or
- substance abuse. (Greene, 1996, page 732)
Where no organic origin can be established, depression may be linked to:
- bereavement; or
- maladaption to stressful life events. (Greene, 1996, page 733)
In other cases individuals can experience long term depression and unhappiness without necessarily having all the indications for a major depressive episode. This is known as a dysthymic disorder and is often associated with a maladaptive personality structure. (Greene, 1996, page 733)
Depression appears to be often linked to “... experiences of major loss in adulthood as a whole. [Depressed individuals are] particularly susceptible to shortcomings in the quality of ongoing social support. However, the onset [of depression] ... is often provoked by a severely threatening event in the most recent period—particularly ‘loss’”
(Brown et. al., 1993)

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Treatment of Depression
The standard western medical treatment regime for depression is medication and psychotherapy. A range of antidepressant medications are available to the physician including tricyclic antidepressants and serotonin reuptake inhibitors. Psychotherapy can be cognitive behavioural therapy, which utilises mood monitoring and re-education of negative thinking patterns, or psychoanalysis, which attempts to explore the personal historical origins of depression. Both medication and psychotherapy are recommended to be maintained for at least several months to allow the patient to re-adapt to a normal life. In cases of severe depression that do not respond to medication, electroconvulsive treatment can be used. (Greene, 1996, page 734)

RESEARCH
Research on Acupuncture for Addiction
Studies on acupuncture’s efficacy as a treatment for addiction offer conflicting views:
“Claims that acupuncture is efficacious as a therapy for ... addiction are not supported by results from sound clinical research.” (Ter Riet, Kleijnen & Knipschild, 1990)“
“Acupuncture was not superior to sham acupuncture for smoking cessation; no particular aspect of acupuncture technique was associated with a positive effect. The conclusions are limited by methodological inadequacies of studies.” (White, Resch & Ernst, 1997)
“At this stage, there remains insufficient evidence to support the use of natural and complementary therapies as a primary intervention for substance use disorders.” (Dean,
2005)
Despite this insufficiency of evidence, there remains a view that acupuncture can be successfully applied to addiction treatment:
“Although none of the treatments reviewed is as well supported by evidence as standard treatments such as antidepressants and cognitive behaviour therapy ... there is some limited evidence to support the effectiveness of acupuncture [as a treatment for depression].” (Jorm, et. al., 2002)
“Incorporating acupuncture into existing programs [for addiction treatment] offers a promising approach.” (Otto, 2003)
Even the National Institute of Health in the USA agrees: “Based on evidence reviewed during the 1997 NIH Consensus Conference, the NIH Consensus Development
Panel conservatively recommended that acupuncture may be used as an adjunct treatment, an alternative, or part of a comprehensive management program for ... addiction”
(Hui)
In a review of research literature on the use of acupuncture as a substance abuse treatment, the Lincoln Medical and Mental Health Centre drew a more forthright conclusion: “... results from controlled studies generally support that acupuncture can be effective in assisting active drug and alcohol users become abstinent.’ (Brewington et. al.,
1994)
Research on Acupuncture for Depression
Studies on acupuncture’s efficacy as a treatment for depression are more positive:
“Acupuncture appears promising as a treatment for depression, but requires further research.” (Jorm et. al., 2002)
“The amount of rigorous scientific data to support the efficacy of complementary therapies in the treatment of depression is extremely limited. Areas with most evidence for beneficial effects are exercise, herbal therapy and, to a lesser extent, acupuncture and relaxation therapies.” (Ernst et.
al, 1998)

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“Compared to other empirically validated treatments, acupuncture designed specifically to treat major depression produces results that are comparable in terms of rates of response and of relapse.” (Gallagher, et. al., 2001)
Psychotherapy
Research on Oriental Medicine and Psychotherapy
Standard Chinese Medicine texts*, which provide the basis of TCM education in
Australia, include ample discussion on the emotional correspondences of the Zang Fu and the Five Phases. Extrapolation of these frameworks into the realm of psychotherapy is rare. A notable exception is Pulses and Impulses which offers a sophisticated analysis of the emotional correspondences of the Zang Fu (Townsend & Dedonna, 1990, pages 126148). Only occasional journal articles offer discussions in this area. (Lucas; Floyd; Weber
& Hoedeman)
In lecture notes for the Master of Acupuncture/TCM course at the University of
Western Sydney, John McDonald offers a detailed description of the emotions in relation to the Zang Fu and the Five Phases, and then highlights how these manifest in healthy and unhealthy conditions. He goes on to describe strategies for optimal emotional
expression for each of the Phases and thereby makes a strong contribution to an Oriental Medicine/
Psychotherapeutic framework. (McDonald, 2005)
No formal research studies on this subject have been found by this author.
* such as Maciocia’s Foundations of Chinese Medicine, Kaptchuk’s The Web That Has No Weaver, Bensky
& O’Connor’s Acupuncture: A Comprehensive Text and Ross’s Zang Fu.

DISCUSSION
Mental health services throughout Australia have recently been the subject of much negative publicity with the release of the report ‘Not For Service: Experiences of Injustice and Despair in Mental Health Care in Australia’. (Mental Health Council of Australia,
2005) This report highlights lack of support for mental illness sufferers. When major depression and manic depression reach extreme levels in an individual, their lives and the safety of those around them can become seriously threatened. Many such people are turned away from hospital admissions to end up being dealt with by the police. (Mental
Health Council of Australia, Submission #178)
Tom, in this study, had not yet come to the attention of the police or Mental Health
Service. If he had experienced a severe downtown in his condition, there is a good chance Tom would have received no institutional help. John Mendoza, of the Mental
Health Council of Australia, says only a limited number of people with mental illness, actually get the treatment they need: “It’s certainly less than half and the best available figures point to around 38 per cent.” (Mendoza, 2005)
The dual challenge for public health policy lies in recognising depression in its early stages and then delivering effective treatment in order to avoid more serious consequences. Oriental Medicine has a distinct advantage over Western Medicine in its ability to meet both of these challenges. If the anecdotal evidence for acupuncture’s efficacy in treating substance abuse and depression is correct, as suggested by this case study, then public money directed towards a preventative mental health program incorporating acupuncture would be well spent.

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CONCLUSION
CONCL
This case raises two questions: “How can the acupuncture profession demonstrate the efficacy of acupuncture in treating substance abuse and depression to an recognisable level in order to contribute to Australia’s mental health services?” and “To what extent was the psychotherapeutic counselling pivotal in achieving a successful result, as distinct from the use of acupuncture alone?”
The first question has two answers: Firstly, the development of neuro-imaging tools, such as positron emission tomography (PET) and functional magnetic resonance imaging
(fMRI), make non-invasive studies of acupuncture’s effects on human brain activity possible. “These powerful new tools open the possibility to new scientific studies of this ancient therapy.” (Shen, 2001) Secondly, the acupuncture profession needs to re-claim the debate on what constitutes a valid research study. “It is time to stop referring to double-blind RCTs as a ‘Gold Standard’ for research. This is a pharmaceutical industry hoax ... because only pharmacy ... can use double blinding. As a profession ... we need to insist that either the Cochrane criteria are fixed, or they are rejected in favour of something more sensible like the Birch criteria.” (McDonald, The Bulletin Board, 2005)
The second question is not so easily answered. Psychotherapist Pauline Lucas, in an article from the perspective of an acupuncture client, found that TCM explanations complemented her own body-mind understanding; she noted that psychotherapy opened up suppressed feelings while acupuncture similarly opened up blocked energy channels.
(Lucas)
I would argue that by treating the body while simultaneously engaging the mind, the resulting therapeutic benefit must be considerably augmented. A practitioner well versed in Oriental Medicine theory and with a clear understanding of psychology can focus a patient’s consciousness on the point of disharmony in the mental-emotional realm and thereby facilitate a process of internal re-orientation and emotional healing. This process, in confluence with acupuncture treatment, generates a powerful resonance within the patient. This subject has implications for the on-going refinement of acupuncture technique and intention. I believe many Oriental Medicine practitioners would instinctively or deliberately utilise similar approaches. It is hoped this paper will encourage further discussion and exploration in this field.

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