The Experience of Acupuncture for treatment of Substance Dependence

Clinical Scholarship The Experience of Acupuncture for Treatment of Substance Dependence Kunsook Song Bernstein Purpose: To ex plore the m eaning of substance abusers’ ex perience w hile receiving acupuncture as a part of the treatm ent for substance dependence. Design: Phenom enology. Eight participants w ith diagnosis of substance dependence w ere selected for the study. T he participants w ere in an inpatient setting w ith detox ification and rehabilitation program s provided to substance abusers. Methods: In 1997, eight substance abusers w ho had accepted acupuncture as a part of their treatm ent for substance dependence w ere interview ed about their ex periences w ith acupuncture treatm ent. D ata collection included interview s w ith each of the subjects, the researcher’s field notes, and dem ographic data obtained from the participants’ m edical records. T he verbatim transcripts of each of the interview s w ere analyzed using G iorgi’s m odification of phenom enological m ethod. Findings: A nalysis of the data after one treatm ent w ith acupuncture indicated seven m ajor them es: anticipation of pain, apprehension concerning a new ex perience, m ood elevation, inability to describe the ex perience, physical sensation, relax ation, and im proved sleep. Conclusions: T he substance abusers’ ex periences w ith acupuncture revealed an acceptance of a new treatm ent m ethod, and dem onstrated potential for healing through integration and balance. Further research is indicated to assess the effects of repeated treatm ents. J OURNAL OF NURSING SCHOLARSHIP, 2000; 32:3, 267-272. © 2000 SIGMA THETA TAU I NTERNATIONAL. [Key w ords: substance dependence, acupuncture, phenom enology, healing] * S ubstance abuse is a major public concern and the problem continues to increase despite efforts by the government and health care professionals to control it. Researchers, the public, and government officials have growing interest in causes and consequences of substance abuse. A better understanding of these problems is needed, along with ways to improve efforts toward achieving greater and more effective prevention and control. Treatment for substance abuse should not be thought of in a simple medical model of acute illness. The symptoms of this chronic disorder and the interventions that may mitigate the symptoms range well beyond the physical, psychological, and psychiatric to include profound social, legal, and economic problems. Acupuncture has been recognized by the American medical community as an effective treatment for su b st a n ce a b u se p r o b lem s su ch a s a lco h o l a n d d r u g dependence. It has been accepted by health care professionals specializing in addictive disorders not only because of its efficacy, but also because of its cost-effectiveness, indicated by its ability to deliver a lot of care within a short period, with negligible costs for equipment. This study was designed to investigate the substance abusers’ experience of receiving * * acupuncture as a treatment for substance dependence in conjunction with other conventional treatment modalities. Background No single theory or conceptual model is sufficiently broad or flexible to explain the varied and highly complex phenomena of substance dependence. H ughes (1989) categorized three broad perspectives of substance abuse and dependence that currently exist and are the predominant approaches for treatment of this disorder: the medical or disease model, the psychoanalytic model, and the addictive behavioral model. One of the most accepted models in the medical community is the concept of substance dependence as disease. According to Hughes, this model remains in favor because it fits scientific Kunsook Song Bernstein, RN, PhD, Alpha Omega, Psychiatric Nurse Practitioner, Psychiatric Consultant, South Oaks Affiliate, Amityville, NY, and Adjunct Assistant Professor, Department of Nursing, Borough of Manhattan Community College, NY. Correspondence to Dr. Bernstein, 4 Bayfront Drive, Baldwin, NY 11510. Email: Kunsook@aol.com Accepted for publication February 29, 2000. Journal of N ursing Scholarship Third Q uarter 2000 267 The Experience of Acupuncture for Treatment of Substance Dependence inquiry, promotes medical progress, and works for the substance abuser. Jellinek (1960) developed the disease concept of alcoholism almost 50 years ago, and it has influenced not only the field of alcoholism and its treatment approaches, but it has also been expanded to include the field of other substance abuse and dependence. Jellinek’s model is based on four assumptions: (a) alcoholics have predisposing characteristics that consistently differentiate them from nonalcoholics; (b) alcoholism is a progressive, inexorable process, progressing through identifiable stages; (c) alcoholics are unable to control their drinking, that is, once they begin to drink they are unable to stop; and (d) treatment of alcoholics requires absolute abstinence. Another leading conceptual model of substance dependence is the addictive behaviors model formulated by M arlatt and Gordon (1985), combining the principles of social-learning theor y, cognitive psychology, and experimental social psychology. M arlatt’s framework emphasizes behavioral lea r n in g a lo n g w it h ca r efu l a t t en t io n t o so cia l a n d environmental influences on that learning. This model shows that a substance abuser has developed maladaptive ways of coping. This differs from the disease model, which indicates the substance abuser to be genetically predisposed to addiction. Concepts of Traditional Chinese M edicine Comprehending the fundamental concepts of Chinese medicine is difficult without understanding its philosophical and conceptual framework. Traditional Chinese medicine has developed over a period of at least 3,000 years. By the 4th century AD, T he Yellow Em peror’s Classic of Internal M edicine that laid the foundations of Chinese medicine had been written. The philosophical foundation of traditional Chinese medicine consists of pattern manifestation, harmony, and continuous interaction between the person and the cosmos. The fundamental principles are based on the concept of Yin and Yang and the five phases: wood, fire, earth, metal, and water. The concept of Yin and Yang holds that nature is one unified system, with polar and complementary aspects; the five elements are regarded as five properties that are inherent processes or tendencies in all things, not essential building blocks. The premise of five phases holds that nature is in constant motion, following cyclic patterns that describe the process of transformation, and the phases provide a system of correspondences and patterns within which numerous phenomena are arranged in ways that relate to the process of change. More specifically, each phase represents a category of related functions and qualities. For example, wood is associated with active functions that are in a phase of growing or increasing, while fire represents functions that have reached a maximal state, and are about to begin a decline (Shanghai College of Traditional M edicine, 1992). The theory of correspondence describes the parallelism and synchronicity of events in the inner and outer world of human organisms. When the elements of nature are in balance, life is harmonious and flourishes. When the balance of polar forces is disturbed, illness and disaster occur (Shanghai College of Traditional M edicine, 1992). 268 Third Q uarter 2000 Journal of N ursing Scholarship Chinese Medical Theory of Substance Abuse Smith and Khan (1988) said that the theory of Traditional Chinese medicine categorizes the phenomenon of substance dependence as a condition of “ empty fire.” The individual lacks a calm inner tone, and the heat of aggressiveness burns out of control when this calm inner tone is lost. This “ empty fire” condition represents the illusion of power, an illusion that leads to more desperate chemical abuse and violence. Kaptchuk (1983) proposed that “ empty fire” represents the disharmony of polar forces of Yin and Yang, presenting the symptoms of the appearance of fire (Yang) in an attempt to complement the insufficient Yin force. Insufficient Yin force is a result of intense and frequent abuse of chemical substances damaging the “ seed” energy, which is believed to be stored in the kidney organ system. The kidney is categorized as Yin in nature. Therefore, the result of kidney damage is described as Yin deficiency. The review of the literature showed no other theories or explanations that address the phenomenon of substance dependence in Traditional Chinese medicine. Acupuncture Treatment of Substance Abuse Proponents of traditional Chinese medicine postulate that acupuncture is a technique that evokes the self-regulating response of the organism to reorganize and replenish the source of energy (Q i). Practitioners believe that acupuncture adjusts the density and flow of Q i in the web-like channels that exist in the human body. When used as a treatment for substance dependence by application of acupuncture to selective points, many believe the subject’s inner harmony is restored. Acupuncture for the treatment of substance dependence has been studied in research on animals and humans. Several mechanisms (H ughes, Terry, M organ, & Fothergill, 1975; Terenius & Wahlstrom, 1975; Theschemacher, O pheim, Cox, & Goldstein, 1975) have been suggested as the mode of action of acupuncture. They are the endocrine system, neurotransmitter effects, and neuronal, sympathetic and p a r a sym p a t h et ic effect s. T h ese st u d ies h a ve lin k ed acupuncture to the production of endogenous opiate p ep t id es, su ch a s b et a -en d o r p h in s a n d m et h ia n in een k ep h a lin . T h is t h eo r y h a s b een su ggest ed a s t h e explanation of the physiological mechanism of its effects on the discomfort of withdrawal. Wen and Cheung (1973) first described the effects of acupuncture as relief from opiate withdrawal symptoms; Smith and Khan (1988) further claimed that acupuncture alleviated the intensity of cravings for drugs and provided general relaxation and enhancement of mental and physical functions. M uch of this research, however, has been severely criticized for a variety of methodological reasons, primarily for the lack of adequate experimental controls (Gossop, Bradley, Strang, & Conbnell, 1984; Lipton & M aranda, 1983). Washburn, Keenan, and N azareno (1990) reported results of a study of 100 people addicted to opiates. Participants were exposed to 21 days of detoxification, and acupuncture was performed in an outpatient setting. Despite greater attendance and retention The Experience of Acupuncture for Treatment of Substance Dependence with the experimental group, speculation arose that subjects’ awareness of random assignment to a sham treatment might have altered the outcome of the study. Clark (1990) also compared treatment outcomes for 84 people addicted to o p ia t es. T h o se p a r t icip a n t s vo lu n t a r ily ch o se eit h er acupuncture or methadone detoxification. At the follow-up interview 90 days after completing treatment, 31% of the acupuncture subjects had drug-free urine compared to 14% of the methadone patients. The outcome of the study showed t h a t t h e d iffer en ce b et w een t h e t w o gr o u p s w a s n o t statistically significant. N ewmeyer, Johnson, and Klot (1984) reported a similar study of treatment for heroin users exposed to one of three detoxification methods: acupuncture, medication, or a combination of the two. Six months after treatment ended, 24% of the acupuncture subjects’ urine tested positive compared to 36% of those in the medication group. These two studies were not statistically sound according to the conventional research standards because random assignment was not used in these studies and a control group was lacking in the research design. Therefore, the outcome of the effectiveness of acupuncture treatment may not be comparable. A more recent research study by Bullock, Culliton, and O lander (1989) evaluated the effectiveness of acupuncture for severe recidivist alcohol dependency. Their study showed that 21 of 40 in the acupuncture treatment group completed the 2-month program, but only 1 of 40 in the placebo group completed the program. This study may have relevance for various aspects of treatment of alcoholism such as the effectiveness of reducing a persistent craving for alcohol and a high retention rate in the treatment program. Lipton, Brewington, and Smith (1990) reported the results of a study of the effectiveness of acupuncture for 150 chronic cocaine or crack abusers at an outpatient clinic. Subjects were randomly assigned to receive either auricular acupuncture at correct sites, or acupuncture at nearby ear points not related to detoxification. The results indicated no significant betweengroup differences in the self-report of cocaine use and attendance data, though a significant difference favoring the experimental group was noted in relation to changes in the level of cocaine metabolites in urine. Experts in urinalysis, however, questioned the reliability and validity of this measurement (M cLellan, Grossman, Blaine, & H averkos, 1993). M ethods Design A qualitative research method was chosen for this study because the focus of the study was an exploratory phase of a phenomenological investigation to understand participants’ experience with acupuncture. Because Giorgi’s phenomenological method focuses on uncovering the meaning of experiences through study of descriptions from the perspective of the participant, it was selected as a suitable method for this investigation. Setting T h e st u d y w a s co n d u ct ed a t a n in p a t ien t u n it fo r detoxification and rehabilitation for substance and gambling addictions. The treatment modality used in the setting was based on the abstinence approach referred to as the Alcoholics Anonymous (AA) model. Acupuncture had been recently added as a treatment modality available to patients at the time of their admission to the unit. The treatment was offered once a week and was provided in a designated room with adequate space, lighting, and privacy. The room was set up with several chairs in a single row against the wall, and each participant was instructed to sit in a chair for the acupuncture treatment. Sam ple selection Participants in this study included patients who had been admitted to an inpatient hospital setting where acupuncture was provided as one of the treatment modalities for substance dependence. Participants were selected from the group of patients who were diagnosed with substance dependence by their attending psychiatrist based on DSM -IV criteria (American Psychiatric Association, 1994). All participants abused multiple substances, including alcohol, cocaine, m a r iju a n a , a n d sed a t ives. T h r ee p a r t icip a n t s a b u sed additional substances such as heroin or painkillers containing opiates. The group was limited to those who were willing to accept acupuncture and further limited to those who had never previously had acupuncture treatments for substance dependence. The sample selection was done in the hospital in consultation with a volunteer informant who was a psychiatric social worker. The researcher interviewed 12 potential participants and accepted 8 for the study. Four potential participants were rejected because they did not meet the sample criteria. T h e sa m p le size w a s eigh t su b ject s. Sa m p lin g w a s terminated when no new information came forth from newly sampled units, which would indicate that redundancy was the primary criterion in sample selection (Lincoln & Guba, 1985). Data Collection The researcher conducted the interview, lasting 45 to 90 minutes, with each participant. Interviews were audiotaped and later transcribed by the researcher. The interview was begun by allowing participants to describe in their own words their stream of consciousness or experience while receiving acupuncture as a part of the treatment for substance dependence. Participants were asked to reflect upon and relate their experience of acupuncture. They were encouraged to describe their experiences until they had related all they wanted to say. General questions were used to guide the interview process, and exploratory questions were asked as needed to clarify answers. Also, understanding that the quality of the descriptions might vary, the researcher was sensitive not to influence the clarification and elaboration process, to ensure that the participants related the experience as it existed, in an unbiased way. The researcher kept a log of her own Journal of N ursing Scholarship Third Q uarter 2000 269 The Experience of Acupuncture for Treatment of Substance Dependence experiences, which was used to understand what was meaningful and helpful to the data collection. Data Analysis The researcher transcribed the audiotaped interview as soon as possible following each interview. While transcribing, the researcher inserted in parentheses any statements made during the interview that were vague or unclear. The researcher then read the transcription several times to sense the meaning of the whole experience of the participant. The Giorgi (1979) modification method was used for data analysis. The procedure of data analysis described by Giorgi contained five steps: (a) the researcher read the transcription to get the sense of the whole meaning of the participant’s experience; (b) central themes and the natural meaning units, from which they were taken, were studied; redundancies in the units were eliminated, and the meanings of the units were clarified and elaborated by relating them to each other and to the whole; (c) the researcher transformed the language of the participant into the language and concepts of science; (d) the researcher synthesized the insights into a descriptive structure of the meanings of the phenomenon being studied. The final product was then communicated to other mental health clinicians for critique; and (e) the researcher integrated insights from all of the interviews into a total description of the phenomenon being studied. Reliability and Validity Field and Morse (1985) emphasized the importance of validity and reliability in relation to the informant’s credibility in sampling, interviewer’s accuracy and competency, interviewer’s bias in data gathering, and the procedural elements in data analysis including time, place, circumstance, language, and consensus. In sample selection, a psychiatrist who determined the diagnosis based on DSM-IV criteria validated the diagnosis of substance dependence. The informant, using the criteria for study participation, did sample selection. The researcher provided a list of the delimitations of the study for the informant to use as a guideline for sample selection. To ensure the informant’s credibility of sampling, the researcher chose a psychiatric social worker with over 10 years experience in the field of substance abuse and dependence. Leininger (1985) described validity in qualitative research as gaining knowledge and understanding of the true nature, essence, meanings, attributes, and characteristics of a particular phenomenon under study. In an attempt to maximize understanding of the meanings of the participant’s experiences, the researcher attempted to construct relaxed and conversational interviews. Taylor and Bogdan (1984) said that interviewing requires an ability to relate to others on their own terms, and they emphasized several points to set the tone for the interview: being nonjudgmental, letting people talk, paying attention, being sensitive, and probing. These points had been reviewed and were considered by the researcher as valuable interview skills to foster knowledge and understanding of each participant’s experience. Following Giorgi’s phenomenological method 270 Third Q uarter 2000 Journal of N ursing Scholarship ensured reliability in its procedural elements of identifying and documenting recurrent themes of participants’ experiences. Findings The study included eight participants, four men and four women, whose ages ranged from 28 to 51 years. Seven were Caucasian and one was Hispanic. The period of the participants’ substance abuse varied from 7 to 25 years. N o significant differences in the findings were noted in relation to sex, age, race, or the length of substance abuse. All participants abused multiple substances including alcohol, marijuana, sedatives, and cocaine. Three participants abused more than one opiate substance. No significant differences in the findings were related to types of substance abuse. Seven major themes of the experience with acupuncture for substance dependence treatment were identified in this study: anticipation of pain, apprehension toward newness, mood elevation, indescribability of the experience, physical sensation, relaxation, and the effect of acupuncture on sleep. Each participant in this study was introduced to acupuncture for the first time, having had no previous exposure to it except hearing about it through friends or the media as an alternative to conventional treatment. The participants’ common perception that a needle stick would induce pain expressed the first theme, anticipation of pain. Two of the participants expressed a fear of pain while the rest minimized their perception of it, although the anticipation of pain was present. In this study, all of the participants stated that they felt no pain from the needle insertion and described the experience of the insertion as one causing the sensation of a “pinch or prick.” This perception was expressed as relief, and the participants in this study emphasized that the acupuncture needles did not induce pain. The second theme identified in the study was apprehension toward the newness of the treatment, which was the participants’ first exposure to acupuncture. Although each participant volunteered to accept acupuncture as an optional treatment available for substance dependence, approaching the unknown created apprehension and anxiety. After receiving the treatment, the participants described a change of their emotional and psychological states to feeling subdued and having revitalized energy. In this study, the participants were apprehensive and preoccupied with interpersonal conflicts, including social and family issues existing before acupuncture treatment was started. With acupuncture, the participants reported a reduction of apprehension along with a clearing of thought processes, peacefulness, self-confidence, decisiveness, and motivation for their recovery. The theme of the participants’ inability to describe some of the experiences with acupuncture was not found in the literature reviewed for this study. Each participant in this study expressed both physical and affective experiences that were unique and unfamiliar. These experiences could be attributed to the participants’ first exposure to acupuncture for substance dependence. The indescribability of the experience pertained to the unfamiliar physical sensations and the unexpected feelings The Experience of Acupuncture for Treatment of Substance Dependence of mood elevation. Participants expressed the movement or flow of physical sensation from the acupuncture site to other areas of the body: pressure-like, headache-like, tingling, soothing, and warming sensations. These sensations were reported by the participants as unfamiliar, strange, subtle, and difficult to describe accurately. Another indescribable aspect of the experience was the affective component of mood elevation. Participants said they were impressed by the natural, pleasurable, and relaxing outcomes of the experience with acupuncture. Despite participants’ familiarity with affective experiences associated with substance-induced altered moods, this unexpected outcome of the acupuncture experience was mysterious and unexplainable. In this study, the inability to describe some of their experiences in suitable language was recognized and acknowledged by each participant. Participants expressed their tacit knowledge of experience with acupuncture, and the researcher was able to convert this to proportional knowledge as a part of the research process. This tacit knowledge became an indispensable part of the research in this study because of participants’ limited ability to articulate some of their experiences. Through the qualitative research process, the tacit knowledge was explicated to the descriptions of relaxation, mood elevation, and physical sensation of their experiences. In spite of the unfamiliarity and indescribability of the experience, the participants’ perceptions of the whole experience were favorable and they accepted the newness of the experience with the intention to pursue it again. Relaxation was the strongest of all the themes reported by participants. Participants described feelings of both emotional and physical relaxation, of calm and serene feelings, accompanied by sleepiness, then followed by revitalized and balanced energy. All participants used the terminology “ relaxation” as the experience with acupuncture. Each participant described the experience of relaxation in various forms: numb and floating sensations, feeling “ high,” sleepiness, and tranquility. The participants said that they were able to achieve physical relaxation followed by clearer thinking and relief of their emotional turmoil. The participants’ descriptions of the experience of relaxation in this study revealed alleviation of tension and anxiety, rebound energy, ability to sleep, and diminished physical discomfort. These experiences associated with relaxation gave the participants a positive impression of acupuncture. Following the treatment, the participants expressed a desire to further explore acupuncture treatment for substance dependence. The theme of mood elevation during the acupuncture treatment was expressed by the participants in terms such as high, floating, mellow, semi-hypnotic, or trance. Because of the participants’ prior experiences of similar effects from substance abuse, they compared the substance experience and the experience with acupuncture. Participants consistently emphasized this experience of mood elevation as being a normal and natural feeling as differentiated from substance-induced mood elevation. The description of the normal and natural feeling with acupuncture, different from the intensity of the substanceinduced mood elevation, was elaborated as an even and neutral state of emotion with a sense of contentment and satisfaction with oneself. The last theme resulting from this study was the effect of acupuncture on sleep. This effect was an unexpected result of the acupuncture, and one that the participants did not anticipate as a benefit. Inability to sleep, even with the assistance of a sleeping pill, is a common problem among substance abusers when they abstain from substances during their recovery phase. O ne participant, interviewed immediately following the acupuncture, did not have a chance to experience the effect of acupuncture on his sleep. All other participants described the benefit of better sleep from acupuncture. They emphasized that sleep disturbance was a serious problem during the period of abstinence from substance use. The themes identified in the study are interrelated. The themes of anticipation of pain and apprehension toward newness were experienced simultaneously. Participants’ apprehension was related to the anticipation of pain as well as to newness. These experiences at the beginning of the treatment were not perceived as a separate entity from the rest of the themes but were considered to be part of the continuum of participants’ experiences. Discussion The results of this research enhance understanding of substance abusers’ experiences while receiving acupuncture for substance dependence. Findings indicate that acupuncture can be viewed as a complex phenomenon with seven intertwined themes related to acupuncture as treatment for substance dependence. Participants’ experiences revealed these common themes as patterns which derived certain meanings that were consistent among all the participants, and that were perceived by the participants as the beginning of the emotional, physical, and psychological healing processes of recovery. Initially, the participants described the effect of substance abuse on the quality of their lives, including social, family, financial, physical, and emotional aspects, and the desire to search for a path to recovery. The participants had to stabilize psychological and physical conditions generated from substance abuse to promote recovery and to maintain their sobriety. In describing their experiences of psychological and physiological relaxation from acupuncture within the first 24 hours following treatment, participants said the relaxation experience was a balancing element for anxiety and depression. Subsequently, it also became a significant factor in both promoting sleep and revitalizing inner strength needed to deal with stress factors. Various studies (Clement-Jones et al., 1979; Pomeranz, 1978, 1982; Wen, H o, Ling, M a, & Choa, 1979) have linked acupuncture to the production of endogenous opiate peptides in substance-dependent people. These studies were focused to determine a physiological mechanism of the effects of acupuncture on reducing the discomfort of withdrawal, and then consequently inducing relaxation; however, the test results were not statistically significant. The researchers concluded that acupuncture is capable of inducing analgesia, and acupuncture is analgesia involves endogenous opiate peptide production. The theme of mood elevation during acupuncture was also reported Journal of N ursing Scholarship Third Q uarter 2000 271 The Experience of Acupuncture for Treatment of Substance Dependence by Margolin and colleagues (1993). The researchers reported their observation that during the acupuncture treatment subjects frequently seemed to enter a somnolent state, some actually fell asleep, and some subjects reported feeling “high.” However, their study indicated that the “high” response to acupuncture usually did not recur after the initial treatment. Further investigation of this finding may be useful for treatment of substance abuse. The experience of relaxation reported in this study can be considered a healing process, manifested by patterns that intertwine within the psychological, physiological, and sociofamilial aspects of each participant’s life. The participants’ experience of the healing process may have led to positive and harmonious feelings of wellness, which are considered to be the Chinese ideal of health. The review of literature showed no research to date which addresses acupuncture treatment for substance dependence through the exploration of the meanings of a substance abuser’s experience with acupuncture. M ost studies of acupuncture related to treating substance dependence have been focused on the effectiveness of acupuncture by measuring retention rate and length of abstinence, and a few studies have measured the amount of drug consumption and withdrawal symptoms. These reported studies have been conducted by quantitative research methodologies based on the Western scientific research model. Conclusions This study was limited to acupuncture treatment for substance dependence and the investigator did not explore acupuncture studies for other conditions. The study sample was small and limited to one interview after one acupuncture treatment for each of eight participants. Participants were p r ed o m in a n t ly C a u ca sia n a n d t h ey a b u sed m u lt ip le substances. Although the study was conducted with a small group and the findings are preliminary and limited to this sample, they are consistent with those found in the literature regarding acupuncture for substance dependence. This study should be replicated using a larger sample, or longitudinal studies of the same subjects could be attempted. Longitudinal studies of the same subjects could provide additional findings of extensive and comprehensive information related to the themes identified in this study. Further study also may determine whether the experience of acupuncture differs among substance abusers abusing different substances such as cocaine, heroin, marijuana, or alcohol, and may identify the forces leading to substance dependence and the decisionmaking processes of selecting treatment. The results of this research reinforce beliefs that substance abusers’ health and illness are complex and multidimensional. Acupuncture as an alternative form of healing has gained credibility, and appears to be an accepted modality among the participants as shown by their eagerness to pursue this treatment in the future. Knowledge about acupuncture as a treatment modality can assist health care providers to incorporate alternative approaches into their practices. JN S 272 Third Q uarter 2000 Journal of N ursing Scholarship References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM - IV; 4th ed.). 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