Ear Acupuncture in Psychiatric Care From the Health Care Professionals’ Perspective: A Phenomenographic Analysis

Abstract

Ear acupuncture is used as a non-pharmacological complement in psychiatric and addiction care to reduce anxiety, depression and insomnia. The aim of this study was to describe health care professionals’ perceptions of giving ear acupuncture in different psychiatric settings. Twenty-four professionals providing ear acupuncture to patients with a variety of psychiatric symptoms and/or addiction were interviewed in focus groups. Data were analyzed with a phenomenographic approach. Ear acupuncture was provided, individually or in groups, to in- and outpatients with a variety of psychiatric symptoms and/or addiction. Three descriptive categories emerged: Another tool in the toolbox, Strengthening the profession and Person-centered care. Participants perceived ear acupuncture to be an effective and safe therapeutic tool, easy to use in concert with other methods and easy to adjust to the patients’ needs and requests. They perceived that their professional self-confidence increased when having this non-verbal, person-centered and non-pharmacological tool in their hands as a complement to ordinary care. Professionals perceived that patients trained their social skills while participating in acupuncture, and that the treatment helped patients to influence their subjective psychiatric health through gaining control over symptoms. Acupuncture helped professionals to build a trustful relationship and communicate with their patients, verbally and non-verbally. The finding shows ear acupuncture as a safe treatment and promising in relieving psychiatric and somatic symptoms. Acupuncture facilitates the communication with patient, emphasizing participation and shared decision-making, valuable dimensions of person-centered care. Managers’ role and attitude in supporting staff needs to be explored in future research.

Background

Acupuncture is used as a complement in psychiatric care (Pilkington, 2010; Samuels, Gropp, Singer, & Oberbaum, 2008). Until today there is a lack of knowledge about health care professionals’ experiences of providing acupuncture. The professional’s preferences is an important framework that helps us understand what facilitates and supports sustainable evidence-based practice.

There is a strong association between psychiatric illness and addiction, insomnia, somatic diseases, as well as higher mortality and increased consumption of care. Depression and anxiety are major and often long lasting health problems. They co-occur with other psychiatric diagnoses, and lead to a reduced quality of life as well as occupational and social difficulties and limitations for the patient (Colten & Altevogt, 2006). Lack of sleep may cause or contribute to many different mental health disorders, thus restoring sleep is important. Medication for insomnia and anxiety has limited effect and often undesired side effects (National Institute of Clinical Excellence (NICE), 2010, 2014). Clinical guidelines restrict the use of sedatives (NICE, 2010, 2014), leading to an interest in non-pharmacological treatments. Psychiatric care is aimed to promote the patient’s subjective health (Buchanan-Barker & Barker, 2008) and the therapeutic relationship is essential (Dziopa & Ahern, 2009; Gabrielsson, Savenstedt, & Olsson, 2016).

Body acupuncture is one of the most used complementary methods in psychiatric care and can be interpreted in neuro-physiological terms. Acupuncture affects the autonomic nervous system, the release of several neurotransmitters and hormones, the HPA-axis and the limbic system (Fang et al., 2009) and it alters the balance of prefrontal cortex activity, resulting in relaxation and decreased anxiety (Sakatani, Kitagawa, Aoyama, & Sasaki, 2010). One review found that acupuncture has a reducing effect on stress-induced biomarkers (Darbandi et al., 2016). These physiological facts offer a possible explanation for acupuncture giving the sense of wellbeing, calmness and relaxation commonly experienced by patients receiving acupuncture including ear acupuncture (Bergdahl, Berman, & Haglund, 2014; Hedlund & Landgren, 2017; MacPherson & Thomas, 2005). Likewise, a long-term beneficial effect on stress, pain and anxiety, as well as regulation of emotions, memory processing and autonomic functions can be explained (Fang et al., 2009). Positive results of body acupuncture have been reported for depression (Chan, Lo, Yang, Chen, & Lin, 2015), and in outpatients treated in primary care, anxiety and depression improved significantly in the acupuncture groups compared to usual care and was still significant after 24 weeks (Arvidsdotter, Marklund, & Taft, 2014).

The evidence for ear acupuncture in relation to sleeping problems and psychiatric disease is sparse but promising. A meta-analysis found that the improvement of sleeping hours produced by ear acupuncture was significantly higher than those of diazepam (Chen et al., 2007). In anxiety, especially ear acupuncture may be as effective as drug therapy (Pilkington, Kirkwood, Rampes, Cummings, & Richardson, 2007).

There is a variety of ear acupuncture styles. National Acupuncture Detoxification Association (NADA) is a standardized ear acupuncture protocol launched in the seventies for treating drug addiction (Stuyt & Voyles, 2016). Five needles are inserted in each ear and left for 30–40 minutes while the patients rest. NADA is given as an adjunct to usual care in out-patients and in-patients, daily when symptoms are intense and once or twice a week when symptoms decrease. The acupuncture treatment continues as long as the patient needs it, often for weeks or months and often in a group setting. Today NADA is used not only to reduce withdrawal symptoms but also to reduce stress, anxiety, depression and sleeping disorders (Stuyt & Voyles, 2016).

Acupuncture is a complex intervention, including both specific (Hou et al., 2015) and nonspecific factors that can influence the results (Carter & Olshan-Perlmutter, 2015; di Sarsina, Alivia, & Guadagni, 2012). Hereby it might not be studied only in bio-medical perspectives. One important factor is the interaction between patient and health care professional. There is still a gap in knowledge about the effect of acupuncture as a safe and effective treatment of psychiatric illness (Samuels et al., 2008). Qualitative ear acupuncture research is sparse but illustrates positive experiences by patients (Bergdahl et al., 2014; Hedlund & Landgren, 2017). To our knowledge, no published article contains the perspective of health care professionals. This study will therefore deepen the knowledge of what ear acupuncture possibly can add to psychiatric care. The aim was to describe health care professionals’ perceptions of giving ear acupuncture in different psychiatric settings.

Methods

Design

A qualitative phenomenographic study (Marton, 1981; Reed, 2006) was used with focus group interviews to explore health care professionals’ perceptions of delivering ear acupuncture in psychiatric care.

Phenomenography

Phenomenography is a qualitative research method that aims to describe, analyze and understand human beings’ perceptions of different phenomena in the surrounding world (Marton & Booth, 1997). A distinction is made between the first-order perspective, which starts with facts that can be observed externally, and the second-order perspective, which is people’s perceptions of something or how something appears to them in daily life. Phenomenography describes experiences from the second-order perspective.

Participants

According to the phenomenographic approach, the selection of the participants was done to receive health care professionals with different backgrounds from different psychiatric contexts, in order to find variations and describe different perceptions of using ear acupuncture as a complement in psychiatric care. A total of 24 health care professionals who provided ear acupuncture as a part of the care of persons with a psychiatric illness and/or addiction, representing eleven psychiatric settings, were interviewed. Fifteen of those 24 professionals were registered nurses, eight were nurse assistants and one was a psychiatrist. Thirteen were specialized in psychiatry and/or various forms of conversational therapy like Cognitive Behavioral Therapy (CBT) and Dialectic Behavioral Therapy (DBT). The participants’ professional experiences of ear acupuncture ranged from one to twelve years (median four). Nine worked at in-patient hospital wards, 13 at out-patient clinics or day care and two in a highly specialized treatment home. Fifteen participants mainly treated persons with affective disorders and neuropsychiatric disorders, five treated addiction, two psychosis and two persons with emotionally unstable personality disorder and severe self-injury behavior.

Focus-group interviews

The focus group is a group discussion where a skilled interviewer leads the discussion with the help of an assistant moderator with the aim to explore new phenomena (Krueger & Casey, 2009). Several interviews are conducted so the researcher can identify trends and patterns of perceptions. The discussions among the participants in the group interview generate the data and the group interaction is an important part of the method (Krueger & Casey, 2009).

Data collection

Three responsible clinic directors in southern Sweden were asked and gave permission to perform the study in the region/municipality where they were in charge. They forwarded information about the study to the heads of department in clinics where ear acupuncture was used, and five heads of department forwarded written information about the study to health care professionals who provided ear acupuncture to patients, in some cases also in co-working clinics. Those who wanted to participate in a focus group contacted the project leader KL. Information about the study, that participation was voluntary and the possibility to withdraw at any time was repeated orally and participants signed informed consent forms before the interview started. Five focus groups, including 2–11 persons from one or more settings, were conducted in 2015–2016. Interviews, lasting 20–70 minutes (median = 60 minutes), were conducted in a conference room at the psychiatric clinics, by KL who moderated the discussions and an assistant who helped with recording. The interviews started with a broad open question: Please share your perceptions of using ear acupuncture as a complement in psychiatric care, followed by probing questions focusing on how they perceived effect in patients, why they continued to give acupuncture and what advantages and disadvantages were perceived. The participants discussed with each other and with the interviewer who stimulated the group interaction and made sure everyone got their say (Krueger & Casey, 2009). The interviews were recorded and transcribed.

Data analysis

The data were analyzed using the phenomenographic procedure, inspired by Marton (1981). In the first stage, all of the authors read the whole text individually in an open-minded way to gain an overall understanding of the experienced phenomenon. In the second stage, the authors reread the transcribed interviews several times individually to search for each group interviews most significant statements pertaining to their perception of ear acupuncture. The statements were selected to describe what the interviewees contributed to the discussion. This step included a reduction of the statements. In the third stage, the analysis process continued with a search for main similarities and differences on how the health care professionals perceived giving ear acupuncture, involving a comparison of the ways in which the interviewees perceived the phenomenon in order to identify conceptions of variation. In this stage, the concepts that seemed to have similarities were grouped into their common features and into preliminary categories of description. KL first presented her version for the co-authors as a platform for a mutual discussion. The following stages of the analysis were conducted by all co-authors together. In the fourth stage, the focus of attention was shifted from the relationships within the perceptions to the relationships between the preliminary descriptive categories. Each preliminary category was given a simulant name to express its core content. This step comprised a comparison between the descriptive categories in terms of similarities and differences in the level of understanding expressed by the interviewees. Characterizing the variation in how a certain phenomenon was perceived led to development of a set of descripting categories. Agreement was reached between all authors, resulting in three descriptive categories and six conceptions.

Findings

In the beginning of each focus group discussion the participants described for the others about how they delivered ear acupuncture, as a way to facilitate the context for the conversations (first-order perspective). Rather soon in the focus group discussion they began to share how they perceived delivery of ear acupuncture (second-order perspective). The result section follows this text order.

The description of ear acupuncture intervention

The participants described that the most common type of acupuncture used was standardized ear acupuncture following the NADA protocol, sometimes combined with one or two body acupuncture points (GV20 and HT9). Some participants described that they added ear acupuncture points according to symptoms, like the point “Sleep” in insomnia, as they then perceived better effect. After the needle session most patients were offered acupressure with different kind of seeds or beads that were attached to certain points in the ear with a plaster. The beads could stay in place in between acupuncture treatments. Some participants also offered semi-permanent needles that could stay in place for ten days. In most of the clinics, a referral from a doctor was required before administering acupuncture. Inpatients were given acupuncture individually, lying in their beds, sometimes just before bedtime. Outpatients could be treated individually when they came to see their therapist or in scheduled groups, 2–3 times/week, or when they picked up medicine. Patients were encouraged to come ten times, before out-ruling the treatment. Patients were seated comfortably, in a treatment room with recliners and relaxing music, or in rooms otherwise used for group therapy or staff meetings. At the treatment home, where patients stayed for months or even years, acupuncture was scheduled twice a week in groups and offered individually on demand in between groups.

The perception of treating with ear acupuncture

The health care professionals who participated in this study perceived ear acupuncture to be a more effective tool than they had expected. They perceived a strengthening of their professional identity by having a non-verbal, person-centered and non-pharmacological tool in their hands as a complement to usual care. Lack of time and the challenge to end a treatment when the professional thought that the patient was ready but the patient wanted to continue, were perceived as disadvantages. The descriptive categories and the conceptions are shown in Table 1.

Table 1. Descriptive categories and conceptions of the health care professionals’ perceptions of giving ear acupuncture as a part of psychiatric care.

Descriptive categories	Conceptions
Another tool in the toolbox	Acupuncture alleviates a variation of symptoms
	A safe alternative to pharmaceuticals
Strengthening the profession	Creating a verbal or non-verbal frame for a therapeutic relationship
	Challenge and stimulation from developing a new skill
Person-centered care	Flexible to adjust the acupuncture
	A tool for patients too

Another tool in the toolbox

The participants perceived an obvious and positive effect of ear acupuncture in a variety of their patients’ symptoms, and they described that the effect of ear acupuncture sometimes could replace medications.

Acupuncture alleviates a variation of symptoms

The participants described ear acupuncture as having an over-disseminating effect on co-existing symptoms in patients, like anxiety, sleep problems, hyperactivity, depression and irritation. Participants perceived that all symptoms were addressed and even patients with chronic diseases could respond with lesser symptoms. Acupuncture was also perceived to reduce withdrawal symptoms from alcohol, drugs and medications, helping patients to endure the withdrawal phase. Another symptom that was perceived to decrease was pain, a usual co-morbidity. As physical pain could be handled with acupuncture, psychiatric symptoms were easier to withstand. Acupuncture was also perceived to bring a physical relaxation, confirmed by patients in the visual analog scales that were commonly used. The participants described ear acupuncture to have a holistic effect, perceived as a definite advantage.

Participant A: She suffered from intense anxiety and an abuse of prescribed medications, originating from a chronic pain syndrome… We suggested NADA and it was wonderful that she wanted to try! She is very content with acupuncture! Participant B: Yes, it can be difficult to offer other things than medication here/at this department for substance abuse/, our patients have a thirst for medication. Participant C: Yes, and for this lady the pain killers were tapered down and she had withdrawal symptoms. Participant A: Yes, it is part of the success in this case that acupuncture reduces her pain. She shows up here almost every day and asks “Can anyone give acupuncture today?” Participant C: Yes, she relies so heavily on acupuncture! It’s really great! And she can relax now. When she started with acupuncture she couldn’t sit down without scrolling on her phone and she read the whole evening paper. Every time we told her to try to relax. Nowadays we don’t need to remind her because now she relaxes! She couldn’t do that earlier! Participant A: It’s about daring to relax. You can see how she benefits from it now. No doubt it´s helping her! Actually you should have filmed her reaction, that´s how good it has become! (FG 2)

Participants perceived acupuncture to give an inner calmness for most patients. They described how patients with acute anxiety or who otherwise were agitated or wound up could sit still with needles in their ears. Patients gradually relaxed, put down their smartphones and went silent during the treatment hour. It was described as a convincing experience for patients who usually could not relax. The relaxing effect was obvious for the professionals. When they returned to remove the needles after 40 minutes, they described that almost all patients were asleep or deeply relaxed. The participants also described an apparent effect on the patients’ night sleep. For patients who had not been able to sleep for a long time it was a relief, making them very content and motivated to continue acupuncture treatment.

Participant A: I had a patient with ADHD, he was really wound up all the time, and couldn’t sleep. When he got acupuncture the first time he passed out/all laugh/. He snored for an hour! So he became totally saved! He was really, he had not slept for a long long time and was really upset, so… Participant B: Since we discovered how good it was to give it before the patients went to bed, when they should go to sleep, we have struggled to get night staff trained. And now C/points at C/who works nights, has been trained which we are grateful for. Because she gives it/acupuncture/in the evening. And then they sleep! Participant C: Yes, I give it in the evening. They sit on a chair when they get the needles, and then they lay in their bed. And for the most part they sleep when I remove the needles./Pause for 5 sec/. And without sleeping pills! We sneak in with headlamps when to remove them/laughter/. (Focus Group; FG 1)

Participants perceived it important to measure patients’ symptoms. To follow whether symptoms were reduced, they let patients evaluate their symptoms on a visual analog scale, and offered further acupuncture treatments for long times if patients reported amelioration. Co-patients who spoke from personal experience were considered the best ambassadors, especially if they had been skeptical before trying acupuncture. However, participants perceived that acupuncture did not attract all patients, for example those who were focused on getting medicine.

Participant E: Some people think that the effect is so small it’s not worth the trouble to come. They have a different daily rhythm from us, these young ones. They stay up at night and they have to come to us during day time. Participant F: Then I have an example. It is an older lady who comes for what we call “maintenance care”, about once a week. And she sometimes says to those who say that it doesn’t help: “You have to be patient”, says this lady. “I’ve been as bad as you are, and it helps.” I mean, they believe in her who speaks of her own experience. She has been a good ambassador, really. Participant E: Yes, often, those who are negative to begin with, and become convinced when they get help, they are the best ambassadors, no doubt. Participant H: This means that group treatment also has that function, they can learn from each other. (FG 4)

A safe alternative to pharmaceuticals

Trying acupuncture as a first intervention was perceived as a safe start. If the effect of acupuncture was insufficient, other interventions, like introducing or increasing the dosage of medicines, were recommended. Participants perceived medications to have none or moderate effect and plenty of negative side effects, especially when several medications were combined. They were therefore pleased that acupuncture sometimes could substitute on demand medication, that it could be an effective alternative without negative side effects when a patient had taken all sedatives they would get, or when the option was to add one more medicine to the patient’s already long list of medications. They could also suggest acupuncture to patients reluctant to medicines, and when medications had been without desired effect. Participants were surprised that even skeptical patients, and patients thirsting for drugs, could find acupuncture attractive and noted that fewer benzodiazepines were used when acupuncture became available as a substitute.

Participant B: I like that, that it’s primarily not medication directly, but it’s acupuncture. … I think that’s a pleasant thought. Those who don’t want to take medicine or are afraid, we can offer acupuncture first, and see. Participant L: I have this a bit boring role to prescribed medications… I am very fond of/acupuncture/, because I see that “oh, wow, this helps”. And it’s something that’s not medicine but still helps. And that they are sitting there, completely passed out! They have had a lot of medicines before and that has not helped them. Then you add acupuncture, and they get helped and calm and happy. Then, instead of adding another medicine to their already long medication-list/showing a long imaginary list between her hands/, if they do not sleep or they still have anxiety, despite this list. Instead you can say, “let’s try ear acupuncture, it’s a great method. I think you can benefit from it.”… Participant B: Yes, it’s so nice to see, it makes me so happy!/laughs/. Seeing that something so easy works! Participant L: Yes! … It has caused me to question what we are doing here, with all the medicines and so on. Because there are really other methods that work too. … Participant B: Yes. I can understand that! (FG 5)

Strengthening the profession

The participants perceived that having this non-verbal tool in their toolbox strengthened their professional self-confidence. They described scientific perspective on NADA and considered this tool to give them a higher status. Acupuncture was perceived to allow a therapeutic relationship/meeting even for patients whom they could not talk to. Being able to help groups of patients that earlier could not be reached was perceived as stimulating.

Creating a verbal or non-verbal frame for a therapeutic relationship

Acupuncture was perceived as facilitating a beneficial, non-confrontative, therapeutic meeting, helping staff transfer a sense of security to and create an alliance with the patient. Alongside the specific needle effect, participants perceived acupuncture as a possibility to convey sympathy and to touch the patient physically in a natural way. Acupuncture was perceived to help patients gain trust so they could really relax. For the patients who the participants perceived could not verbalize their trauma, this non-verbal tool was appreciated as a hands-on tool, helping them reach patients they otherwise could not have a dialog with. Sometimes acupuncture was the only way they could connect with and help a patient who could not participate in counseling. In the undemanding and silent environment that arose, participants perceived they could come close and build a non-verbal relationship with the patient who was allowed to relax without having to give anything back.

Participant R: You’re sitting there in a group. … You have the opportunity to just sit there with needles in your ears without having to perform anything. Without doing anything. Without saying anything. It’s good to discover that too. That’s how I think. Participant S: Yes. It’s fun to do acupuncture. Otherwise, there’s so much talking and asking, and … Participant D: This is the quiet treatment! Participant S: Mmm. You almost don’t want to go in and disturb when the treatment is completed. … Participant R: We have also tried to do acupuncture, NADA, during counselling, when someone is anxious. They get the needles then, during the therapy. It helps them to gather their thoughts, keeping their minds together. They get calmer inside. (FG 1)

On the other hand, acupuncture was also perceived to increase patients’ ability to verbal and non-verbal communication. Participants perceived that patients’ ability to concentrate and listen increased with acupuncture. Patients receiving acupuncture calmed down easier and gained better control of impulses when they got upset, having fewer disturbing thoughts, and were prepared to talk calmly with fewer misunderstandings. Agitated and anxious patients communicated and co-operated better, and counseling became more effective as patients became more reflective and flexible and could focus better on the exercises. Sometimes ear acupuncture was used during counseling, to help patients focus and stay calm.

Participant C: When they are very excited, wound up, they don´t listen to me. But after NADA, you can sit down and talk with them in a, we can call it in a normal way. Then they can take the message. They get a completely different ability to concentrate and focus… Participant A: Yes. Even when they are not with their therapist, all staff here use all therapeutic skills all the time. We follow individual crisis plans and everyone is using DBT. Participant C: Yes. We work with DBT from the very first moment. Participant A: We see acupuncture as a distraction technique. You get an opportunity to think of something else, to do something else, something that’s so obvious that you react with both your body and your soul, everything reacts. And then they let go of their self-harm thoughts, those destructive thoughts they have. Participant C: Yes, actually. (FG 3)

Challenge and stimulation from developing a new skill

To give acupuncture was perceived as a time-efficient procedure that could give impressive results. Participants perceived satisfaction seeing patients benefit from such a cheap, user-friendly method. By reducing the patients’ symptoms and helping them endure, they became “the good cop”. It was rewarding to hear from patients that acupuncture was their best experience. The participants compared acupuncture with CBT, mindfulness or tactile massage, and acupuncture was perceived as time effective and easy to implement. Participants expressed a relief to put the needles in and let the needles do the job.

Participant L: I have been doing several other courses, yes, CBT and mindfulness and everything else. But I was never allowed to use it, because they are more extensive and longlasting treatments. But/acupuncture/is so simple! We are allowed to use that. … What I’m thinking of as the only disadvantage, is that, one is easily questioned in some places where/acupuncture/is not accepted. I have noticed scepticism from both colleagues and relatives who think this is unscientific. … But I just think it’s such an appealing method! As I said, it’s so simple! And what I said before here, it’s only four days of training, and it’s such an effective treatment. You can help people in such a simple way. You can have the needles in your pocket and you are ready to help … Yes, thinking of all years I have gone to school…/laughs/But ear acupuncture, it’s "wow"! Yes! That’s how it is!/Laughter/Participant B: I completely agree with you! It’s a simple method that costs nothing. It’s comfortable, and fast… (FG 5)

Consensus in the team that acupuncture should be an integrated part of the care, and support from the management in terms of allowing time, facilities and supervision was considered crucial for successful implementation. Some participants perceived that their management promoted the use of acupuncture, including it as a natural part in usual care. They pointed out facilitators like a positive boss providing training for staff caring for both in- and out-patients, and that all professionals at the unit had decided to promote acupuncture as a part of the treatment. Other participants described how they had worked hard on convincing parts of the management and new physicians who had no knowledge or were skeptical about acupuncture. It was seen as a professional challenge to be questioned by colleagues who argued that acupuncture was nonscientific. On the other hand, it was perceived as stimulating when physicians suggested acupuncture as a first intervention and when physicians from other units referred patients for acupuncture treatment. Most physicians trusted the staff’s opinions and the necessary referral was only a phone call away. The health care professionals who could decide whom to give acupuncture without consulting a physician perceived this as a relief and a stimulating responsibility.

Participant A: It feels like part of the management do not regard acupuncture as something functional, but more like hocus pocus. Participant C: Precisely! Hocus pocus! But our former boss, she was really enthusiastic and sent us to the NADA-training. Because she was used to acupuncture from the psychiatric clinic where she worked before. But our current boss … Participant A: He’s a bit more opposing. Our current boss is not as convinced that it works. Participant C: No, he isn’t. So now we always have to…/pause/Interviewer: Argue for it? Participant C: Yes, precisely. Mmm./Pause/(FG 3)

Participants noted the importance of reminding each other and the team about ear acupuncture when the interest was fluctuating. To allow the acupuncture part of the treatment to maintain or even grow, they had to make it visible. A persistent “engine”, an enthusiast, who would take responsibility for continuously promoting acupuncture, was considered favorably. Participants perceived needing time and space to provide acupuncture. Acupuncture had to be offered often enough to have effect, and participants described how they covered up for each other to be able to provide acupuncture when patients needed it. It was perceived as beneficial that acupuncture had effect no matter who did it.

Participants described how they tried to give a professional impression, keep safe routines, provide the acupuncture calmly and painlessly, allowing an hour of harmony to optimize the treatment ritual. Oral and written information about ear acupuncture to all new patients was considered crucial for successful implementation, although the interest for acupuncture often spread between patients. Those who were afraid of needles were shown how tiny the needles are.

Person-centered care

The participants perceived acupuncture to be a person-centered care, easy to adjust to the patient’s needs. It was perceived as not only a tool for the staff, but also for the patients, allowing them to influence their well-being.

Flexible to adjust the acupuncture

Participants described perceiving the ability to give attention generously and without demand to the patient during acupuncture. It was a possibility to spend time with the patient, to come close and to communicate, verbally or non-verbally. The participants appreciated the standardized NADA-acupuncture, easy and fast to administer enabling patients to get it whenever they wanted. They also liked the flexibility to choose points and methods according to the patients’ needs and preferences. They could adjust the frequency of acupuncture, the combination of needles perceived to give fastest effect, and try out semi-permanent needles and beads, perceived to have a long-term effect, in order to optimize the treatment. Those who initially were afraid of needles were introduced to acupressure from either seeds or beads to certain points in their ears and could thereafter try one needle. Choosing points and methods from what participants thought was most helpful, and from what patients desired, was perceived as a way to give person-centered care. Other participants perceived an individualized choice of acupuncture points as time consuming and stuck to the standardized NADA-protocol to save time.

Participants were aware that many factors could influence the outcome and they tried to optimize the treatment. During the treatment hour patients could be offered pillows and blankets. For example, patients who liked sitting in a special sensory stimulating chair could choose to receive acupuncture there, enveloped in weight and warmth. Participants stated that they did not know which of the factors that had effect but considered this less important. Music was selected by the participants to fit the group, or could be switched off if silence was preferred. Participants offered individual or group treatment, and patients could choose to sit or lie down during the treatment. Those who could not participate in a group were offered individual treatment.

Participant R: It’s a moment for chatting, when you put the needles in, which is important, I think. … They have time for their own needs there, they feel nurtured. That’s my experience. Participant J: Yes, I believe that there is much in this pampering. … the relaxing music, and they get a blanket and so on. And afterwards, we serve them a glass of water, sometimes it has been with lemon. Then it’s like "ooohh!", to be a bit pampered. And our patients are really not used to being pampered! And it is a kind of, well, a kind of love/laughter/Yes! It is a spiritual spa, I usually say. All: Yes! (FG 1)

A tool for patients too

The health care professionals described perceiving patients’ autonomy to increase as they could choose if and when to receive acupuncture. They could reject, try, opt-out and later they could opt-in for acupuncture again. They could control how often and for how long they wanted needles and how many needles they wanted. They could ask for acupuncture when symptoms like anxiety or aggression increased or when their sleep was disturbed enough to trigger a relapse. Not least helping patients regain better sleep was perceived as preventing relapse and avoiding in-patient stays and visits to the emergency unit as patients could handle their symptoms in out-patient care while they got help regulating emotions and symptoms. According to participants, even the most ill patients could use acupuncture as a distraction technique, seen as obviously influencing both body and soul, so that patients could let go of tormenting negative thoughts.

Participant K: They say that acupuncture is the best, and if they get it, they do not need to increase the dose of medication. Sometimes they say that “Now I need/acupuncture/more than once a week”. Then it’s important that they can get it. … I have some patients who usually come once a week, who can say like “I have slept badly for a while, and I recognize my psychotic symptoms, they are showing up, now I have started to think those strange thoughts again, now I need to get back on track. Can I come? ”And then they can come and get needles three to four times a week. … then they stay floating for a while, they can manage. It’s interesting. Participant H: And then, it has become the patient’s tool for recovery! It’s not only our tool! Participant M: The patients I meet do not belong to those who usually make phone calls. They do not call me and ask for help about other things, it’s rather the opposite. But asking for acupuncture has become an established way in our relationship. When we encounter problems, we deal with them with ear acupuncture. Usually, problems will solve and if they don’t, then we’ll continue with plan B. (FG 4)

Acupuncture was perceived to increase initiative where passivity was a problem, and became a training of social skills in patients’ rehabilitation. It was seen as an activity that helped patients who otherwise lived in isolation to get up in the morning, dress and go to meet others at the clinic. Participants who gave acupuncture as a group treatment perceived that the patients discovered not being alone in their situation but able to connect to and learn from each other. However, as some patients wanted to continue receiving acupuncture, participants compared it with changing one addiction to another, and said it could be a challenge to terminate. For persons with chronic conditions participants perceived acupuncture to be a good option to reduce symptoms, on and off for months and years, but for other patients, the participants perceived that acupuncture should be offered only until the patient had learned other strategies to handle his/her symptoms.

Discussion

To our knowledge, this is the first study describing health care professionals’ perceptions of giving acupuncture as a part of psychiatric and addiction care, which we find remarkable as ear acupuncture is used in this context in many countries (Landgren, 2008; Stuyt & Voyles, 2016). The participants in our study were enthusiastic, describing acupuncture as a non-verbal, non-pharmacological tool in an environment otherwise founded on verbal therapy and medication. While acupuncture on one hand was appreciated for being non-verbal, on the other hand, it was perceived to enhance following communication. Acupuncture was described as easy to adjust to the patients’ needs and requests and perceived to have a good effect in a variety of symptoms for many patients. Participants’ perceived that their self-confidence increased, as they could give a hands-on treatment with obvious effect. With acupuncture, the health care professionals who already were well-educated caregivers with many therapeutic tools, got another handy tool, easy to use in concert with the others. Acupuncture had become one of the favorite “dishes on their menu”.

The health care professionals in the present study experienced acupuncture to be a person-centered intervention, promoting partnership with the patient. The goal with person-centered psychiatric care is a safe and effective care, developed in partnership with the patient from his or her resources and limitations (Gabrielsson, Savenstedt, & Zingmark, 2015). Person-centered care is holistic and individualized, embodying respectfulness from the caregiver and empowerment for the care recipient and it should be recovery focused (Buchanan-Barker & Barker, 2008). Adding acupuncture to psychiatric care is in line with the contemporary movement towards person-centered care, emphasizing participation, shared decision-making and autonomy (Foley & Steel, 2017; di Sarsina et al., 2012). Patients with psychiatric illness, acute or chronic, need help to reduce symptoms, and participants in the present study perceived that acupuncture decreased symptoms in the patients. These findings are congruent with quantitative studies (Chen et al., 2007; MacPherson & Thomas, 2005; Pilkington et al., 2007), and understandable from a neurophysiological perspective (Darbandi et al., 2016; Fang et al., 2009; Hou et al., 2015; Sakatani et al., 2010). When ear acupuncture, like in the present study, is delivered often, regularly, with easy access and with respect for patients’ needs and preferences it gives place for communication, collaboration, and patient empowerment, and is an example of how person centered care can be promoted (Foley & Steel, 2017; di Sarsina et al., 2012). Professionals get an opportunity to motivate, inspire, commend, ask reflective questions and to convey practitioner empathy (Buchanan-Barker & Barker, 2008).

By offering patients to choose how often they wanted acupuncture, health care professionals gave patients an opportunity to self-manage symptoms like stress, fear, anger and depression, thus taking an active role in decision-making on their health and recovery. Letting the patient be an expert, the health care professionals can adapt the treatment after the patients’ needs, and simply and fast, unconditionally and with respect, give them what they request, an approach proposed by the tidal model for promoting recovery (Buchanan-Barker & Barker, 2008). Patients in psychiatric care might feel that nurses spend minimal time with them (Gabrielsson et al., 2015). One of the commitments in the tidal model is giving the gift of time. By investing a fairly small amount of time, health care professionals who give acupuncture get an opportunity to see the patients often, giving the professionals recurrent opportunities to genuinely listen to patients’ stories, building a trustful relation. At these frequent clinical encounters health care professionals have a chance to establish and develop the essential supporting therapeutic relationship needed by psychiatric patients (Gabrielsson et al., 2015). A complex intervention, like acupuncture, influences the therapeutic outcome with specific and nonspecific factors (Carter & Olshan-Perlmutter, 2015; di Sarsina et al., 2012). One nonspecific factor may be the opportunity to connect to patients when giving them acupuncture. Essential criteria in a therapeutic relationship are conveying understanding and empathy, accepting individuality, being available and demonstrating respect (Buchanan-Barker & Barker, 2008). Giving acupuncture was perceived as an opportunity to provide this support and to reach chronically ill patients otherwise difficult to connect to and “difficult to love”. Staff giving acupuncture get frequent opportunities to inform, listen and collaborate with the patient, helping them become aware of changes and thereby promoting their subjective health.

Acupuncture even involves touching the patient in a non-threatening way. For some patients this was the only situation where they allowed someone else to touch them, perceived by the professionals as an asset in creating a good therapeutic relationship.

Being able to influence your symptoms and well-being leads to a sense of power and control, thereby increasing self-esteem and confidence (Buchanan-Barker & Barker, 2008). Helping patients become calm and reflecting supports empowerment, a core element in person-centered care (Gabrielsson et al., 2016). Empowerment is generated in an interaction where the patient is an active participant. When acupuncture treatment is offered so that the patient can influence factors like how often they want acupuncture and if they want to join a group or prefer individual treatment is a good example of this. A sense of having control, the possibility to influence your treatment and the training of social skills relates to empowerment and is a step towards recovery and being a part of the society in order to live a satisfying life within the limitations caused by illness (Buchanan-Barker & Barker, 2008). As many out-patients continue to come regularly once or twice a week, health care professionals get many opportunities to give patients something they perceive reduces their symptoms, thereby empowering and guiding them towards a better quality of life. By focusing on well-being, patients’ confidence in their own ability and their subjective psychiatric health may increase.

When providing acupuncture, health care professionals come close to the patient and they can communicate, verbally and/or non-verbally. When the needles are inserted, patients sit or lay quietly, resting and reflecting for half an hour (Stuyt & Voyles, 2016), and when the needles are removed both patient and participant again get an opportunity to communicate, verbally and/or non-verbally. Thus the arrangement gives a golden opportunity for patients to practice stillness and calmness (Carter & Olshan-Perlmutter, 2015), as also described in an earlier qualitative study where acupuncture was described as an undemanding treatment that helped patients to be silent, relax and reflect (Hedlund & Landgren, 2017), and might prepare patients for verbal therapies by helping them focus.

In persons with overlapping psychiatric and somatic diagnoses, often combined with addiction, we are looking for treatments that can give relief, and if not cure, help patients endure during their journey towards recovery (Buchanan-Barker & Barker, 2008). Earlier literature (White, 2004) stressed that acupuncture is a safe treatment, helping patients reduce symptoms and restore sleep. In the present study, participants described how acupuncture was used as a complement to necessary pharmacological treatment, sometimes replacing medicines or preventing prescriptions of more sedatives or hypnotics, which was seen as a benefit (NICE, 2010, 2014). Acupuncture is reported to reduce side effects of antidepressants (Chan et al., 2015), which can be another benefit when medications are necessary but have undesired side effects.

Standardized ear acupuncture requires considerably shorter training compared to the common but more complicated body acupuncture, and is time efficient and cost-effective especially when given in groups (Stuyt & Voyles, 2016). In the context of usual care, it means that the ordinary staff could provide this simple type of acupuncture, a benefit compared to relying on externally recruited body acupuncturists (Fogarty & Ramjan, 2015). With this backdrop, and the results in our study, ear acupuncture presents an interesting treatment modality as an adjunct in psychiatric care.

Strengths and limitations

Participants in this study represent different professions, gender and age, and they use acupuncture in a variety of psychiatric settings, assuming that the results may be transferable to a broad psychiatric setting. However, those who wanted to participate might be more enthusiastic ambassadors for acupuncture compared to those who did not participate. This could explain why few disadvantages were mentioned. The voices of health care professionals who have learned acupuncture but prefer other tools in their toolbox are not heard here.

The analysis was conducted systematically and rigorously with consensus between the researchers concerning conceptions and descriptive categories. One interview was only 20 minutes but generated interesting data as the two participants were focused and verbal.

Phenomenographical research seeks to capture knowledge on collective, rather than individual, accounts for diversity in people’s experience and understandings of a phenomenon (Marton & Booth, 1997). Discussions between participants in focus groups can give more perspectives on a phenomenon compared to individual interviews (Krueger & Casey, 2009). Therefore, focus group interviews were seen to be an appropriate method. This method helped us gain insight in how acupuncture is perceived to work as a complement to usual care in clinical praxis in the real world.

Conclusion

Ear acupuncture was perceived by the health care professionals to be a simple, safe and hands on complement to the participants´ other therapeutic treatment skills, promising in relieving psychiatric and somatic symptoms. Acupuncture may have a relevant place as a person-centered approach in the contemporary landscape of clinical psychiatric care. Acupuncture facilitates the communication with patient, emphasizing participation and shared decision-making. Managers’ role and attitude in supporting staff needs to be explored in future research.

Ethics approval: The study was approved by the Regional Ethical Review Board (Dnr 2014/698). Participants signed informed consent.

Availability of data and material: Regarding the privacy of our informants, data cannot be shared.

Disclosure statement

KL teaches ear acupuncture. The authors declare that they have no other competing interests.