Beliefs and values in Japanese acupuncture: an ethnography of Japanese trained acupuncture practitioners in Japan.

BACKGROUND: Japanese acupuncture is gaining international recognition. However, previous research has failed to comprehensively describe the characteristics of Japanese acupuncture by not investigating it within the Japanese clinical environment. This study aimed to identify unique and routine elements of Japanese acupuncture, describe these elements in detail, and examine how the current beliefs and attitudes of Japanese acupuncture practitioners related to philosophical concepts in their practice.
METHODS: Between August 2012 and December 2016, ethnographic fieldwork was conducted in Japan. Japanese trained acupuncture practitioners were recruited by chain referral and emergent sampling. Data were collected through participant observation, interviews, and by analyzing documents. Thematic analysis was used to critically evaluate the data.
RESULTS: Thirty-eight participants were recruited. Of these participants, 22 agreed to clinical observation; 221 treatments were observed with 172 patients. Additionally, 17 participants consented to participate in formal semistructured interviews and 28 to informal unstructured interviews (fieldwork discussion). Besides "knowledge," "beliefs and values" was a major theme interpreted from the data. Subthemes-including Zen Buddhism, effect through technique, instant effects of treatment, anatomical areas of significance, resolution of abnormalities, minimal stimulation, and patient comfort and customer service-were identified.
CONCLUSION: Beliefs and values are an underrepresented, yet extremely important aspect of philosophical concepts influencing acupuncture practice in Japan. Uniquely Japanese beliefs and values that do not rely on a commitment to any spiritual or religious affiliations or proprietary knowledge of traditional or biomedicine may be successfully exported from Japan to advance acupuncture education, research and practice in international contexts.

Introduction

Acupuncture based on traditional Chinese medicine (TCM) is used worldwide, and practitioners are educated through under- and postgraduate university courses internationally.1, 2 As familiarity with acupuncture from TCM has developed, so has the understanding of acupuncture in other East Asian countries. Particularly, acupuncture from Traditional Japanese Medicine is gaining popularity as an alternative to acupuncture from TCM in the West.3, 4, 5 However, there appears to be misconceptions and contradictions in the published English language literature describing Japanese acupuncture.6, 7, 8, 9, 10, 11

The tripartite typology of health, illness, and healthcare has long been used in the explanation of medical systems.12, 13, 14 In this typology, healthcare refers to the technical or practical aspects of care provision, usually to oneself or someone who is unable to do so themselves. The beliefs and behaviors surrounding healthcare are profoundly affected by the interaction of culture, society, and individual experiences. It is therefore important to investigate these elements collectively and create contextually appropriate explanations of healthcare practices, including acupuncture. Therefore, this study focused on professional healthcare as it relates to Japanese acupuncture within the sociocultural context of Japan.

In describing Japanese acupuncture, philosophical concepts were included as a key category of investigation. Philosophical concepts have been identified as some of the most important aspects of acupuncture, and are inextricably linked with the study and practice of acupuncture in Traditional East Asian Medicine (TEAM).18, 19 The International Standard Terminologies on Traditional Medicine in the Western Pacific Region provides an explanation of the philosophical concepts in TEAM acupuncture. According to the World Health Organization, philosophical concepts relate to the branch of TEAM dealing with the basic concepts, theories, rules, and principles. The World Health Organization suggests that different acupuncture styles are based on certain theories or philosophical concepts, which identify them as distinct from other TEAM acupuncture approaches. Other authors also state that TEAM acupuncture styles are made up of variations and combinations of traditional concepts, theories, and conceptual models that mark them as unique, and have used philosophical concepts as a thematic category to compare, contrast, and describe acupuncture styles.21, 22, 23, 24 Investigation with a specific focus on philosophical concepts was determined as a necessary step in describing Japanese acupuncture practice in Japan.

The aim of this research was to understand the philosophical concepts in Japanese acupuncture. Specifically, this study sought to identify procedural elements of Japanese acupuncture, describe these elements in detail, and investigate the current beliefs and attitudes of Japanese acupuncture practitioners in Japan toward their practice.

Methods

Setting, recruitment, and practitioners

This study aimed to describe and interpret the characteristics of Japanese acupuncture by investigating it in the diverse social and cultural constructs in which it is found. Therefore, ethnography was selected as the methodology to address the descriptive and explorative aims of this study. Consequently, long-term ethnographic fieldwork was conducted in Japan. The research project was approved by the University of New England Research Ethics Committee (approval number HE-12-142) and was carried out in accordance with the ethical principles of the World Medical Association (Declaration of Helsinki) for research involving humans.

Participants were required to be experts in Japanese acupuncture and were eligible for recruitment if they held acupuncture qualifications obtained from a Japanese educational institution and were nationally registered practitioners. Prior to recruitment and data collection, practitioners received information sheets and consent forms, which when signed and returned, indicated their informed consent to participate in the study. Practitioners were recruited through chain referral25, 26 and emergent sampling, which is common in ethnographic research when targeting members of a specialized and difficult to reach population.14, 28, 29

Fieldwork began in August 2012 and concluded in December 2016. The study was based in Osaka, and fieldwork was conducted at a variety of prefectures (n = 7) across Japan. The positioning of the primary fieldworker in this study was one of an Australian trained practitioner of acupuncture with a cultural understanding of acupuncture in Japan and Australia, as well as clinical and educational experiences of acupuncture in Japan and Australia.

Data collection

A single researcher conducted all data collection. This was accomplished according to the principles of ethnographic fieldwork30, 31, 32 and involved participant observation, semistructured interviews, and analysis of documents. Participant observation involved shadowing practitioners, watching them, asking questions, and recording what was seen and heard. Recordings in participant observation were informed by observation guidelines developed for this study, which were revised iteratively. The guidelines included prompts for what should be observed in relation to the clinical environment, clinical procedures, patient–practitioner interaction, tools, and techniques. Observation included taking photographs and audio recordings. Interviews were conducted according to the interview schedule that was revised iteratively and covered topics related to philosophical concepts, routine elements of the clinical encounter, and general practitioner experiences (Table 1). Interviews were recorded digitally and in notebooks. Additionally, relevant documents were acquired for analyses.

Table 1

Original interview schedule.

Demographic data
Age	Sex
Birthplace	Educational qualifications
Professional experience	Average patients per week
Average service fee	Average consultation time
Q1. Please describe a typical day in your clinic.
Probe for procedures in relation to receiving, treating, and concluding with patients
Probe for how their procedures have evolved or might be compared to others
Probe for how or if this changes during the year
Q2. How would you describe your style of acupuncture?
Probe for philosophical concepts, diagnostic methods, and treatment principles
Probe for how their style fits in with what they consider as Japanese acupuncture in general
Probe for how their style fits in with any schools of thought they know about
Probe for the most important aspects of their style
Q3. What, if any, are the unique aspects of Japanese acupuncture in relation to acupuncture elsewhere?
Probe for philosophical concepts, diagnostic methods, and treatment principles
Probe for any procedural differences		Probe for a rationale of their opinions
Q4. What do you think patients expect from your treatments?
Probe for how clinical encounters have shaped their current practice
Probe for any differences in patients between them and their colleagues
Q5. If you gave a workshop or seminar on your style of acupuncture abroad, what would you teach and talk about?
Probe for philosophical concepts, diagnostic methods and treatment principles
Probe for a rationale of their opinions
Q6. In your opinion, what is the future of Japanese acupuncture?
Probe for what they want to know more about
Probe for what they want other therapists to know about
Probe for hopes and fears for the future of acupuncture
Q7. If you were interviewing Japanese acupuncturists about how they classify, clarify, and describe acupuncture, what questions would you ask?
Probe for a rationale of their opinions
Probe for other aspects of acupuncture not related to classification or description
Q8. If after the interview some issues are unclear, the researcher would like to contact you to clarify any outstanding issues. The researcher may also ask for your opinions and interpretations on the data obtained during the study. Do you agree to be contacted for this?

Data analysis

As is common in ethnographic research,33, 34, 35 thematic analysis was the key analytical method. Thematic analysis was conducted after every data collection opportunity and involved translation and transcription of data. Data were analyzed using theoretic and inductive analysis.33, 36 All transcription and coding was performed by a single researcher. A coding template was developed based on the World Health Organization definition of philosophical concepts in the International Standard Terminologies on Traditional Medicine in the Western Pacific Region (Table 2).

Table 2

Coding template for philosophical concepts.

Code label	Description	Examples
Philosophical concepts	Elements that relate to the branch of TEAM acupuncture concerned with the basic concepts, theories, rules, and principles.	Yin/Yang, five phases, channels, & collaterals

TEAM, Traditional East Asian Medicine.

Data allocation and analysis were guided by, but not confined to, the coding template; additional themes were identified as they emerged through reappearing stories, phrases, ideas, actions, and objects, and when they represented some level of patterned response or meaning significant to the research aims through the entire data set. The analysis involved recognizing how different data from multiple collection methods, data sources, and environments supported or opposed each other. As is common in ethnography,29, 37, 38 triangulation was used as a method to compare, contrast, corroborate, or contradict this variety of data, and analytic bracketing39, 40, 41 was used to address bias.

Results

Practitioners

All practitioners were given pseudonyms to maintain confidentiality and protect their identity. Table 3 shows the demographic data about practitioners at the time of recruitment, including their pseudonym, sex, age, qualifications, and occupation. Where it was not possible to gain information about age owing to sociocultural reasons, age was established according to age groups; practitioners were described based on appearing either middle-aged or as a young adult. A total of 38 practitioners were recruited. This included males (n = 24) and females (n = 14) with an age range of young adults (≤35) to seniors (≤60). The majority of practitioners were only qualified in acupuncture and moxibustion (n = 28). In addition to being qualified in acupuncture and moxibustion, a number of the practitioners also held qualifications related to Japanese acupuncture including massage (n = 5), judo therapy (n = 4), and chiropractic (n = 2). Practitioners had a range of acupuncture-related occupations including clinician, teacher, and researcher. Researchers were those conducting postgraduate research related to acupuncture.

Table 3

Practitioner demographic data.

Practitioner pseudonym	Sex	Age (y)	Qualifications	Occupation
Tsuru	Female	Middle-aged	Acupuncture	Clinician
			Moxibustion
Ginnosuke	Male	36	Acupuncture	Clinician
			Moxibustion
Asajiro	Male	Middle-aged	Acupuncture	Clinician
			Moxibustion
Takizou	Male	36	Acupuncture	Clinician
			Moxibustion
Bunzaemon	Male	39	Acupuncture	Clinician
			Moxibustion
			Judo Therapy
Ume	Female	35	Acupuncture	Clinician
			Moxibustion
			Massage
Zenkichi	Male	67	Acupuncture	Clinician
			Moxibustion
			Chiropractic
Koremitsu	Male	Middle-aged	Acupuncture	Clinician
			Moxibustion
Genrokurou	Male	36	Acupuncture	Clinician
			Moxibustion
			Judo Therapy
Kojiro	Male	45	Acupuncture	Clinician
			Moxibustion
			Massage
Iwamatsu	Male	48	Acupuncture	Teacher
			Moxibustion
			Massage
Kame	Female	35	Acupuncture	Clinician
			Moxibustion
Shinokichi	Male	46	Acupuncture	Clinician
			Moxibustion	Teacher
			Massage
			Judo Therapy
Tarobi	Male	Middle-aged	Acupuncture	Clinician
			Moxibustion	Teacher
Denkuro	Male	36	Acupuncture	Clinician
			Moxibustion
Bunshichi	Male	Middle-aged	Acupuncture	Teacher
			Moxibustion
			Massage
Kiemon	Male	72	Acupuncture	Clinician
			Moxibustion
Toko	Female	40	Acupuncture	Clinician
			Moxibustion
Yae	Female	Middle-aged	Acupuncture Moxibustion	Clinician
Benio	Male	Middle-aged	Acupuncture	Clinician
			Moxibustion	Teacher
			Judo Therapy
Sayo	Female	Middle-aged	Acupuncture	Teacher
			Moxibustion
Rin	Female	41	Acupuncture	Researcher
			Moxibustion
Zenpachi	Male	Middle-aged	Acupuncture	Teacher
			Moxibustion
Miyo	Female	Middle-aged	Acupuncture	Teacher
			Moxibustion
Nobuhide	Male	Young adult	Acupuncture	Researcher
			Moxibustion
Chusuke	Male	38	Acupuncture	Teacher
			Moxibustion
Sasuke	Male	52	Acupuncture	Teacher
			Moxibustion
Heijiro	Male	40	Acupuncture	Teacher
			Moxibustion
			Chiropractic
Kinu	Female	40	Acupuncture	Teacher
			Moxibustion	Researcher
Otoemon	Male	28	Acupuncture	Researcher
			Moxibustion
Sukegoro	Male	48	Acupuncture	Teacher
			Moxibustion
Hikoemon	Male	31	Acupuncture	Researcher
			Moxibustion
Heisuke	Male	57	Acupuncture	Clinician
			Moxibustion
Mitsu	Female	Young adult	Acupuncture	Clinician
			Moxibustion
Kiyo	Female	Middle-aged	Acupuncture	Clinician
			Moxibustion
Iwa	Female	Middle-aged	Acupuncture	Clinician
			Moxibustion
Atsu	Female	Middle-aged	Acupuncture	Clinician
			Moxibustion
Hana	Female	Middle-aged	Acupuncture	Clinician
			Moxibustion

Practitioner contributions were individually negotiated at recruitment. Some practitioners agreed to be formally interviewed and recorded (n = 18). Other practitioners agreed to engage in informal interviews (n = 28), sometimes in addition to a formal interview. Almost half of the interviewed practitioners (n = 18) participated in follow-up interviews. Additionally, some practitioners consented to allow treatment observations (n = 22). Some practitioners were observed on multiple occasions (n = 4). In total, 172 patients were observed during 221 treatments over 4 and a half years of ethnographic fieldwork.

Important themes

Within philosophical concepts, two major subthemes were identified: knowledge and beliefs and values. Knowledge refers mainly to academic and clinical knowledge concerned with anatomy, physiology, aetiology, differential diagnosis, pathophysiology, prognosis, and treatment. Beliefs and values reflect the socially and culturally constructed systems of traditions, attitudes, and behaviors related to health, illness, and healthcare in Japan. The aim of this research is to report on the results related to beliefs and values in Japanese acupuncture. The rubric of themes analyzed in relation to philosophical concepts and beliefs and values are shown in Fig. 1.

Fig. 1

Thematic categories related to beliefs and values.

Two major themes related to philosophical concepts were identified: beliefs and values, and knowledge. Beliefs and values included seven subthemes; Zen Buddhism, effect through technique, instant effects of treatment, anatomical areas of significance, resolution of abnormalities, minimal stimulation, and customer service/patient comfort. The themes reported on in this article are discussed in the following subsections.

Beliefs and values were reflected in procedural routines of clinical acupuncture practice, and demonstrated in practitioner attitudes related to Japanese acupuncture, health, illness, healthcare, and life in general. Quotes from practitioners that exemplify thematic categories are provided. Practitioners are labeled with a pseudonym, and described as acupuncture and moxibustion, massage, judo therapy, or chiropractor practitioner, which indicates both their qualifications and profession. Additionally, some practitioners were senior lecturers at educational institutions; this is included in their label.

Zen Buddhism

Whereas other schools of Buddhism have mostly influenced the spiritual life of Japanese people, ideas from Zen Buddhism have been accepted into almost every facet of Japanese culture. Although Zen Buddhism is a religion, Zen concepts are so embedded in nonreligious beliefs and behaviors (including the practice of acupuncture) that they no longer retain religious meaning in those contexts. Simplicity, minimum effort for maximum effect, and the respect for practicality above convention were some of the dominant values that informed Japanese acupuncture practice.

The most important thing is whether the sickness changes or not. If your method is perfect but nothing changes then you’re not practicing medicine. The important thing is whether the pain goes or not, whether they get better or not.

Ginnosuke, acupuncture and moxibustion practitioner

Although each of the beliefs and values were distinctly identified themes in the data, many of them can be related to Zen Buddhism. The Zen maxims of practical experience and deliberate practice seem to have influenced many aspects of Japanese culture including Japanese acupuncture.

I think, these days I’m somewhat puzzled about what Japanese acupuncture is, what it means exactly. But I think Japanese acupuncture means finding your own way, like Zen. Like Buddhist philosophy….Just practice and just study. Finally you will find your own way.

Takizou, acupuncture and moxibustion practitioner

Effect through technique

This is the value of skills above knowledge. This value was represented by the importance of practitioner sensitivity and the significance given to the arrival of Ki (Japanese language term for Qi), above the circulation of Ki. This value was also connected to the practice of causing tangible treatment effects and detecting subtle changes in the patient condition. It is this value that demonstrated the de-emphasis of complex pattern differentiation and the emphasis of location and treatment of body tissue abnormalities.

If you compare it to Chinese acupuncture, our acupuncture methods are gentle. The best way to express Japanese acupuncture is sensitive…. Chinese acupuncture treats forcefully, but we treat with technique.

Sasuke, acupuncture and moxibustion practitioner/senior lecturer

Instant effects of treatment

This represents the belief that acupuncture and moxibustion can have instantly verifiable treatment effects. The process of trial and error throughout treatment and the constant confirmation of intervention effects typified this belief. This also connected to the concept of overtreatment and the ability to monitor and prevent over treating a patient. Applying too much stimulation or making too many attempts to improve the patient’s condition without a positive result was believed to be detrimental to the patient’s overall condition.

In Japanese acupuncture, while we insert needles we are constantly checking the patients’ condition at the same time. In Chinese acupuncture, they don’t pay much attention to how many needles they insert and they don’t check the patients’ condition while the needles are inserted.

Chusuke, acupuncture and moxibustion practitioner/senior lecturer

Anatomical areas of significance

Some areas of the body were valued as more significant to health than others. One major area of significance was the abdomen. The diagnosis and treatment of this area alone could constitute a practitioner’s entire clinical procedure. The skin was also observed to be an important area of significance that was typified by skin palpation, shallow needling, and contact needling techniques. Areas such as the hands, feet, head, spine, and sacrum were also prioritized depending on the commitment to certain knowledge systems.

I only ever use points here at the occiput. I usually use either one or two points depending on what reaction the patient has during the examination.

Zenkichi, acupuncture and moxibustion/chiropractic practitioner

Resolution of abnormalities

Physical abnormalities or palpable disturbances of Ki, whether part of the main complaint or not, were considered sites of dysfunction that should be rectified. The search for, and treatment of abnormalities, especially on significant anatomical areas, was an important theme. This resulted in the recognition of abnormalities in relation to a predicated natural order and remedying any disorder by the application of prescribed techniques.

Where tissue feels like it is bunching up and your hand seems to stop there, then that is the place you need to treat.

Sayo, acupuncture and moxibustion practitioner/senior lecturer

Minimal stimulation

The belief that it was not necessary for needles to be inserted into the body to have a therapeutic effect, and that moxibustion stimulation need not be felt by the patient, represents the value of minimal stimulation. This value is also evidenced by the large range of contact tools and minimally or noninserted needle techniques that were believed to have an effect on body tissues and Ki.

In my case, I don’t insert needles. I just touch the skin surface with them which is called contact needling. When I do tonification, I just touch the skin with the needle. But when I apply draining, I insert needles about 5 mm. I also use teishin to stimulate the treatment site and release muscle tension.

Chusuke, acupuncture practitioner/senior lecturer

Patient comfort and customer service

This value represents the belief that patients should be comfortable, and treatment need not cause inadvertent injury to patients. It was common for practitioners to be described as “craftsmen,” implying a high level of skill and expertise. It was generally seen as unprofessional to cause discomfort to the patient with needles. This was somewhat demonstrated with the use of thin needles and guide tubes. Additionally, mild stimulation of treatment sites and the idea of not overtreating the patient are also practices that were connected to patient comfort.

I don’t need to be honoured for curing patients; I just want them to enjoy their lives. I hope all practitioners can understand that. I want all practitioners to think about their patients all the time while they are giving treatments.

Bunzaemon, acupuncture and moxibustion/Judo therapy practitioner

Discussion

In the published English language literature describing Japanese acupuncture, “philosophical concepts” has been equated to what this study suggests is actually “knowledge.” This study reports that “philosophical concepts” includes both “knowledge” and “beliefs and values,” and that delineation in itself is an important finding of this study. Although understanding preferences or biases in knowledge is extremely important in understanding Japanese acupuncture, definitions of philosophical concepts and literary discussion describing acupuncture in Japan have generally ignored the sociocultural aspects of health, illness, and healthcare in favor of the description of knowledge and skills.42, 43, 44, 45, 46, 47, 48 Aside from personal discussions of Zen as it may be related to acupuncture49, 50 and Buddhist styles of Japanese acupuncture,51, 52 the beliefs and values of Japanese acupuncture have been understated in the literature.

Beliefs and values were found to be identifiable with Japanese nationality in general and somewhat bound to the environment and customs prevalent in Japanese society. In the Japanese acupuncture setting, the beliefs and values reported by this study interact with opinions and behaviors concerned with health and illness, as well as the healthcare activities that are included in its practice. They are socially ingrained, have developed and been culturally legitimated over time, and influence expectations, clinical settings, clinical relationships, and the roles practitioners play in the professional medical arena with patients, and in society at large. These beliefs and values also assist in the development of strategies and evaluative standards that guide choices related to healthcare practices and assist in assessing the processes and outcomes of clinical interventions and care. They guide the intellectual and interactive procedures for managing sickness, which involve disease labeling, differentiating, and offering meaningful explanations of health, illness, and the healthcare experience. In addition, the unique beliefs and values found in the Japanese clinical environment guide the provision of all types of therapeutic interventions and advice related to health enhancing, or illness prevention behaviors. Finally, they direct the management of clinical outcomes including improvement of the health condition, cure, treatment failure, progression, and management of long-term illness, disability, and death.

It is likely that education and licensing also play a role in developing the beliefs and values of Japanese acupuncture practitioners. Japan has a national license examination for traditional medical modalities including acupuncture and moxibustion, and students must graduate from a recognized institution then pass the national license examination to become a nationally registered practitioner.52, 53 Regarding acupuncture and moxibustion, universities offer a 4-year program and technical colleges a 3-year course that includes about 2800 hours of study, and although institutions are required to teach out a certain number of hours for legislated subjects, the guidelines for the contents of the courses are purposefully basic to encourage some curricular independence and individuality in each school.53, 54, 55

This study recognizes that the beliefs and values of Japanese acupuncture are closely connected to and inform the application of skills and knowledge. This is similar to research in psychology and business56, 57, 58 that views understanding values as an essential element of knowledge provision. In regard to the education and practice of acupuncture internationally, some authors have suggested that developing an appreciation of local beliefs and values across a range of cultural environments could assist in the adaptation of the education and practice of acupuncture in non-Chinese contexts.59, 60 This study supports that acupuncture practice and knowledge can and should be adapted to local environments by developing a cross-cultural understanding of beliefs and values. Additionally, this study proposes that garnering an awareness of the beliefs and values of Japanese acupuncture will contribute to understanding acupuncture internationally and promote awareness about how beliefs and values manifest in clinical actions and inform clinical reasoning.

This study relied only on willing and available practitioners that could be recruited warrants limited generalization. Many factors influenced who was able to be recruited and how practitioners contributed. The consequence of Osaka as the primary research site, as well as the length of time spent in the field, resources available to perform fieldwork, who the patients were, and with what conditions they presented, are factors to consider when contextualizing this project in relation to Japanese acupuncture at large, and the future of research into Japanese acupuncture in Japan.

Beliefs and values are an underrepresented yet extremely important aspect of philosophical concepts influencing acupuncture practice in Japan. Among Japanese acupuncture practitioners, there seems to be homogeny in knowledge that is provided by the nationally standardized education system. There also seems to be homogeny in beliefs and values provided by the unique sociocultural setting. However, knowledge and values of Japanese acupuncture are probably synthesized into clinical reality in a variety of different ways owing to heterogeneity in practitioner preferences for certain knowledge, the strength of various values, and personal/professional experience.

Japanese acupuncture beliefs and values may be successfully integrated with acupuncture practice outside of Japan, especially: effect through technique, instant effects of treatment, minimal stimulation and resolution of abnormalities. These beliefs and values do not rely on a commitment to any spiritual or religious agenda, nor is there any need for commitment to proprietary knowledge of traditional or biomedicine. One of the outcomes of this study highlights the importance of future research focusing on how beliefs and values may affect clinical efficiency.

Conflicts of interest

The authors have no conflicts of interest to declare.