Dry cupping · Atlas

1. Introduction

Version followed: dry cupping (the skin is not pierced) as described by NCCIH (US National Institutes of Health), the Merck Manual consumer edition, the Aboushanab and AlSanad (2018) classification review, and practitioner bodies (British Cupping Society, British Acupuncture Council). Chinese (TCM) and Middle Eastern/Islamic traditions are described as their sources state. Wet cupping and hijama, which involve skin incisions and bleeding, are a separate practice with separate medical risks. They are named here only and covered in Domain XI. [source: NCCIH; Aboushanab & AlSanad 2018; Mayberry 2019]

What it is. In cupping, a glass, ceramic, bamboo or plastic cup creates suction on the skin. The vacuum is made by heating the air in the cup (fire cupping) or with a pump or suction device attached to the cup. In dry cupping the skin is drawn up into the cup but not cut. [source: NCCIH; Merck Manual] Sources trace cupping to ancient Egypt, Chinese, Unani, Korean and Tibetan medicine, Hippocratic medicine, and Arabic and Islamic physicians (Ibn Sina, Al-Zahrawi, Al-Razi), and record its spread in Europe from the 14th to the 17th century. [source: Aboushanab & AlSanad 2018]

How change is said to happen (attributed, not fact).

In traditional Chinese medicine, practitioners hold that cupping "dispels stagnation" of blood and improves the flow of qi. Qi, stagnation and meridian concepts belong to that tradition and are not established physiology. [source: Wikipedia summary of TCM sources; uncertain: primary TCM text not verified]
In Islamic tradition, cupping (hijama, usually the wet form) is regarded as a Prophetic practice (Sunnah). A Bukhari hadith is cited as saying "There is healing in cupping." This is a religious claim held by the tradition. [source: Mayberry 2019]
Modern proponents suggest effects through suction, local blood flow and immune changes. The overview review concludes that no clear mechanism has been identified. [source: Aboushanab & AlSanad 2018]

Evidence status (as reliable sources give it). NCCIH: most research is of low quality; cupping may help reduce pain, but the evidence is not very strong, and there is not enough high-quality research to judge other conditions. [source: NCCIH] The Merck Manual says evidence for uses beyond neck and low back pain is limited. [source: Merck Manual] Burns specialists call the physiological benefit "dubious" and suggest psychological factors may play a larger part. [source: Seifman et al. 2017] The American Cancer Society is reported as stating that the evidence does not support claims of health benefit. [source: Wikipedia; uncertain: not verified at ACS] Cupping is not a treatment for cancer or any other physical disease. Promotion of hijama for chronic disease in place of conventional care has been documented in the UK. [source: Mayberry 2019]

Who delivers it. Cupping is delivered by acupuncturists and TCM practitioners, massage and sports therapists, cupping or hijama therapists, and some medical and healthcare professionals. In the UK there is no statutory regulation of cupping. The British Cupping Society (founded 2008 by medical and healthcare professionals) describes itself as a membership body that sets standards for education, ethics and competency. The British Acupuncture Council is a voluntary self-regulating body on the Professional Standards Authority's Accredited Register scheme. [source: BGi BCS page; BAcC professional codes] A UK review calls hijama practice "totally unregulated" and says most practitioners have limited clinical training. [source: Mayberry 2019] In Canada, massage therapy is regulated by a college only in Ontario, British Columbia, New Brunswick, Newfoundland and Labrador, and Prince Edward Island. [source: HHR-RHS Canada; CBC 2021] In Australia, massage therapists are not nationally registered and fall under the National Code of Conduct for health care workers and state complaint bodies. [source: HaDSCO WA; AMT] Which US state acupuncture or massage boards include cupping in their scope of practice varies by state. [uncertain: not verified]

Who this guide is for. A psychotherapist does not deliver cupping. It is a hands-on technique that also carries fire and skin risks. This guide covers the psychotherapist's work alongside it: when it is reasonable to discuss or suggest it, how to vet and refer, how to prepare clients with trauma histories for touch, how to integrate the experience, safeguarding when marks are seen, and how to recognise adverse effects and pass them on. [synthesis]

2. Framework

Cupping has no published phased treatment model. Practitioner sources describe a sequence of steps within a session, and the frequency of sessions is set by the practitioner. Session counts are not given here. [source: Aboushanab & AlSanad 2018; T/CWEMS 024-2022] Below are the practitioner's sequence (for the therapist's understanding only) and the parallel psychotherapy tasks. [synthesis]

Practitioner sequence as sources describe it (not instructions):

Screening and consent. The practitioner screens against contraindications (Section 3). In China, a group service standard lists exclusions for serious heart, brain, lung, kidney or liver disease, blood disorders, mental illness or intoxication, infectious disease, and tumours or unclear diagnoses. [source: T/CWEMS 024-2022; Aboushanab & AlSanad 2018]
Preparation. The practitioner prepares the room and equipment, cleans their hands, and positions the client comfortably. [source: T/CWEMS 024-2022] Infection control covers hand hygiene, PPE, skin disinfection, disposable equipment and waste disposal. [source: Aboushanab & AlSanad 2018]
Application. Cups are placed using fire, manual vacuum or electrical vacuum. Variants include retained cups, flash cupping (repeated quick application and removal) and massage or gliding cupping over oiled skin. [source: Aboushanab & AlSanad 2018; Wikipedia] Cups may stay in place for a period. [source: Merck Manual]
Observation and removal. The practitioner watches the skin. The Chinese standard says that if blisters form, cups are removed at once and the area is treated. [source: T/CWEMS 024-2022]
Aftercare. The Chinese standard advises keeping warm, with home-care advice from the practitioner. Marks are expected to be temporary. [source: T/CWEMS 024-2022; NCCIH]

Parallel psychotherapy tasks:

Before: clarify the client's reason and expectations; screen at a basic level and refer for medical clearance; prepare a consent plan for touch; agree how you will talk about the experience afterwards. [synthesis]
During the period of treatment: ask about the client's experience of each session (felt safety, consent, any adverse effects); keep the touch work and the psychotherapy separate. [synthesis; EABP 6.b]
After: integrate what the body experience meant; record and pass on adverse effects or boundary concerns. [synthesis]

Criteria for moving on or stopping: any burn, blistering, infection, worsening skin condition, fainting, distress during touch, or a boundary violation means stopping and referring. Medical concerns go to a GP or physician. Conduct concerns go to the practitioner's professional body or regulator. [synthesis; NCCIH; T/CWEMS 024-2022]

3. Guiding principles

Attribute, do not endorse. Present qi, stagnation, toxin-removal and Prophetic-medicine claims as the tradition's beliefs. In practice: "In TCM, practitioners understand cupping as…", never "cupping removes toxins." [source: NCCIH; Wikipedia; Mayberry 2019]
Never a substitute for medical care. Cupping does not treat cancer or other physical disease. In practice: if a client is using cupping in place of diagnosis or treatment, address this directly and encourage medical review. [source: Mayberry 2019; NCCIH]
Stay in your lane. Mainstream therapy codes require competence and referral. Only body-psychotherapy codes address touch directly, and none of the codes covers cupping. In practice: do not apply cups yourself or combine hands-on work with psychotherapy. [source: UKCP 2019 items 23–24; BACP 2018 para 13; USABP VIII; EABP Principle 7]
Consent before and during, with the right to stop. In practice: help the client plan how they will consent, and stop, with the practitioner. Body-psychotherapy codes give the client the right to refuse or end touch at any time. [source: USABP VIII.2, VIII.5]
Never sexual. Genital or sexual touch is always inappropriate in any touch-based work. In practice: any sexualised touch or remark from a practitioner is a reportable boundary violation. [source: USABP VIII; UKCP item 4; BACP 2018 para 34]
Safety screening first. In practice: anticoagulants, bleeding disorders, damaged or inflamed skin, pregnancy, serious illness, pacemakers and similar conditions all mean medical clearance before cupping, or not having it. [source: Aboushanab & AlSanad 2018; NCCIH]
Fire is a hazard. In practice: ask whether fire cupping or alcohol is being used, especially at home. Most registry burns occurred at home with methylated spirits. [source: Seifman et al. 2017]
Marks are expected and can be misread. In practice: circular bruise-like marks are normal after cupping, but do not let that assumption close down safeguarding enquiry. [source: NCCIH; Scales et al. 1999; Lupariello et al. 2019]
Cultural and religious respect. In practice: for Muslim clients, hijama may be a valued Sunnah practice. Explore it respectfully, while keeping the medical-risk discussion separate. [source: Mayberry 2019; synthesis]
Trauma-informed choice. In practice: emphasise predictability, control, the option to keep clothing on where possible, and the option to stop. Use your own synthesis here, as cupping sources do not address trauma. [synthesis]

4. Intervention inventory

The practitioner's techniques (Section 2) are described for understanding only. The interventions below are the psychotherapist's own. Steps and wording are illustrative [synthesis] unless a source is given.

4.1 Exploring the client's interest and expectations

Purpose / when: use this when a client raises cupping, shows marks, or asks whether to try it. The aim is to understand the motive (pain, relaxation, faith, culture, sport, curiosity) and correct expectations. [synthesis]
Steps: (1) Ask what draws them to it and what they hope it will change. (2) Ask which form it is: dry, fire, pump, or wet/hijama. (3) Give the evidence status in plain terms: possible modest help with pain, weak evidence, not a treatment for disease. [source: NCCIH; Merck Manual] (4) Present traditional explanations as the tradition's beliefs. (5) Check that it is not replacing medical care. [source: Mayberry 2019]
Example language (illustrative): "In Chinese medicine, cupping is understood to move qi and blood. Research so far suggests it may help some people's pain a little, though the studies are weak. What are you hoping it will do for you?"
Watch for: hopes of a cure for serious illness; cupping used to avoid a medical assessment; pressure from family or community; shame at being "unscientific". It is working when the client can state realistic expectations and still has their medical care in place.

4.2 Basic safety screening and referral for medical clearance

Purpose / when: before you suggest cupping, or when a client plans it. You are not clearing anyone medically; you are spotting the need for a medical opinion. [synthesis]
Steps: (1) Ask about anticoagulant or antiplatelet medicines, bleeding disorders (haemophilia), anaemia, recent blood donation and recent wet cupping. (2) Ask about the skin at the intended site: eczema, psoriasis, wounds, inflammation, varicose veins. (3) Ask about pregnancy or the postnatal period, heart, kidney or liver failure, cancer, a pacemaker, DVT, fractures and acute infection. [source: Aboushanab & AlSanad 2018; NCCIH] (4) Ask about epilepsy, intoxication or severe mental illness, which the Chinese service standard lists as exclusions. [source: T/CWEMS 024-2022] (5) If any apply, advise a GP or physician review first, and tell the practitioner. (6) Record the conversation.
Example language (illustrative): "Cupping leaves bruise-like marks, so it matters if you're on blood thinners or have skin or heart problems. Would you check with your GP before booking?"
Watch for: clients minimising medical conditions to avoid being "stopped"; scalp cupping, which NCCIH links to rare bleeding inside the skull; worsening eczema or psoriasis. [source: NCCIH] It is working when contraindications are cleared or the plan is dropped.

4.3 Vetting a practitioner and making a referral

Purpose / when: when the client wants to go ahead, or you are suggesting a supportive adjunct for pain. [synthesis]
Steps: (1) Ask the client to confirm the practitioner's professional body and insurance, for example a British Acupuncture Council member (Professional Standards Authority Accredited Register) or British Cupping Society membership with indemnity. In Canada, check with the provincial college where massage therapy is regulated. In Australia, check the association and the state complaint route. [source: BAcC; BGi BCS page; HHR-RHS; HaDSCO; AMT] (2) Ask whether the practitioner screens health history, takes written consent, uses single-use or sterilised equipment, and how they make suction. NCCIH warns against reusing equipment without sterilisation. [source: NCCIH; Aboushanab & AlSanad 2018] (3) With the client's consent, share only relevant information, such as touch sensitivities. (4) Agree how the client will tell you about the sessions.
Example language (illustrative): "Before you book, it's worth asking who they're registered with, whether they're insured, and whether the cups are new or sterilised for each person."
Watch for: practitioners with no professional body, no health questions, reused cups, cure claims for chronic disease, or pressure to have the wet form. These are red flags for referral. [source: Mayberry 2019; NCCIH]

4.4 Preparing a client with a trauma history for touch

Purpose / when: for clients with histories of physical or sexual abuse, medical trauma or dissociation who plan cupping. Cupping involves lying down, partial undressing, touch to the back and other areas, heat and pulling sensations. [synthesis]
Steps: (1) Map possible triggers: lying face down, a practitioner behind them, fire or the smell of alcohol, suction and pulling, marks on the body afterwards. (2) Build a consent plan: which areas are acceptable and which are off-limits, what clothing stays on, and the gender of the practitioner. (3) Agree a clear stop word or signal and rehearse saying it. The right to refuse or end touch at any time is a core touch-ethics principle. [source: USABP VIII.5] (4) Discuss bringing a chaperone or companion. (5) Suggest asking the practitioner to explain each step before doing it, and to check in during the session. (6) Plan grounding for afterwards.
Example language (illustrative): "You're allowed to say 'stop' at any point, even halfway through, and a good practitioner will take the cups off. Shall we practise how you'd say that?"
Watch for: freezing or appeasing ("I'll just put up with it"); dissociation during the session; distress about bruise-like marks resembling past injuries. It is working when the client feels able to stop, or chooses not to go ahead without guilt.

4.5 Fire-cupping and home-use safety conversation

Purpose / when: when the client or family uses fire cupping, especially at home. [source: Seifman et al. 2017]
Steps: (1) Ask who does the cupping and how the flame is made. (2) Share the burns-service finding: Australian and New Zealand registry cases were mostly flame burns at home with methylated spirits. Many needed surgery, and some needed skin grafts. [source: Seifman et al. 2017] (3) Note that burns can also occur when alcohol remains on the cup. [source: Scales et al. 1999] (4) Encourage using a trained practitioner and not doing fire cupping at home. Refer to medical care for any burn.
Example language (illustrative): "Burns units see injuries from fire cupping done at home, often when spirit spills and catches light. If it's being done at home, could we talk about safer options?"
Watch for: home use by untrained family members, especially on children or older relatives; untreated burns or blisters. It is working when fire cupping at home stops or medical care is sought.

4.6 Responding to cupping marks on an adult client

Purpose / when: when you see circular marks or bruises, or the client mentions them. [synthesis]
Steps: (1) Ask neutrally about the marks rather than assuming their cause. (2) If the client says they are from cupping, check whether the pattern fits: round marks matching cup placement. [source: Scales et al. 1999] (3) Remember that routine enquiry about abuse and domestic violence still applies. (4) Suggest the client tell other health providers about cupping so that marks are not misread. [source: NCCIH]
Example language (illustrative): "I noticed some round marks on your neck. Can you tell me about them?"
Watch for: an explanation that does not fit the pattern; marks in places cupping is not typically applied; other injuries; a partner who controls the client's appointments. [synthesis; Scales et al. 1999]

4.7 Safeguarding when marks are seen on a child or vulnerable adult

Purpose / when: marks on a child or vulnerable adult. Cupping marks have been mistaken for physical abuse, and in rare cases this led to legal action against parents. Burns from cupping are a real harm in their own right. [source: NCCIH; Wikipedia; Scales et al. 1999]
Steps: (1) Follow your service's safeguarding procedure. Neither dismiss the marks nor assume abuse. (2) A forensic case report used examination, psychological interviews, medical history and a review of the family's cultural background to conclude the marks came from cupping, and recommended a multidisciplinary approach. [source: Lupariello et al. 2019] (3) Ask whether the family has a cultural practice and who carried it out. (4) Consult your safeguarding lead. Burns, blistering, wet cupping on a child, injuries elsewhere, or an explanation that does not fit are reasons to refer. (5) In contexts where hijama is linked with ruqyah (spiritual healing), note that prosecutions have involved vulnerable adult and child protection issues. [source: Mayberry 2019]
Example language (illustrative): "Some families use cupping when children are unwell. Is that something your family does? Who did it, and how?"
Watch for: cultural explanation used to close down enquiry; a frightened or withdrawn child; marks of different ages; unregulated home practice. [synthesis; Scales et al. 1999]

4.8 Integrating the body experience in psychotherapy

Purpose / when: after sessions, when the client reports relaxation, emotion, pain change, or discomfort with touch or with the marks. [synthesis]
Steps: (1) Invite a description of the sensations and feelings, without interpreting them in TCM terms. (2) Explore meaning: being cared for, tolerating sensation, control, faith practice, body image. (3) Link this to therapy goals, for example pain coping or body awareness. (4) Separate the experience from any claim that it "released" something, unless that is the client's own framing, which you can then explore as their meaning. EABP asks therapists to consider carefully, and discuss with the client, the implications of similar services received from other professionals. [source: EABP 6.b]
Example language (illustrative): "What was it like to lie there with the cups on? What did you notice in your body, and what did you notice in your mind?"
Watch for: strong emotional reactions or memories after touch; dependence on treatments; pain relief reported in a way that replaces needed medical care. It is working when the client can use the experience as information about themselves.

4.9 Recognising and passing on adverse effects

Purpose / when: at every check-in while the client is having cupping. [synthesis]
Steps: (1) Ask about marks that do not fade, blisters, burns, scarring, skin infection, flare-ups of eczema or psoriasis, dizziness or fainting, headache, nausea, fatigue and itching. [source: NCCIH; Aboushanab & AlSanad 2018] (2) Urgent: a burn, a spreading infection, or severe headache after scalp cupping, which NCCIH links to rare bleeding inside the skull. Advise same-day medical care. [source: NCCIH] (3) With the client's consent, tell the practitioner and suggest they report to their professional body. A Korean systematic review found most adverse events would have been avoidable with trained practitioners following safety guidelines. [source: Kim et al. 2014] (4) Record the event and your actions.
Example language (illustrative): "Have the marks faded as you were told they would? Any blistering, soreness that's getting worse, or feeling faint?"
Watch for: clients normalising blisters as "toxins coming out"; anaemia symptoms with repeated wet cupping (Domain XI). [source: NCCIH; Kim et al. 2014]

4.10 Recognising boundary violations and supporting the client to report them

Purpose / when: when a client describes touch outside the agreed areas, sexualised remarks, unnecessary undressing, pressure to continue after they said stop, or secret or home sessions with no records. [synthesis; USABP VIII]
Steps: (1) Name clearly that sexual or genital touch is never part of legitimate practice. [source: USABP VIII] (2) Validate the client and check their current safety. (3) Explain the complaint routes: the practitioner's professional body (for example the BAcC complaints process). In Canada's regulated provinces, the provincial college. In Australia, state health complaint entities under the National Code and the AMT discipline process. In Quebec and other unregulated provinces, associations only. [source: BAcC; CBC 2021; HaDSCO; AMT] (4) Follow mandatory reporting duties and the police route where a crime may have occurred. (5) Consult supervision.
Example language (illustrative): "What you describe is not part of cupping or of any proper treatment. It wasn't your fault. Would you like to go through the options for reporting it?"
Watch for: self-blame; fear of community consequences where the practitioner is known in a faith or cultural community; retraumatisation. It is working when the client feels believed and in control of the next steps.

4.11 Respectful work with religious and cultural cupping practice

Purpose / when: for clients for whom cupping or hijama is a faith or family practice. [synthesis]
Steps: (1) Ask what the practice means to them, for example as a Sunnah practice or a family remedy. [source: Mayberry 2019] (2) Do not argue theology. Keep the risk discussion medical. (3) For wet cupping or hijama, explain that it is a different procedure, with incisions and bleeding risks, and point to medical advice (see Domain XI). [source: NCCIH; Mayberry 2019] (4) Respect preferences about the practitioner's gender and modesty. [synthesis]
Example language (illustrative): "I can hear this matters to you as part of your faith. Can we also make sure whoever does it is trained and the equipment is safe?"
Watch for: practice linked with ruqyah or exorcism-type pressure on a vulnerable person; promotion in place of treatment for chronic disease. [source: Mayberry 2019]

4.12 Keeping roles separate if you are also trained in cupping

Purpose / when: for a therapist who also holds a cupping or acupuncture qualification. [synthesis]
Steps: (1) Check your code. The mainstream codes reviewed (BACP, UKCP, BPS, HCPC, APA, AAMFT) do not address touch, but they require competence and limiting practice to the forms of therapy in which you are trained, and they warn against harmful dual relationships. [source: UKCP items 23–24; BACP 2018 paras 13, 33; HCPC 2.12–2.13] (2) Body-psychotherapy codes permit touch only with assessment, informed consent (written consent recommended) and documentation. [source: USABP VIII.1–VIII.4] (3) The safest default is not to cup your own psychotherapy clients, and to refer to someone else. [synthesis]
Example language (illustrative): "Because I'm your therapist, I won't do the cupping myself. I can give you names of practitioners so our work here stays clear."
Watch for: blurred roles, dependency, and clients feeling unable to decline. [source: USABP VIII; EABP 5.a]

5. Handling problems

Most guidance here is [synthesis], because cupping sources do not address psychotherapy problems. Sourced points are tagged.

Client insists on cupping despite contraindications. Respect their autonomy, give the specific risk (for example bleeding with anticoagulants), ask them to tell the practitioner and their GP, and record the conversation. [source: Aboushanab & AlSanad 2018; synthesis]
Client expects cupping to cure a disease or wants to stop medical treatment. State the evidence status plainly: weak evidence, mainly for pain, not a disease treatment. Explore the fear behind the hope, and liaise with their medical team with consent. [source: NCCIH; Mayberry 2019]
Distress or flashback during or after a session. Use grounding, review the consent plan, and consider pausing cupping. Explore whether the trigger was position, heat, being touched from behind, or the marks. [synthesis]
Overwhelm at the sight of the marks. Expect that some clients may read marks as injury. Prepare them beforehand, explore any links to past abuse, and consider forms or sites that avoid visible marks only with practitioner advice. [synthesis; NCCIH]
Rupture: client feels judged for a cultural or faith practice. Acknowledge and repair. Separate respect for the practice from safety concerns. [synthesis]
Rupture: client resents a safeguarding referral. Explain your duty honestly, keep them informed where safe, and acknowledge that cultural practices are often misread. [source: Lupariello et al. 2019; synthesis]
Non-adherence to medical clearance. Revisit the specific risk, offer to help them plan what to say to the GP, and keep it on the agenda. [synthesis]
Burns or injury at home. Direct them to urgent medical care, then explore safer arrangements. With children, apply safeguarding procedure. [source: Seifman et al. 2017; Scales et al. 1999]
Unregulated practitioner or cure claims. Share the red flags (no professional body, reused equipment, disease-cure advertising) and offer to help them find a registered professional. [source: Mayberry 2019; NCCIH]
Client discloses a sexual boundary violation. Follow 4.10, safeguarding and reporting duties, and supervision. [source: USABP VIII; synthesis]
Therapist uncertainty about scope. Take it to supervision. Mainstream codes require referral when a need is outside your competence. [source: BACP 2018 para 13; UKCP item 24; AAMFT 1.10]