Tai chi and clinical adaptations (Tai Chi for Arthritis, Tai Ji Quan)

1. Introduction

Version followed: two published clinical adaptations, Tai Chi for Arthritis (and its falls-prevention edition, Tai Chi for Arthritis and Fall Prevention) from Dr Paul Lam and the Tai Chi for Health Institute, and Tai Ji Quan: Moving for Better Balance (TJQMBB) from Fuzhong Li at Oregon Research Institute, in the format listed by the US National Council on Aging (NCOA); traditional taijiquan is described as UNESCO records it, as context only.

What it is. Taijiquan is a Chinese movement tradition that began as a martial art. UNESCO inscribed it on the Representative List of the Intangible Cultural Heritage of Humanity in 2020 (China, file 00424). UNESCO describes relaxed, circular movements combined with breath regulation and cultivating "a righteous and neutral mind", built on wubu (five steps) and bafa (eight techniques), practised as routines, exercises and tuishou (partner push hands). It emerged in the mid-seventeenth century in Wenxian County, Henan, and has developed into schools named after clans or masters [source: UNESCO]. The styles commonly named are Chen, Yang, Wu (Wu Jianquan), Wu (Hao) and Sun [source: LA County TCMBB presentation]; the Chenjiagou village origin often cited is [uncertain: not verified].

Concepts belong to the tradition. UNESCO describes taijiquan as influenced by Daoist and Confucian thought and traditional Chinese medicine, built on the cycle of yin and yang and the idea of the unity of heaven and humanity [source: UNESCO]. Qi (vital energy), dantian and meridians are concepts of that tradition and of Chinese medicine; they are not established physiological facts and should be presented to clients as the tradition's way of describing the practice. The Tai Chi for Health Institute says its qigong component improves relaxation and "vital energy", without a theory or source for that concept [source: TCHI, What is TCA].

The clinical adaptations. These are short, standardised, safety-adapted programmes, not therapies for mental disorders:

Tai Chi for Arthritis (TCA), created by family physician Paul Lam with tai chi and medical specialists in 1997, is based on Sun style. Sun style was chosen for its qigong, its "healing component" and its fit for mobility and balance. It has warm-up and cool-down exercises, qigong breathing, a Basic Core of six movements and an Advanced Extension of six movements, with adaptations for older adults [source: TCHI, What is TCA].
TJQMBB is a "functional therapy" that applies "Tai Ji Quan principles and Yang-style-based movements" and integrates motor, sensory and cognitive components. It aims to improve postural control, gait, mobility and daily functional tasks, and to reduce falls in older adults and people with neurodegenerative movement disorders [source: Li 2014, abstract]. It is derived from the simplified 24-form routine and consists of an 8-form core with built-in practice variations and a subroutine, Tai Ji Quan: Mini-Therapeutic Movements [source: NCOA].

How change is thought to happen. In the clinical adaptations, change is described in physical-functional terms: slow, continuous, weight-shifting movement trains postural stability, coordination, lower-limb strength and range of motion [source: NCOA; LA County presentation]. The meditative attention and controlled breathing that accompany the movement are the route by which mental-health effects are hypothesised [source: NCCIH]. For psychotherapy, tai chi is an adjunct: a structured, low-intensity group movement practice that can support mood, regulation, social contact and confidence in moving, which the therapist then helps the client to make use of [synthesis].

Evidence status in brief. NCCIH summarises a 2019 Cochrane review: tai chi may reduce the rate of falls in older adults by 19% (low-certainty evidence) and the number of people who fall by 20% (high-certainty evidence) [source: NCCIH]. The 2019 American College of Rheumatology/Arthritis Foundation guideline "strongly recommends" tai chi for knee and hip osteoarthritis [source: NCCIH]. Reported mental-health benefits (depression, anxiety, sleep, psychological well-being) come mostly from studies in people with physical conditions or pregnancy; NCCIH calls for larger, better-quality studies. A 2023 trial of "cognitively enhanced" tai chi in mild cognitive impairment reported cognitive gains lasting six months [source: NCCIH]. Tai chi is not a treatment for cancer or other physical disease. NCCIH reports possible improvements in fatigue, sleep and quality of life in cancer, with no definite conclusions [source: NCCIH].

2. Framework

Tai chi in psychotherapy has two routes. Route A: the therapist refers to a programme run by a certified instructor and works alongside it. Route B: a psychotherapist who has completed the developer's instructor training delivers the programme as published, usually as a group within a service [synthesis].

2.1 Who may teach (credentials)

Traditional taijiquan. It is transmitted through clan lineages or the master-apprentice model, formalised in the baishi discipleship ceremony, and is also taught in formal education in China [source: UNESCO]. In the US, tai chi instructors need no licence, there is no federal or state regulation, and there is no national certification standard; organisations certify on differing criteria [source: NCCIH]. Teaching authority therefore rests with lineage holders, schools and associations, not with any state body.
TCA and its derivatives. Instructors attend an authorised workshop led by Dr Lam or an authorised Master Trainer (in person or online, with a self-paced virtual Stage 1 option). They prepare beforehand from the instructional DVD, the book Teaching Tai Chi Effectively and the TCA handbook, are assessed on performance of the forms and a written test, register with the Institute, and recertify every two years through update workshops or a correspondence course. An instructor whose certification lapses may not use the Institute's or Dr Lam's name. Eligible for certification: tai chi teachers or advanced students with at least one year of experience, physiotherapists, occupational therapists, allied health professionals, nurses, rheumatology professionals, qualified exercise instructors and "other appropriate health professionals". Master Trainers, Senior Trainers and instructors follow a code of ethics [source: TCHI, how to become an instructor]. Whether a psychotherapist without movement-teaching experience qualifies as "other appropriate health professional" is decided by the Institute [uncertain].
TJQMBB. No professional licence is required. Deliverers may be trained lay leaders, fitness instructors, physical or occupational therapists or nurses, but every instructor must be trained by authorised TJQMBB trainers, online or in person [source: NCOA]. Oregon Research Institute Master Trainers trained about 400 instructors in 30 trainings during a 2011-2013 multi-state rollout [source: Ory et al. 2014]. A trained psychotherapist may therefore deliver TJQMBB after completing the authorised training [synthesis from NCOA].

2.2 Published programme formats

	Tai Chi for Arthritis	TJQMBB
Developer	Paul Lam, Tai Chi for Health Institute (1997)	Fuzhong Li, Oregon Research Institute
Style base	Sun	Yang (from the simplified 24 forms)
Content	Warm-up and cool-down; qigong breathing; Basic Core (6); Advanced Extension (6); older-adult adaptations	8-form core with built-in variations; Mini-Therapeutic Movements subroutine
Published course format	Most learners acquire the basic movements in 8 to 12 one-hour lessons, with practice between lessons; then open-ended continued practice	Current NCOA listing: two one-hour group sessions a week for 24 weeks (in person, at home or online). Earlier CDC-era rollouts ran 12 weeks; the California version allowed 3 x 60, 2 x 60 plus home practice, or 2 x 90 minutes per week, targeting 36 instructional hours
Group size	Not stated in the sources cited	10 to 15 participants
Target group	People with arthritis; falls-prevention edition for older adults	Older adults at risk of falling; people with Parkinson's disease or walking difficulties

[source: TCHI, What is TCA; NCOA; Ory et al. 2014; LA County presentation; Montana State University Extension]. These formats are the developers' programme structures. They are not individual exercise prescriptions; individual pacing is set by the certified instructor and the client's medical team.

2.3 Phases for the psychotherapist [synthesis]

Assessment and fit. Goals (mood, anxiety, embodiment, fear of falling, social isolation); physical and psychiatric screening (section 4.1); medical clearance where indicated. Move on when the goal is clear, contraindications are addressed and the client agrees.
Matching and preparation. Choose the programme and teacher, explain what classes involve, including any partner work or hands-on correction, rehearse self-protective choices. Move on when the client knows what to expect and has a plan for difficult moments.
Learning phase. Covers the published course (TCA basics over roughly 8 to 12 lessons; TJQMBB over its full course). The therapist reviews experiences in sessions without coaching the movement. Move on when attendance is stable and the client reports the practice as tolerable or helpful.
Integration and maintenance. Link body experiences to therapy themes, plan continued community practice and relapse prevention. Move on when practice continues independently or a deliberate decision to stop is made.

The programmes publish no phase criteria for psychological goals; the criteria above are clinical judgement.

3. Guiding principles

Slow, relaxing, continuous, circular and mind-directed movement [source: LA County presentation]. In practice, speed and force are never the point; let clients move within comfort.
Weight shifting and direction of the core are central [source: LA County presentation]. In practice, balance is trained through controlled weight transfer, so the floor, footwear and space need to be safe.
Integrate motor, sensory and cognitive components [source: Li 2014, abstract]. In practice, attention and memory of sequences are part of the training, not a distraction from it.
Progress from easy to difficult [source: Ory et al. 2014]. In practice, clients begin with the simplest version and add complexity only when ready.
Adapt to the learner. TCA includes older-adult adaptations and TJQMBB has built-in variations [source: TCHI; NCOA]. In practice, no one has to perform the full version, and seated or supported practice is legitimate.
Fidelity to the core elements: a certified instructor, the full programme dose, good attendance and completion of all forms [source: LA County presentation; Ory et al. 2014]. In practice, do not mix and match pieces and still call it TJQMBB or TCA.
Teach only what you are certified to teach. TCA instructors must hold current certification to use the programme name [source: TCHI]. In practice, the therapist's own competence boundary decides the route (refer or deliver).
Safe, obstacle-free space with good lighting (mirrors ideal) [source: LA County presentation]. In practice, check the room before any session.
Tai chi does not replace medical care. Clients should not use it to delay seeing a provider and should talk to their providers about it [source: NCCIH]. In practice, ask about medical follow-up whenever new symptoms appear.
Attribute tradition concepts. Qi, yin-yang and Daoist ideas belong to the tradition [source: UNESCO]. In practice, use phrases such as "in tai chi teaching, this is described as..." and never present energy flow as fact.
Respect lineage and teaching authority. Traditional transmission runs through masters, clans and schools [source: UNESCO]. In practice, do not teach traditional forms or rituals you have not been authorised to teach, and do not proceduralise ceremonial elements such as discipleship rites.
Consent for touch, always revocable (push hands, hands-on correction) [source: USABP Code VIII; EABP Principle 7]. In practice, ask before each touch, offer a no-touch alternative, and stop at any sign of discomfort; touch is never sexual.
Stay within your professional code. Mainstream codes (BACP, UKCP, APA) require working within competence and referring when appropriate, and prohibit any sexual contact with clients [source: BACP 2018; UKCP 2019; APA Ethics Code]. In practice, as instructor, keep group teaching and individual psychotherapy roles clearly separated and discussed with the client.

4. Intervention inventory

The inventory has four parts: A, screening and safety, which applies to both routes; B, the programme components as the developers publish them, for certified instructors; C, partner and traditional elements; D, the psychotherapist's own procedures. Forms are described qualitatively. The movement names, counts and teaching scripts belong to the developers' licensed materials and are learned in their instructor training; they are not reproduced here.

A. Screening and safety

4.1 Physical and psychiatric screening before a class

Purpose: to make sure the class is safe and suitable, and to decide whether medical clearance is needed. Use it before any referral or enrolment.
Steps:
1. Ask about falls in the past year, fear of falling, walking aids, dizziness, joint replacements, acute joint flares, osteoporosis, heart or blood-pressure problems, pregnancy and recent surgery [synthesis].
2. Note the published eligibility. TJQMBB rollouts targeted adults aged 60+ who "can walk easily with or without assistive devices" and relatively fit older adults without major ambulatory problems or cognitive impairment. Higher-risk or more limited people were directed to Stepping On or Otago instead [source: Ory et al. 2014; LA County presentation]. Some current providers require a pre-enrolment health questionnaire and possibly physician consent [source: Montana State University Extension]; one multi-state rollout did not require medical clearance [source: Ory et al. 2014]. Follow the local provider's rule.
3. Advise the client to talk to their doctor before starting if they are pregnant (NCCIH notes no published safety studies in pregnancy and advises asking a provider first), have an unstable medical condition, or have new or unexplained symptoms [source: NCCIH; synthesis].
4. Psychiatric screen: current psychosis or a history of psychotic episodes, dissociative episodes, panic with body sensations, trauma reactions to being watched, corrected or touched, and aggression [synthesis]. Chinese psychiatry has described psychotic, dissociative and anxiety reactions after qigong practice (zou huo ru mo, "qigong deviation"), and the DSM-IV glossary of culture-bound syndromes listed "qi-gong psychotic reaction"; the causal link is debated [source: Shan 2000]. Gentle clinical tai chi programmes are not the same as intensive qigong, but avoid pushing clients with active psychosis toward meditative or energy-focused practice.
5. Record the decision and any clearance [synthesis].
Example language (illustrative): "Before we look at a class, I'd like to ask about your body and your balance: falls, joints, heart, anything your doctor is following. Tai chi is gentle, but a good start depends on knowing this."
Watch for: minimising of falls or dizziness; recent changes in medication; a client who wants tai chi to replace medical treatment (NCCIH: do not use it to delay seeing a provider). It is working when the client can name their own limits and has clearance where needed.

4.2 Safety set-up of the room and group (instructor route)

Purpose: to prevent falls and injury during weight-shifting practice.
Steps: use a space free of obstacles with sufficient lighting, mirrors if possible [source: LA County presentation]; keep group size within the published 10 to 15 for TJQMBB [source: Ory et al. 2014]; place chairs within reach for supported or seated variations; know the venue's emergency procedure [synthesis].
Example language (illustrative): "A chair is always beside you. Using it is part of the programme, not a sign of doing it less well."
Watch for: slippery floors, socks without grip, crowded spacing, participants who hide unsteadiness. It is working when no one has to choose between keeping up and staying safe.

B. Programme components (certified instructors)

4.3 Warm-up and cool-down exercises (TCA)

Purpose: to prepare joints and attention before the forms and to settle afterwards. Used at the start and end of each TCA lesson [source: TCHI, What is TCA; TCHI, how to become an instructor].
Steps: begin with light activity such as gentle walking, shaking out the limbs or self-massage. Then lead gentle exercises from the top of the body down: neck (tilts and turns with the eyes following the hand), shoulders (rolls and arm sweeps coordinated with the breath), spine (stretches with the arms rounded as if holding a large ball, gentle waist turns with the back upright), hips, knees and ankles (heel and toe taps, foot circles). Do every movement slowly, continuously and smoothly, well within each person's comfortable range, and on both sides where it applies. Stop any movement that is painful, and offer a chair or wall for support if balance is difficult. End every lesson with the cool-down exercises as taught. [source: TCHI, Warm Up and Stretching Exercises; TCHI, Guide to Using the TCA Package] Invite rather than demand [synthesis].
Example language (illustrative): "Move only as far as is comfortable today. If a joint complains, make the movement smaller."
Watch for: pain during or after a session, especially in inflamed or replaced joints; competitiveness in groups. It is working when participants adjust range on their own.

4.4 Qigong breathing exercises (TCA)

Purpose: relaxation and calm attention; the Institute says qigong improves relaxation and "vital energy" [source: TCHI, What is TCA]. Energy concepts belong to the tradition.
Steps: teach the breathing exercises as published in TCA training, with gentle, natural breathing coordinated with simple movement. Give no breath-holding or forced breathing, and no timing targets [synthesis consistent with safety practice]. Let anyone who becomes dizzy or anxious return to ordinary breathing at once.
Example language (illustrative): "Let the breath stay easy, without forcing anything. In tai chi teaching, this is described as gathering energy; you can simply notice whether you feel calmer."
Watch for: light-headedness, tingling or panic (signs of over-breathing), and dissociative drifting in trauma survivors. It is working when clients report feeling calmer and more present, not spaced out.

4.5 Basic Core movements (TCA, six movements)

Purpose: the core learning unit; most people learn the basic movements in 8 to 12 one-hour lessons with regular practice between lessons [source: TCHI, What is TCA].
Steps: use Dr Lam's Stepwise Progressive Teaching Method as an Institute Master Trainer describes it. (1) Watch Me: name the movement and demonstrate the whole form facing the group, so they see the entire picture. (2) Follow Me: break the movement into small parts (sequential parts, or upper and lower body separately), turn away from the group so they need not mirror you, and lead each part with simple descriptions, speeding up and talking less on each round. (3) Show Me: let participants do the part at their own pace, framed as individual practice, not evaluation; if they struggle, give one suggestion and return to Follow Me. (4) Build progressively: once the part is good enough, add the next one and follow through both before showing again, until the whole form is learned. After Show Me, give just one corrective comment on the most important point, phrased positively (for example "let the shoulders sink a little" rather than "don't raise your shoulders"). [source: TCHI, Teaching Tai Chi the Learners' Way] For home learners, Dr Lam advises learning no more than one movement per session, staying within the comfort zone and visualising what cannot yet be done [source: TCHI, Guide to Using the TCA Package]. Offer the published older-adult adaptations as needed.
Example language (illustrative): "We'll learn just one small piece today. Smooth and slow is more important than getting it 'right'."
Watch for: frustration with memorising, which can activate shame in clients with perfectionism or trauma, and knees moving past the toes or twisting under load [synthesis]. It is working when movements become continuous and clients practise between lessons.

4.6 Advanced Extension movements (TCA, six movements)

Purpose: to deepen practice once the Basic Core is secure. The Institute says the programme has enough depth to keep improving over many years [source: TCHI, What is TCA].
Steps: introduce only after the Basic Core can be performed continuously; teach in the same stepwise way [source: TCHI; synthesis for the readiness criterion].
Example language (illustrative): "You've got the first part. Would you like to add something new, or keep polishing what you know?"
Watch for: pressure to progress before balance is ready. It is working when the client chooses progression and stays steady.

4.7 Seated and adapted versions (TCA family)

Purpose: to include people who cannot stand safely or tire quickly. TCA includes adaptations for older adults [source: TCHI, What is TCA]. A seated version of TCA exists, with its own instructor workshop [source: TCHI]; its content is not described in the sources here [uncertain].
Steps: offer seated or chair-supported practice as taught in training; let participants switch freely between seated and standing [synthesis].
Example language (illustrative): "Seated practice is real tai chi practice. Choose what keeps you steady today."
Watch for: reluctance to sit because of shame. It is working when people choose their option without apology.

4.8 TJQMBB 8-form core routine with built-in variations

Purpose: to train postural stability, functional walking, movement symmetry and coordination, ankle and hip range of motion, lower-extremity strength and global cognitive function [source: NCOA]. The forms "progress from easy to difficult" [source: Ory et al. 2014].
Steps:
1. Teach the eight forms as learned in authorised TJQMBB training, keeping the qualities of slow, continuous, mind-directed movement with emphasis on weight-shifting and direction of the core [source: LA County presentation].
2. Use the routine's built-in practice variations to match each participant's ability [source: NCOA], including chair-supported progressions that run from fully assisted to unassisted [source: ACL intervention summary].
3. Aim to have the group complete all eight forms across the course, which is one of the published fidelity criteria [source: LA County presentation].
4. The names and order of the eight forms are taught in authorised training and are not listed in the sources here [uncertain].
Example language (illustrative): "Feel your weight travel slowly from one foot to the other, and only as far as you feel steady."
Watch for: near-falls during weight transfer, fatigue in later minutes, and difficulty remembering sequences (cognitive load is part of the design but can overwhelm people with impairment). It is working when transfers become smoother and participants report more confidence in walking.

4.9 Tai Ji Quan: Mini-Therapeutic Movements

Purpose: a subroutine within TJQMBB [source: NCOA] made up of eight integrated therapeutic activities. It emphasises body-weight shifting, trunk rotation while bearing weight on one leg, ankle sways and coordinated eye–head–hand movements, aiming to stimulate the musculoskeletal and sensory systems [source: ACL intervention summary].
Steps: use as taught in authorised training, typically as simpler building blocks before or alongside the full forms [uncertain]. The programme also has a separate home-based exercise subroutine for practice between classes [source: ACL intervention summary]. The exact movements and their order are taught in authorised training [uncertain].
Example language (illustrative): "This is a smaller piece of the routine that we'll practise on its own first."
Watch for: the same balance and fatigue cues as 4.8. It is working when participants can carry the small movements into the full forms.

4.10 Cognitive and sensory integration within practice

Purpose: TJQMBB integrates motor, sensory and cognitive components [source: Li 2014, abstract]. A related "cognitively enhanced" tai chi improved cognition in mild cognitive impairment [source: NCCIH].
Steps: within the published routine, cue attention to sensation (feet, weight, alignment) and to recalling the sequence; avoid adding unvalidated dual tasks to a branded programme [source: Li 2014; synthesis for the caution].
Example language (illustrative): "Notice where your weight is now, before you move. What comes next in the sequence?"
Watch for: overwhelm or shame in people with cognitive difficulties. It is working when participants remember more of the sequence and stay engaged.

4.11 Fidelity and attendance monitoring

Purpose: to deliver the programme as tested. Published fidelity criteria (California): a certified instructor, the full programme hours, a class attendance rate of 75%, and completion of all eight forms. A CDC class observation form exists for checking adherence to core elements [source: LA County presentation; Ory et al. 2014].
Steps: keep attendance records; follow up absences; arrange peer or trainer observation where offered; record deviations [source: Ory et al. 2014; synthesis].
Example language (illustrative): "I noticed you missed the last two classes. What got in the way, and what would make it easier to come back?"
Watch for: low attendance. In one multi-state rollout, average attendance was 13.6 of 24 classes [source: Ory et al. 2014]. It is working when most participants attend most sessions.

C. Partner and traditional elements

4.12 Tuishou (push hands) and hands-on correction

Purpose: in traditional taijiquan, tuishou is partner practice of sensing and yielding to pressure [source: UNESCO]. It does not appear in the published descriptions of TCA or TJQMBB. Some teachers also correct posture by touch.
Steps:
1. Before referral, ask the teacher whether partner work or hands-on correction is used [synthesis].
2. With the client, agree in advance that they may decline any touch and practise solo or with verbal cues instead [synthesis; USABP Code VIII: the client may refuse or end any touch at any time].
3. Consent is asked before each touch and can be withdrawn during it; touch is limited to what the exercise needs (arms, forearms, shoulders) and is never sexual [source: USABP Code VIII; EABP Principle 7].
4. As an instructor-therapist, prefer verbal and demonstration cues; if touch is used, name the place and purpose first, use the least contact possible, and document consent [synthesis; USABP VIII.2-4].
5. Competitive push hands and martial applications (throws, locks, strikes) carry contact-injury risk and are not part of the clinical programmes; do not refer clinical clients to them without separate assessment [synthesis].
Example language (illustrative): "In some classes the teacher or a partner may touch your arms to guide you. You can say 'no touch, please' at any point, and I can help you practise saying that now."
Watch for: freezing, startle, holding the breath, appeasing smiles (fawn), anger at being pushed, re-enactment of power dynamics, and any teacher who disregards a 'no'. It is working when the client sets limits and stays present.

4.13 Traditional forms, lineage and ceremony (context, not procedure)

Purpose: to understand what a client meets in a traditional school.
Steps: describe practice as schools publish it: routines, basic steps and techniques, partner practice, and transmission through masters, clans and the baishi discipleship ceremony [source: UNESCO]. The psychotherapist does not teach traditional forms or conduct ceremonies. Help the client to ask about lineage, the teacher's training and the school's expectations (fees, commitment, discipleship) [synthesis; NCCIH advises asking about an instructor's training and experience].
Example language (illustrative): "Traditional schools often have a master-student structure. It's fine to ask what's expected of you before you commit."
Watch for: pressure toward discipleship, unquestioning obedience, escalating fees, claims that the practice cures disease, or isolation from other help, which are red flags for an abusive teaching dynamic [synthesis]. It is working when the client's choices stay free and informed.

D. The psychotherapist's procedures [synthesis throughout, built on the sources cited]

4.14 Deciding when to suggest tai chi

Purpose: to decide whether a tai chi class serves this client's therapy goals; use it at assessment or when movement, falls or isolation come up.
Purpose: to match an adjunctive practice to therapy goals.
Steps: consider it for clients with fear of falling, low mood or anxiety alongside physical illness, isolation in later life, arthritis-related distress, or a wish for gentle, mindful movement. NCCIH reports possible benefits for depression, anxiety, sleep and psychological well-being in some groups [source: NCCIH]. Present it as a complement, not a replacement for evidence-based psychological treatment. Postpone during acute psychosis, mania or severe dissociation.
Example language (illustrative): "Some people find a slow movement class helps them feel steadier in body and mood. Would that interest you as something alongside our work here?"
Watch for: the client agreeing to please you; using it to avoid therapy topics. It is working when the client chooses it with clear personal reasons.

4.15 Choosing a programme and teacher

Purpose: to find a safe, competent and suitable class; use it before any referral.
Steps: prefer a certified TCA or TJQMBB instructor for older or medically complex clients; check current certification (TCA certificates lapse after two years without renewal [source: TCHI]); ask about class size, partner work, touch, use of chairs and how the teacher responds to injury. Remember that tai chi instructors are unlicensed and certification standards vary [source: NCCIH]. For TJQMBB, look for instructors trained by authorised trainers [source: NCOA].
Example language (illustrative): "Questions worth asking the teacher: what training do you hold, do you use touch, and how do you adapt for someone with balance problems?"
Watch for: teachers who promise cures, dismiss medical advice, or discourage questions. It is working when the client finds a teacher they trust and can talk to.

4.16 Preparing clients with trauma, dissociation, psychosis or aggression

Purpose: to reduce the risk that body-focused group practice destabilises vulnerable clients; use it before the first class and again after any difficult experience.
Steps:
1. Map triggers: being watched, mirrors, standing behind others, slow-motion attention to the body, eyes-closed practice, touch, martial imagery.
2. Plan choices: position near the door or wall, eyes open, permission to sit or step out, a grounding cue (feel the feet, name objects in the room), and a no-touch agreement.
3. For clients with psychosis, prefer the externally focused clinical programmes, steer away from energy-focused or long meditative practice, and monitor for unusual bodily or energy experiences given the reported qigong-related psychotic reactions [source: Shan 2000].
4. For clients working on aggression, discuss martial imagery and partner pushing openly; clinical programmes contain no combat practice.
Example language (illustrative): "If anything in class makes you feel far away or on edge, you can open your eyes, feel your feet, sit down, or leave. None of that needs explaining."
Watch for: derealisation, intrusive memories during slow body focus, unusual energy sensations interpreted as special powers or attack, and irritability during partner work. It is working when the client uses the plan and returns to class.

4.17 Integrating class experiences into therapy

Purpose: to turn class experiences into therapeutic material; use it throughout the learning and maintenance phases.
Steps: at intervals, review what the client noticed (balance, breath, mood before and after, self-criticism while learning, connection with the group); link these to therapy themes such as patience, perfectionism, trust in the body and asking for adaptations; encourage home practice as the programmes recommend, without setting targets yourself [source: TCHI notes practice between lessons; synthesis].
Example language (illustrative): "When you lost the sequence in class, what went through your mind? Is that familiar from elsewhere?"
Watch for: practice turning into another arena for self-criticism, or the class becoming the only social contact. It is working when insights from class carry over into daily life.

4.18 Recognising and passing on harms

Purpose: to detect physical, psychological or relational harm early and route it correctly; use it at every review.
Steps: ask routinely about pain, falls, dizziness and emotional reactions; refer new or worsening physical symptoms to the client's doctor [source: NCCIH: do not delay care]; report unsafe practice to the programme holder (Tai Chi for Health Institute; TJQMBB trainers via Oregon Research Institute) or the instructor's professional body; take any report of sexual or abusive conduct seriously, support the client to report it, and follow local safeguarding duties.
Example language (illustrative): "Has anything in class hurt, frightened or upset you, or made you uncomfortable with how someone treated you?"
Watch for: reported adverse events are mostly minor musculoskeletal aches and pains, similar in rate to other exercise [source: NCCIH]; falls during class; psychological reactions. It is working when problems are spoken about early.

4.19 Delivering a programme within a therapy service (instructor route)

Purpose: to run TCA or TJQMBB yourself, safely and to fidelity; use it only after certification.
Steps: complete the developer's instructor training and keep certification current [source: TCHI; NCOA]; run the programme as published (fidelity, section 4.11); obtain informed consent that covers group format and any touch; keep group teaching separate from individual therapy content, and discuss the dual role with clients who are also your therapy clients (EABP 6.b asks therapists to consider and discuss parallel services with the client) [source: EABP 2020]; check that your indemnity covers exercise instruction [synthesis].
Example language (illustrative): "In this group I'm your tai chi instructor. What we talk about in our individual sessions stays there unless you choose to bring it up."
Watch for: confusion of roles, group members disclosing therapy material, and expectations that the therapist will 'heal' through movement. It is working when roles stay clear and the group runs to fidelity.

5. Handling problems

The developers' public materials say little about psychological difficulties. Unless a source is tagged, the guidance below is [synthesis].

Pain or joint flare after class. Advise reducing range and effort, and telling the instructor; if pain persists or a joint swells, refer to the GP or rheumatology. NCCIH reports minor musculoskeletal aches as the main adverse events [source: NCCIH]. Don't reassure away new symptoms.
Fall or near-fall in class. The client should report it to the instructor and their doctor. Review fear of falling in therapy and consider whether a more supported option (seated adaptation; Stepping On or Otago, which TJQMBB rollouts used for higher-risk people [source: Ory et al. 2014]) fits better. Example (illustrative): "Losing your balance there sounds frightening. Let's look at what would make the next class feel safe, or whether a different programme suits you better right now."
Non-attendance and drop-out. This is common; one rollout averaged 13.6 of 24 classes [source: Ory et al. 2014]. Explore practical barriers (transport, pain, timing), shame at slow learning, and social anxiety. Use motivational interviewing about the client's own reasons. Consider online formats where the provider offers them [source: NCOA].
Frustration, perfectionism, "I can't remember the moves". Normalise; the programmes are built to progress from easy to difficult [source: Ory et al. 2014]. Work in therapy on self-criticism. Example (illustrative): "Your teacher expects people to forget. What would it be like to be a beginner on purpose?"
Overwhelm, dissociation or flashbacks during slow, inward practice. In class: eyes open, feet on floor, sit, step out. In therapy: explore triggers, adjust the plan from 4.16, and consider pausing until stabilisation work is further on.
Panic or dizziness with breathing exercises. Return to ordinary breathing; drop breath focus; check for over-breathing patterns; medical review if dizziness persists.
Unusual experiences (energy surges, voices, feeling controlled, grandiose spiritual meaning). Stop energy-focused practice, assess for psychosis or mania, and involve psychiatric services. Qigong-related psychotic reactions are described in Chinese psychiatric classification and were listed in the DSM-IV glossary [source: Shan 2000]. Do not interpret experiences through qi theory as if it were fact.
Touch problems (unwanted correction, push hands). Support the client to state limits, switch to solo practice, or change class. If touch was sexual or coercive, treat it as a safeguarding and conduct matter and help the client report it (section 4.18). Touch is never sexual [source: USABP Code VIII; BACP 2018 para 34].
Teacher makes medical or cure claims, or discourages medical care. Tai chi is not a treatment for cancer or other physical disease; NCCIH advises against using it to delay care [source: NCCIH]. Discuss with the client and consider a different teacher.
Cultic or abusive school dynamics (pressure to become a disciple, isolation, escalating fees, punishment for questions). Name the pattern, support the client's autonomy and exit plan, and document. Traditional discipleship (baishi) is a recognised cultural form [source: UNESCO]; the problem is coercion, not tradition itself.
Cultural meaning and spiritual conflict. Some clients are drawn to, and some are troubled by, Daoist or Chinese-medicine concepts. Present the concepts as the tradition's, invite the client's own framework, and suggest the secular clinical programmes if preferred.
Rupture with the therapist (client feels "sent away" to exercise, or the class feels like homework). Acknowledge, re-explore the shared rationale, and make the class optional rather than a condition of therapy.
Instructor-therapist dual-role strain. Keep roles separate, discuss in supervision, and offer referral to another instructor or therapist if the overlap harms either relationship [source: EABP 2020 6.b; UKCP 2019 item 8].
Lapsed or unclear instructor credentials. Only currently certified TCA instructors may use the programme name [source: TCHI]. Check before referral; if unclear, look for another class.

Sources

Web sources:

Cited as reported by the web sources above: the 2019 Cochrane review of exercise for preventing falls (figures as reported by NCCIH); the 2019 ACR/Arthritis Foundation osteoarthritis guideline (as reported by NCCIH); the CDC falls-prevention guide recommendation of TCA in 2013 (as reported by the Tai Chi for Health Institute); the DSM-IV Glossary of Culture-Bound Syndromes (as reported by Shan 2000).

Books named: Lam P, Teaching Tai Chi Effectively: Simple and Proven Methods to Make Tai Chi Accessible to Everyone (Tai Chi for Health Institute materials; year [uncertain]); Lam P, Horstman J, Overcoming Arthritis: How to Relieve Pain and Restore Mobility Through a Unique Tai Chi Program (DK, 2002), part of the TCA home-learning package.

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