Traditional Chinese Medicine

1. Introduction

Version followed: Traditional Chinese Medicine (TCM) as codified in WHO's ICD-11 Chapter 26 (Traditional Medicine Conditions, Module I, "TM1") and as regulated in China (national TCM authorities), Australia (Chinese Medicine Board of Australia under AHPRA), Ontario (Traditional Chinese Medicine Act, 2006), the US (state acupuncture licensing, NCCAOM) and the UK (accredited voluntary registers, MHRA product rules); the psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI) and its supplementary modules.

What it is. TCM is a living, codified medical system, not a psychotherapy. It is practised by its own licensed or registered practitioners (TCM physicians, acupuncturists, Chinese herbal medicine practitioners and dispensers), who assess "body system disorders using traditional Chinese medicine techniques" and treat them with TCM therapies, in the words of Ontario's statute [source: Ontario TCM Act 2006, Bill 50]. Its therapies include acupuncture, moxibustion, Chinese herbal medicine, dietary therapy (including medicinal congees), tuina (therapeutic massage) and qigong/tai chi [source: NCCIH TCM page lists acupuncture, tai chi, Chinese herbal products and qigong] [uncertain: moxibustion, tuina and food therapy as named components]. For qigong forms see Domain X, entry 123.

Its own account of change. Within the system, illness is understood as a disturbance of balance and function that the practitioner identifies as a disorder and, more specifically, as a pattern: ICD-11 describes TM1 patterns as a picture of the patient's whole clinical presentation at a point in time, built from principle-based contrasts (yin/yang, heat/cold, excess/deficiency, exterior/interior), environmental factors (wind, cold, dampness, dryness, fire, summer-heat), body constituents (qi, blood, fluid, essence) and organ systems (liver, heart, spleen, lung, kidney and others) [source: ICD-11 Ch. 26]. Treatment aims to correct the identified pattern. The five-phase (wu xing) theory and the four classical diagnostic methods (inspection including the tongue, listening and smelling, inquiry, palpation including the pulse) are central in TCM textbooks [uncertain]. These are the tradition's concepts, described here as the system holds them, not as established physiology.

Where the psychotherapist stands. A psychotherapist does not diagnose TCM patterns, needle, prescribe or recommend herbs, or perform tuina, cupping or moxibustion unless separately trained and registered in TCM. Your work alongside TCM is culturally responsive psychotherapy: understanding the client's explanatory model, mapping their help seeking, coordinating safely with registered practitioners and prescribers, recognising harm, and keeping your own assessment and risk duties intact [source: DSM-5-TR CFI; synthesis].

2. Framework

TCM is a whole system with its own clinical process; this guide gives that process as regulators publish it, then a framework for the psychotherapist's parallel work.

2a. The TCM clinical process (as its bodies describe it)

Assessment and diagnosis. The practitioner assesses and communicates a TCM diagnosis that identifies a body system disorder as the cause of symptoms; in Ontario, communicating such a diagnosis is a controlled "authorized act" restricted to College members [source: Ontario TCM Act 2006, s. 4].
Disorder and pattern. ICD-11 Chapter 26 separates TM1 disorders (grouped by organ or body system, e.g. liver, heart, spleen, lung, kidney, brain, qi-blood-fluid, mental and emotional) from TM1 patterns (the presentation at a given time) [source: ICD-11 Ch. 26].
Treatment. Therapies are chosen to match the pattern: acupuncture (in Ontario, procedures below the dermis are an authorized act), herbal medicine, and other TCM therapies [source: Ontario TCM Act 2006]. In China, practitioners qualified through the "proven expertise" route are assessed separately for internal herbal treatment or for external therapies, and may practise only the techniques and conditions approved at assessment [source: NHFPC Order No. 15, 2017].
Coding alongside biomedicine. ICD-11 Chapter 26 is an optional supplementary chapter (470 categories from SA00, each labelled "TM1"), not intended for mortality reporting; a TM1 code is meant to be used together with a code from the conventional chapters 1–24, not instead of it [source: ICD-11 Ch. 26]. This is the official model for dual framing that the psychotherapist can also follow [synthesis].

2b. Who may practise and how they are recognised

China. TCM is a state-regulated profession; licensed TCM physicians (中医类别执业医师) qualify through the medical licensing system. The 2017 Interim Measures on Qualification Assessment and Registration for TCM Practitioners with Proven Expertise (中医医术确有专长人员医师资格考核注册管理暂行办法; National Health and Family Planning Commission Order No. 15, signed 10 Nov 2017, in force 20 Dec 2017) add a route for people trained by apprenticeship (at least five continuous years with a qualified mentor and two recommending TCM physicians) or by long practice with a documented lineage (至少5年实践). An expert panel of at least five assesses lineage, safety risk, questioning and practical skill; successful candidates receive a 中医（专长）医师资格证书 (qualification certificate), register locally for a practice certificate, practise only within the approved techniques and conditions and, in principle, only in their province, and are reviewed every two years; practising beyond scope can bring suspension and fines [source: gov.cn State Council Gazette 2018 No. 7]. A 2016 State Council press briefing described this as resolving the status of practitioners trained outside universities, through three routes (recognition of established practitioners, apprenticeship leading to the licensing exam, and limited licences for a specific skill) [source: zjol.com.cn report, 7 Dec 2016]. The National Administration of Traditional Chinese Medicine (NATCM, 国家中医药管理局) is the national TCM authority [uncertain: its detailed remit]; the Law of the PRC on Traditional Chinese Medicine (中医药法) was under review in December 2016 [source: zjol.com.cn]; its articles and commencement date [uncertain: not verified].
Australia. Chinese medicine is a nationally registered profession overseen by the Chinese Medicine Board of Australia (CMBA) within AHPRA. Protected titles under s. 113 of the National Law are "Chinese medicine practitioner", "Chinese herbal dispenser", "Chinese herbal medicine practitioner", "Oriental medicine practitioner" and "acupuncturist" (the last also available to endorsed practitioners of other professions); unregistered people may not use them or "hold out" as registered (s. 116) [source: CMBA protected titles FAQ]. Names of the divisions of the register and start date of national registration [uncertain: not verified].
Ontario, Canada. The Traditional Chinese Medicine Act, 2006 (Royal Assent 20 Dec 2006) created the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario (CTCMPAO); only members may use the titles "traditional Chinese medicine practitioner" or "acupuncturist" or hold themselves out as qualified; the authorized acts are acupuncture below the dermis and communicating a TCM diagnosis [source: Ontario TCM Act 2006, Bill 50]. Year the College began registering, and the title abbreviations used [uncertain]. Other provinces regulate differently [uncertain: not verified].
United States. Most states and the District of Columbia regulate acupuncture; most require certification from the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) [source: NCCIH TCM page]. State rules for herbal practice vary [uncertain]; check the relevant state board.
United Kingdom. The British Acupuncture Council (BAcC), a self-regulatory body for traditional acupuncturists trained in TCM and related systems (Five Elements, Stems and Branches, Japanese meridian therapy), holds Accredited Register status with the Professional Standards Authority (renewal assessed 2025) [source: PSA register page]. Acupuncture and herbal medicine are not statutorily regulated professions in the UK [uncertain]. Herbal products: Aristolochia has been prohibited since 1999; registered traditional herbal products carry a THR number and licensed ones a PL number; most herbal medicines on the UK market are unlicensed and of variable standard [source: MHRA Drug Safety Update 2007, 2008].

2c. Evidence status (independent summary)

NCCIH (page last updated April 2019) reports that acupuncture may help chronic low-back pain, neck pain, knee osteoarthritis and carpal tunnel syndrome, may reduce tension-headache frequency and help prevent migraine, but that real and sham acupuncture often perform similarly; tai chi may help balance, some pain conditions and mood and quality of life in heart failure; Chinese herbal products have been studied for mental disorders among other conditions, but many studies are of poor quality and no firm conclusions can be drawn [source: NCCIH TCM page]. NCCIH advises not to use TCM to replace or delay conventional care [source: NCCIH]. No TCM therapy should be presented as a treatment for cancer or other serious physical disease [synthesis, consistent with NCCIH].

2d. The psychotherapist's framework alongside TCM [synthesis]

Phase	Goals	Typical sessions	Move on when
1. Engagement and cultural assessment	Learn the client's framing, TCM use, practitioners, products; core CFI	1–2 (50–60 min)	Explanatory model, help-seeking map and current products/practitioners are recorded
2. Shared formulation	Hold the TCM account and your psychological formulation side by side; risk assessment	1–2	Client recognises the formulation as theirs; risk plan agreed
3. Coordination	Consent-based contact with GP/prescriber and, if wished, the registered TCM practitioner; safety screen of products	Ongoing, often between sessions	Releases signed; prescriber informed of all products
4. Psychotherapy with integration	Usual evidence-based therapy, using the client's TCM-informed language where it helps	Per the therapy chosen	Goals reviewed at standard intervals
5. Review and ending	Consolidate; plan for future help seeking across systems	1–2	Relapse/help-seeking plan covers both systems

The phases overlap; safety concerns (Section 5, Harm account) override the sequence at any point.

3. Guiding principles

Two systems, two sets of competence. You assess and treat psychologically; TCM practitioners assess and treat within TCM. Practical meaning: never interpret tongue, pulse or TCM patterns, and never suggest acupuncture points, herbs or formulas [synthesis; source: Ontario TCM Act authorized acts].
Attribute, don't adjudicate. Describe qi, yin-yang, "heart spirit" or liver qi stagnation as the client and the system hold them, neither as fact nor as superstition. Practical meaning: "In the way your doctor explained it…" rather than "Your qi is…" or "That's not real" [synthesis].
Dual framing is official, not a compromise. ICD-11 pairs TM1 codes with conventional codes. Practical meaning: you can accept "depression disorder (TM1)" from a TCM physician and still make your own psychological assessment [source: ICD-11 Ch. 26].
Ask about every remedy, every time. Regulators repeatedly found undeclared and harmful ingredients. Practical meaning: include herbal and imported products in every medication review and pass the list to the prescriber [source: NCCIH; MHRA].
Never advise on medicines. Practical meaning: do not endorse starting, stopping or combining herbs and psychiatric medicines; route every such question to the prescriber or pharmacist [synthesis].
TCM must not delay needed care. Practical meaning: unexplained kidney problems, serious illness or acute psychiatric risk go to medical care now, whatever else the client uses [source: NCCIH; MHRA].
Check credentials as a routine courtesy, not an accusation. Practical meaning: help the client look up their practitioner on the public register where one exists [source: CMBA; PSA; Ontario Act].
Consent and confidentiality govern coordination. Practical meaning: contact a TCM practitioner only with written consent and a clear purpose [synthesis].
Cultural humility and anti-racism. Services have both dismissed TCM users and stereotyped Chinese clients. Practical meaning: examine your own reactions; ask about experiences of discrimination in care, as the CFI's clinician–patient relationship section invites [source: DSM-5-TR CFI].
Bodily language is clinical data. Clients may describe distress in organ, heat or qi terms. Practical meaning: explore the meaning; do not translate it straight into a DSM label or dismiss it as somatisation [synthesis; source: ICD-11 TM1 mental and emotional disorders].
Touch-based therapies are someone else's room. Practical meaning: support the client's consent and safety around acupuncture, tuina, cupping and moxibustion; never touch the client yourself as part of this work [synthesis].
Risk duties are unchanged. Practical meaning: suicide and safeguarding assessment follows your usual standards regardless of the client's TCM framing [synthesis].

4. Intervention inventory

These are the psychotherapist's own interventions alongside TCM. The CFI items are paraphrased, not reproduced; the CFI may be used with patients without permission, but modified versions need APA written permission [source: DSM-5-TR CFI]. TCM's own therapies are described in Section 1–2 and are performed only by registered TCM practitioners.

4.1 Cultural self-examination before and during the work

Purpose / when: Before seeing clients who use TCM, and whenever you notice strong reactions (admiration, scepticism, alarm). Both dismissing and over-endorsing TCM distort care [synthesis].
Steps: (1) Write down what you believe about TCM, acupuncture and Chinese herbs and where those beliefs came from. (2) Note any assumptions linking Chinese clients to TCM use; many do not use it, and many non-Chinese clients do [synthesis]. (3) List what you do not know (e.g. the client's region, language, generation, religion). (4) Bring these notes to supervision. (5) Revisit after a few sessions.
Example language (illustrative, to yourself or a supervisor): "I notice I want to warn her off herbs before I know what she takes." / "I am assuming his family follows TCM because of his name."
Watch for: Sessions dominated by your opinion of TCM; the client going quiet about remedies after you react. Working: you can ask about TCM with plain curiosity and the client volunteers detail.

4.2 Core Cultural Formulation Interview with a TCM-using client

Purpose / when: At initial assessment, or when the problem is framed in bodily or TCM terms, treatment stalls, or the client is seeing several kinds of helper. The CFI has 16 questions in four domains: cultural definition of the problem; cultural perceptions of cause, context and support; cultural factors affecting self-coping and past help seeking; cultural factors affecting current help seeking. It supports clinical understanding and is not a basis for diagnosis on its own [source: DSM-5-TR CFI].
Steps: (1) Explain that you ask everyone how they understand their difficulties. (2) Work through the four domains in order, using the client's own words for the problem. (3) In the past-help-seeking domain, ask explicitly about traditional or alternative healing, including TCM doctors, acupuncturists, herbal shops and family remedies (the CFI names traditional, alternative and folk healing as forms of help) [source: CFI Q12 as described]. (4) Record what helped and what did not. (5) In the current help-seeking domain, ask what kind of help the client prefers and what family or friends suggest. (6) Close with the clinician–patient relationship questions about language, culture and trust. (7) Summarise back in the client's terms.
Example language (illustrative): "How would you describe the problem to your family, in your own words?" / "Some people see a Chinese medicine doctor or take herbs as well as coming here. Has that been part of your path?" / "Is there anything about me or this service that might make it harder to tell me what you really think?"
Watch for: Polite agreement that hides a different view; shame about using TCM; the client expecting you to judge. Working: the client corrects your summary, names helpers you did not know about, and their own term for the problem appears in your notes.

4.3 Explanatory Model module: exploring the client's TCM account

Purpose / when: When the client explains their distress through TCM (e.g. "liver qi stagnation", "too much heat", "my heart spirit is unsettled", "weak spleen") or has been given a TCM diagnosis. The module (14 questions) covers general understanding, illness prototypes, causes, expected course and treatment expectations, substituting the client's own term for the problem [source: CFI Supplementary Modules]. Kleinman's explanatory-model questions come from Kleinman, Eisenberg and Good (1978) [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]; that they underlie the module is [uncertain].
Steps: (1) Ask what name the client or their practitioner uses. (2) Ask what they understand it to mean in everyday life (sleep, temper, appetite, worry). (3) Ask who else they know who had it and what happened. (4) Ask what causes it in their view (diet, overwork, suppressed anger, weather, family stress). (5) Ask how they expect it to go and what would help. (6) Note matches with ICD-11 TM1 mental and emotional entries if a practitioner has used them, e.g. depression disorder (TM1), insomnia disorder (TM1), uneasiness disorder (TM1), repressed fire disorder (TM1) (linked in ICD-11 to chronically repressed anger), liver qi stagnation pattern (TM1) (restlessness, irritability), gallbladder qi deficiency pattern (TM1) (panic, suspicion, easily frightened) [source: ICD-11 Ch. 26]. (7) Hold this account alongside, not against, your own psychological formulation (4.9).
Example language (illustrative): "Your doctor called it liver qi stagnation. What does that feel like day to day?" / "What do you think set it off?" / "If it got better, what would be different?"
Watch for: Equating a TM1 pattern with a DSM disorder (they are different classifications; ICD-11 expects both to be coded separately) [source: ICD-11]; explanations that carry blame ("I am weak"), which are psychological material [synthesis]. Working: the client links the TCM account to emotions and situations, and both frames are usable in therapy.

4.4 Coping and Help-Seeking module: mapping TCM use

Purpose / when: When the client uses several sources of help, or when adherence to psychological or medical care is uneven. The module (13 questions) covers self-coping, the social network, help from healers and others outside the network, and the current treatment episode; it asks about natural remedies and non-prescribed medicines and about helpers other than doctors, what they recommended and whether it helped [source: CFI Supplementary Modules].
Steps: (1) Draw a simple help-seeking map with the client: self-care, family remedies, food therapy, herbal shops, TCM clinic, acupuncturist, GP, psychiatrist, you. (2) For each, note what was recommended, how often it is used, and the client's view of its usefulness. (3) Note who in the family influences choices. (4) Ask whether each helper knows about the others. (5) Mark gaps where information is not shared and agree what to do (4.7).
Example language (illustrative): "Let's draw everyone who has been helping, including the herbal shop and your mother's soups." / "Does your doctor know you also see the acupuncturist?"
Watch for: Products bought online or abroad, or by relatives on the client's behalf (higher contamination risk; see 4.5 and Harm account) [source: MHRA; NCCIH]. Working: a complete map that the client is willing to share with the prescriber.

4.5 Remedy inventory and prescriber hand-off (safety-critical)

Purpose / when: Whenever the client takes, or is considering, herbal products, pills, powders, teas or topical preparations from TCM or similar sources, and at each medication review. Herbs can change the levels of prescribed drugs, with most concern for drugs with a narrow therapeutic index such as warfarin [source: NCCIH Clinical Digest, Herb-Drug Interactions], and a few Chinese herbal products are linked to liver injury [source: LiverTox]. NCCIH reports contamination of herbal products with undeclared drugs (e.g. warfarin, diclofenac), heavy metals (arsenic, lead, cadmium), pesticides and sulfites, and organ damage from wrong herbs; MHRA reports undeclared Aristolochia, potent drugs (e.g. fenfluramine) and steroids [source: NCCIH; MHRA].
Steps: (1) Ask the client to bring all products or photos of labels, including ones bought abroad or online. (2) Record names exactly as written (Chinese and English), maker, source and whether a practitioner prescribed it. (3) In the UK, note whether a THR or PL number appears (registered or licensed product) [source: MHRA 2008]. (4) Do not comment on safety, dose or combination yourself. (5) With consent, send the list to the GP, psychiatrist or pharmacist and ask them to review interactions with prescribed medicines. (6) Record that you did so. (7) If the client reports kidney symptoms, jaundice, unusual bleeding or new physical illness, advise prompt medical review today [synthesis; MHRA advises asking about herbal products in unexplained nephrotoxicity].
Example language (illustrative): "I don't advise on herbs or medicines myself, but I'd like your doctor to see the full list so nothing clashes. Could you bring the packets next time?" / "This is a question for your prescriber; I'll help you write it down."
Watch for: Labels naming aristolochia, bragantia or asarum, or products called Guan Mu Tong, Ma Dou Ling, Mu Tong or Xi Xin, which FDA linked to aristolochic acid recalls (label names are a prompt for urgent prescriber review, not a test you perform) [source: FDA 2001 actions; foodnavigator]; slimming, "detox", diabetes or "natural steroid-free" products [source: MHRA]; products advising the client to stop prescribed medicine [source: MHRA 2008]. Working: the prescriber has the list and the client keeps reporting new products.

4.6 Checking a practitioner's credentials

Purpose / when: When the client sees a TCM practitioner, acupuncturist or herbalist, especially for mental-health complaints or invasive treatment.
Steps: (1) Ask the practitioner's name and clinic. (2) Offer to look them up together on the relevant public register: CMBA/AHPRA in Australia (protected titles include acupuncturist and Chinese herbal medicine practitioner); CTCMPAO in Ontario; the state acupuncture board in the US (most require NCCAOM certification); in the UK the BAcC register or the PSA "Check a practitioner" tool [source: CMBA; Ontario Act; NCCIH; PSA]. In China, licensed TCM physicians hold practice certificates; "proven expertise" physicians are limited to approved techniques, conditions and province [source: NHFPC Order No. 15]. (3) If not listed, explain neutrally what registration offers (a complaints route, standards). (4) Leave the decision to the client unless safeguarding applies.
Example language (illustrative): "I check registration for any clinician my clients see, including psychologists. Shall we look her up together?"
Watch for: Someone using a protected title without registration (an offence in Australia and Ontario) [source: CMBA; Ontario Act]; the client feeling accused. Working: the client knows the practitioner's status and where to complain if needed.

4.7 Consent-based coordination with the TCM practitioner and prescriber

Purpose / when: When the client wants their helpers to work together, when products need a prescriber review, or when TCM and psychological advice conflict [synthesis].
Steps: (1) Agree with the client what will be shared, with whom, and why; obtain written consent for each recipient. (2) Contact the prescriber first about any products. (3) If contacting the TCM practitioner, introduce your role and ask about their understanding of the client's difficulties in their terms; do not request or comment on formulas or point selection. (4) Share only what is needed (e.g. risk level, therapy goals). (5) Agree how urgent concerns will be passed on. (6) Feed back to the client what was said.
Example language (illustrative, to a practitioner): "I'm Ms Lin's psychotherapist. With her consent I'd value your understanding of her sleep and mood problems, and to let you know we are also working on panic in therapy."
Watch for: Breaches of confidentiality through family members; a practitioner advising the client to stop psychiatric medicine (route to prescriber at once) [synthesis]. Working: consistent messages and no surprises for the client.

4.8 When the client wants to replace prescribed medicine with herbs

Purpose / when: The client says they will stop, or have stopped, antidepressants, mood stabilisers or antipsychotics in favour of TCM.
Steps: (1) Thank them for telling you. (2) Explore reasons (side effects, stigma, family pressure, belief in natural treatment) with the explanatory-model questions. (3) State clearly that decisions about medicine belong with the prescriber and that you cannot advise either way. (4) Offer to help prepare for an urgent prescriber appointment; if they have already stopped, encourage contact now. (5) Assess current risk (relapse, withdrawal, mania, suicidality) by your usual standards. (6) Document.
Example language (illustrative): "It makes sense to want something that fits how you see your health. I can't advise on medicines, but stopping suddenly can matter, so can we get you in front of Dr Patel this week?"
Watch for: Rapid deterioration, sleep loss, agitation; the client hiding the change. Working: the client and prescriber make the decision together and therapy continues.

4.9 Dual formulation: TCM account and psychological formulation side by side

Purpose / when: After 4.2–4.4, when building the shared formulation. ICD-11 itself pairs TM1 codes with conventional codes rather than merging them [source: ICD-11 Ch. 26].
Steps: (1) On one page, write the client's TCM account (e.g. "heat in the liver from years of holding in anger"). (2) Beside it, write your psychological formulation (triggers, maintaining cycles, relationships). (3) Mark where they agree (e.g. suppressed anger, overwork, poor sleep). (4) Use the client's terms for shared targets. (5) Keep your DSM/ICD assessment and risk plan separate and explicit [synthesis].
Example language (illustrative): "In Chinese medicine terms you've been told it's repressed fire; in our work we've noticed anger you swallow at work. Both point to the same place. Shall we start there?"
Watch for: Using TCM terms to sound aligned without understanding them; the client feeling one account is being swapped for the other. Working: the client uses both vocabularies freely.

4.10 Risk and diagnostic assessment inside TCM framing

Purpose / when: When symptoms that need psychiatric assessment (severe depression, mania, psychosis, dementia, suicidality) are framed in TCM terms. ICD-11 TM1 includes manic disorder (described as disturbing the "heart spirit"), depression disorder, dementia disorder and patterns with restlessness, insomnia and raving (phlegm-fire harassing the heart) [source: ICD-11 Ch. 26]; these labels do not replace psychiatric assessment [synthesis].
Steps: (1) Ask directly about suicidal thoughts, plans and intent, using standard practice; TCM framing does not lower or raise the threshold. (2) Screen for mania and psychosis whatever the label. (3) If risk is present, follow your usual pathway (safety planning, lethal-means counselling about safe storage and removal, urgent medical or crisis referral). (4) Explain the plan in the client's terms where possible.
Example language (illustrative): "Whatever we call it, when someone sleeps this little and feels this hopeless I always ask: have you had thoughts of ending your life?"
Watch for: Family accepting a TM1 label as reason not to seek psychiatric care; acute symptoms waiting for the next herbal consultation [source: NCCIH, do not delay conventional care]. Working: risk is assessed and managed regardless of framing.

4.11 Preparing for and processing needle- and touch-based treatments

Purpose / when: When a client is about to start, or has had, acupuncture, tuina, cupping or moxibustion and has trauma, needle fear, dissociation, or questions about consent. You do not perform or describe technique [synthesis].
Steps: (1) Ask what the client knows will happen and what worries them. (2) Help them plan what to tell the practitioner (e.g. areas not to be touched, need to sit up, a stop signal). (3) Rehearse saying no or stop. (4) Remind them that they may ask questions at any point and that registered practitioners have complaints routes (4.6). (5) Afterwards, debrief bodily reactions and any distress. (6) If they describe chest pain or breathlessness after needling, fever or spreading redness, nerve pain or burns, advise urgent medical care [source: NCCIH lists infection, punctured organs, collapsed lung, CNS injury; burns from moxibustion/cupping: uncertain: not verified].
Example language (illustrative): "What would you like the acupuncturist to know before she starts?" / "How did your body respond, and how did you feel about it afterwards?"
Watch for: Any sexual or genital touch, or touch without consent: these are never part of legitimate treatment and are reportable to the regulator [synthesis]; dissociation during treatment. Working: the client experiences treatment as chosen and controllable.

4.12 Supporting client-chosen qigong or tai chi

Purpose / when: When the client practises or wants to practise qigong or tai chi for wellbeing. NCCIH reports these appear safe, with minor aches possible, and tai chi may improve mood and quality of life in some groups [source: NCCIH]. Forms and teaching are covered in Domain X, entry 123.
Steps: (1) Ask what the practice means to the client and where they learn it. (2) Link it to therapy goals (routine, sleep, social contact, bodily calm). (3) Do not teach forms yourself unless trained. (4) Encourage medical advice in pregnancy and with health conditions, as NCCIH suggests.
Example language (illustrative): "You said the morning group in the park steadies you. How could we protect that time?"
Watch for: Groups that discourage medical or psychological care, demand money or isolate members (assess for coercion) [synthesis]; unusual experiences during intensive practice (assess, cross-refer Domain X 123). Working: practice supports, rather than replaces, care.

4.13 Spirituality, Religion and Moral Traditions module

Purpose / when: When the client's health beliefs connect with religious or moral traditions (e.g. Daoist, Buddhist, ancestral or family duty frames). The module (16 questions) covers identity, role in daily and family life, relationship to the problem, and stresses or conflicts [source: CFI Supplementary Modules].
Steps: (1) Ask whether any tradition shapes how the client understands health. (2) Explore what it says about suffering and help. (3) Explore conflicts (e.g. family duty vs personal wishes). (4) Involve a religious adviser only at the client's request.
Example language (illustrative): "Does any tradition or teaching shape how you see this illness?"
Watch for: Assuming TCM is a religion (it is a medical system) [synthesis]. Working: values are named and usable in therapy.

4.14 Language, interpreters, cultural identity and family

Purpose / when: Clients with limited English or whose TCM terms do not translate; families who make health decisions jointly. The Cultural Identity module covers background, language, migration, religion, gender identity and sexual orientation, and notes migration status may be sensitive [source: CFI Supplementary Modules].
Steps: (1) Use a professional interpreter, not family. (2) Brief the interpreter to render TCM terms as said, with the Chinese term, and to flag where no English equivalent exists. (3) Ask whom the client wants involved; with consent, invite family to a session to share their understanding. (4) Explore migration history and generational differences in TCM use.
Example language (illustrative): "Please give me the Chinese word too, so I don't lose the meaning." / "Who in your family has a say in your health?"
Watch for: Interpreters who soften or editorialise; family members speaking for the client. Working: the client's own words are recorded.

4.15 The clinician–patient relationship, discrimination and trust

Purpose / when: At assessment and after any rupture. The CFI ends with questions on perceived racism, language barriers and cultural difference that may undermine care [source: DSM-5-TR CFI].
Steps: (1) Ask about past experiences of being dismissed for using TCM or for being Chinese or Asian. (2) Acknowledge them without defending services. (3) Ask what would help this relationship. (4) Revisit at review points.
Example language (illustrative): "Have health workers ever made you feel judged for using Chinese medicine?"
Watch for: Reluctance to disclose remedies after earlier ridicule. Working: disclosure increases.

4.16 Recognising and reporting suspected harm

Purpose / when: When the client describes symptoms or events that may follow a product or procedure (see Harm account).
Steps: (1) Advise urgent medical care for acute symptoms. (2) Encourage the client, with their doctor, to keep the product and packaging. (3) Support a complaint to the relevant regulator (CMBA/AHPRA, CTCMPAO, state acupuncture board, PSA-accredited register or the practitioner's body) or a product report to the medicines regulator; FDA asked health professionals to report kidney disease or cancer cases linked to aristolochic acid products, and MHRA asks to be contacted about the sale or supply of suspect products [source: foodnavigator on FDA; MHRA 2007]. (4) Follow safeguarding procedures where a child or adult at risk is involved (4.17). (5) Offer therapy for the psychological impact.
Example language (illustrative): "That needs a doctor today. Please take the packet with you."
Watch for: Self-blame, shame or loyalty to the practitioner delaying reports. Working: medical review happens and the client feels supported, not judged.

4.17 Children and young people

Purpose / when: When a parent gives a child TCM products or treatments. NCCIH advises consulting a health care provider before TCM for a child or in pregnancy and breastfeeding [source: NCCIH].
Steps: (1) Ask about all remedies the child receives. (2) Encourage disclosure to the child's doctor. (3) Seek age-appropriate assent for any procedure. (4) Where a child appears harmed or necessary medical care is withheld, follow local child-protection procedures [synthesis].
Example language (illustrative): "Many parents use herbal remedies. Does her paediatrician know what she's taking?"
Watch for: Treating culturally ordinary care as abuse, and missing real harm presented as tradition [synthesis]. Working: the child's doctor has the full picture.

5. Handling problems

The sources describe safety and regulation; the clinical responses below are largely [synthesis] unless tagged.

Client will not disclose remedies. Often follows past ridicule. Response: normalise ("most people I see use something besides what I suggest"), explain why the prescriber needs the list, ask again at review; use 4.15 [synthesis; CFI clinician–patient section].
Client asks you whether a herb or formula is safe, or which acupuncturist to see. Response: decline to advise on products; route to prescriber or pharmacist; offer the register check (4.6) rather than a recommendation [synthesis].
Client stops psychiatric medicine for TCM. Response: 4.8; risk assessment; urgent prescriber contact; no ultimatum that ends therapy [synthesis].
Stuck: TCM and psychological accounts compete. Response: return to 4.9; find the shared target (sleep, anger, worry, family strain); let the client hold both [synthesis].
Resistance framed as "Western therapy doesn't fit me". Response: explore with the CFI current-help-seeking domain what help would fit; adapt pace, directness and family involvement; consider a referral to a culturally matched clinician if the client wishes [synthesis; CFI].
Rupture after you voiced concern about a product. Response: acknowledge that the concern may have felt like criticism of the client's culture or family; restate your role (safety, not judgment); repair before continuing [synthesis].
Overwhelm or bodily distress described in TCM terms (e.g. heat rising, chest oppression, palpitations). Response: ground and stabilise as usual; ask about medical review where symptoms are new or physical; do not interpret them as TCM patterns [synthesis; ICD-11 lists such symptoms in TM1 heart-system disorders].
Non-adherence to homework because the TCM practitioner advised rest or dietary restriction. Response: ask what the advice means to the client; negotiate homework that fits; if dietary restriction looks extreme or coexists with eating-disorder signs, assess and involve the GP [synthesis].
Family pressure to use TCM only. Response: family session with consent (4.14); explore fears about psychiatric labels and stigma; keep the client's autonomy central [synthesis].
A practitioner tells the client their anxiety is purely a qi problem that therapy cannot touch. Response: avoid a turf war; ask the client what they make of it; offer coordination (4.7) [synthesis].
Physical red flags (unexplained kidney problems, blood in urine, jaundice, chest pain after needling, burns, signs of infection). Response: urgent medical care; ask about all products and procedures; support reporting (4.16) [source: MHRA; NCCIH].
Suspected unregistered practice or sexual misconduct. Response: support a complaint to the regulator or accredited register; follow safeguarding procedures; therapy for the impact [source: CMBA; Ontario Act; PSA; synthesis].
Problems the sources do not address [synthesis]: clients who experience TCM as a link to a deceased parent or homeland (grief work, not product debate); clinicians who are themselves dual-trained and must keep roles distinct (separate consent, separate records, do not combine sessions without explicit agreement and professional-body guidance [uncertain]); clients from China who carry certificates under different registration routes, whose meaning abroad is unclear (ask the local regulator).

Harm account

This account covers practices and products linked to documented harm. It is not a judgment on TCM as a whole; registered practitioners and regulators themselves act against these harms.

What was actually done

Aristolochic acid in herbal products. In Belgium, clients of a single diet clinic were given a prescription weight-loss capsule into which, according to the Belgian Ministry of Health's tracing, an aristolochic-acid-containing herb had been put in place of another herb; at least 100 clients developed end-stage kidney failure [source: foodnavigator 2001 on FDA warning]. The outbreak of rapidly progressive kidney failure was observed in 1992–1993 [source: Vanherweghem 1994]. Similar cases were reported in the UK and France [source: foodnavigator]. In the US, FDA received reports of two patients with serious kidney disease and in 2001 issued a nationwide alert (20 June 2001) and obtained recalls, including Blue Light's "Treasure of the East" products (Guan Mu Tong, Ma Dou Ling and about a dozen combinations) and Pacific Biologic capsules of Mu Tong and Xi Xin, which had been distributed to doctors, naturopaths, licensed acupuncturists and herbal practitioners; a joint-supplement recall measured aristolochic acid at 9.5 ppm [source: FDA 2001 enforcement compilation]. Labels may say aristolochia, bragantia or asarum rather than aristolochic acid; FDA found it in at least 16 US products [source: foodnavigator]. The UK prohibited Aristolochia (and commonly substituted species) in 1999, yet MHRA repeatedly found traditional Chinese medicines containing it, often not listed on the label [source: MHRA 2007]. In Taiwan, exposure to Aristolochia-based herbal medicines is regarded as the main reason for a high incidence of upper urinary tract urothelial carcinoma [source: Dickman et al. 2022].
Contamination and adulteration. Products have contained undeclared plant or animal material, prescription drugs (warfarin, diclofenac), heavy metals (arsenic, lead, cadmium), pesticides and sulfites [source: NCCIH]; MHRA warnings cover heavy metals, fenfluramine, undeclared steroids (betamethasone in a herbal body lotion) and an unlicensed diabetes product that told patients to stop prescribed medication [source: MHRA 2008].
Herb–drug interactions and liver injury. A small number of Chinese herbal products have been linked to clinically apparent liver injury, and mixtures sold under one name can vary in composition [source: LiverTox, Chinese and other Asian Herbal Medicines]; herbs can alter drug levels through liver enzymes and gut transporters, with most concern for narrow-therapeutic-index drugs such as warfarin [source: NCCIH Clinical Digest, Herb-Drug Interactions]. The presence of warfarin in products itself creates bleeding risk with other anticoagulants [synthesis from NCCIH].
Acupuncture injuries. Rare serious complications with non-sterile needles or improper delivery: infections, punctured organs, collapsed lungs (pneumothorax), central nervous system injury [source: NCCIH].
Moxibustion and cupping burns. Burns from these heat-based procedures have been reported: NCCIH lists persistent skin discoloration, scars, burns and infections among cupping side effects [source: NCCIH, Cupping], and burns are documented in case reports of moxibustion [source: Safety of Moxibustion: A Systematic Review of Case Reports].
Endangered-species ingredients. Some traditional formulas have used animal and plant parts from protected species, now restricted under international trade law; pangolins are listed in CITES Appendix I, and pangolin scales were removed from China's approved TCM ingredients in 2020 [source: Mongabay, 10 June 2020].

How it caused harm

Aristolochic acids are nephrotoxic, carcinogenic and mutagenic even in very small amounts; they cause a characteristic renal fibrosis ("Chinese herb nephropathy") that can progress to end-stage renal failure within 6–24 months of ingestion, and some patients develop transitional-cell carcinoma of the renal pelvis, ureter and bladder [source: MHRA 2007]. Several Belgian patients were also found to have kidney or bladder cancer [source: foodnavigator]. Damage is described as permanent [source: foodnavigator]. Most at risk: people taking unlabelled, imported or slimming products, and people whose remedies were substituted without their knowledge [source: MHRA; foodnavigator].
Undeclared drugs and metals expose users to effects and interactions they cannot anticipate, including bleeding (warfarin), steroid effects, and toxic-metal exposure; sulfites can cause asthma or severe allergic reactions [source: NCCIH; MHRA].
Advice to stop prescribed medicine led to suspected adverse reactions in the MHRA diabetes case [source: MHRA 2008]; the same mechanism applies to psychiatric relapse when medicines are stopped abruptly [synthesis].
Procedure injuries follow from needle sterility failures and needling over organs or nerves [source: NCCIH].
Psychological sequelae (shame, self-blame for choosing the product, loss of trust in all care, health anxiety after kidney failure or cancer) are not documented in the cited sources [synthesis].

Recognising it today

Products with no ingredient list, only Chinese labelling, or ingredients named aristolochia, bragantia, asarum, Guan Mu Tong, Ma Dou Ling, Mu Tong or Xi Xin [source: FDA 2001; foodnavigator].
In the UK, absence of a THR or PL number (most herbal products are unlicensed and standards vary widely) [source: MHRA 2008].
Slimming, "detox", diabetes, skin or joint remedies bought online, abroad or from unregistered sellers [source: MHRA; FDA 2001].
Any instruction to stop prescribed medicines, or claims to cure cancer or serious illness [source: MHRA 2008; NCCIH].
Practitioners using protected titles without registration, or who cannot name their register [source: CMBA; Ontario Act; PSA].
Reused or non-sterile needles, treatment without explanation or consent, any sexual touch [source: NCCIH; synthesis].
Unexplained kidney impairment in someone who has used herbal products [source: MHRA 2007].
How legitimate practice differs: registered practitioners work within a regulator's code, take histories, use products subject to national controls (e.g. UK prohibition of Aristolochia; Australian registration of herbal dispensers), and accept coordination with medical care [source: CMBA; MHRA; synthesis].

What to do instead and how to help those harmed

Safer route: a registered practitioner (4.6), products disclosed to and reviewed by the prescriber or pharmacist (4.5), and TCM used alongside, not instead of, conventional care [source: NCCIH].
Immediate response: medical review for physical symptoms; keep packaging; report to the medicines regulator or the practitioner's regulator (4.16) [source: MHRA; FDA].
Therapy for affected clients [synthesis]: assess for depression, anxiety, health anxiety and adjustment to chronic kidney disease, dialysis or cancer; address self-blame without endorsing the product; work with the renal or oncology team; respect the client's continued relationship with TCM if they wish it.
Ethical, reporting and legal duties [synthesis]: follow safeguarding procedures for children and adults at risk; report sexual misconduct or unsafe practice to the relevant regulator with the client's consent unless law or safeguarding requires otherwise; document advice given and referrals made; stay within your competence by never advising on products or medicines.

Sources

Web pages:

Books and other works referred to:

American Psychiatric Association. 2022. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Section III, Cultural Formulation [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf].
Kleinman A, Eisenberg L, Good B. 1978. "Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research." Annals of Internal Medicine 88:251–258 [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader].

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