Altered States (or, the Sketchy Guy)

Last week I had an experience I haven’t had in a long, long time: I needed to get someone to leave the clinic. Basically I politely maneuvered them out, which has happened only a handful of times -- usually the people who come in, stay. Afterwards I thought the situation was a good writing prompt from the universe about boundaries, so here goes.

I was the clinic supervisor, working with three interns. I came out of the treatment room into the lobby to find two new patients filling out paperwork. One of them seemed to be doing fine, while the other one, a skinny guy in a baseball cap, wasn’t. I never used to say or think these things before I moved to the West Coast but -- his energy was just off.

A quick note about the community acupuncture job: it’s about being centered, and also making sure the space itself is centered. Certain kinds of energy can knock the clinic space off its axis, and so you have to intensively manage those energies in order to protect it. If a person is agitated, it’s your job to help them become less agitated. Too much agitation or noise or disruption in the clinic space will make it not work, and in community acupuncture, you need the space to work for you and with you to successfully treat a high volume of patients. There are some disruptions you can’t help, like somebody snoring or accidentally knocking over a lamp, but there are other disruptions that you have to stop, like somebody taking calls on their cell phone in the treatment room or otherwise disturbing the peace.

The patient who was having trouble with his paperwork seemed agitated. He kept getting up, moving around the waiting room, picking things up and putting them down. His mask kept slipping off his nose. He spoke very quickly and very softly. He asked to put a bottle of liniment “on his account” and the receptionist said, okay, and put it aside for him. He picked up one of our business cards, squinted at it, and asked me a question about it; as I answered I noticed that he was holding the card upside down. After a little while, I also noticed that he wasn’t actually filling out the new patient forms, in fact he didn’t even have them; he had taken a couple of our “COVID questionnaire forms” (the little slips that we ask people to fill out every time they come in for a treatment affirming that they don’t have a fever, etc) and he was writing furiously in the margins.

I thought, hmm, this person is in an altered state.

Patients and potential patients in altered states represent an interesting category of interactions for community acupuncturists. Altered states are sometimes, but not always, a reason why it might not be safe to offer a treatment to that person at that time. In my experience, interacting with people in altered states requires checking in with my gut about what’s happening and what I might need to do about it.

In this case, my gut said: this person seems to be high. Also (separately) it feels to me like he’s casing the joint.

In WCA Cully’s 19 years in business, we’ve had patients steal things (to my knowledge) a handful of times. In one of those instances, I did an intake with a patient who was behaving oddly and later it turned out they’d been casing us, so I recognize the vibe. That person was not in an altered state (or if they were it wasn’t apparent) but something about their energy just seemed off-kilter, fundamentally and memorably different from other patients’ energy in the clinic: they weren't there because they wanted to get acupuncture, but for other (nefarious) reasons. Last week’s prospective patient seemed to be BOTH altered AND up to no good (it’s important not to conflate the two). Being altered probably made him less effective at being up to no good.

My thought process went something like this: I want to protect the clinic, hold our boundaries, and do those things without being rude to this person or knocking the clinic off its energetic axis. Sketchy energy usually doesn’t enter WCA because we’re clear we don’t want it; now that it’s here I want it to disperse without any additional drama. That’s not going to happen on its own -- I need to step in and manage this situation.

The next time the prospective patient put down his writing and wandered over in the direction of the front desk, I stood up and held out a clipboard to him. “Hey, I’m sorry, there’s been some confusion. These are the new patient forms we need you to fill out.”

He looked away and didn’t take them from me. “Oh...I have a hard time with paperwork.”

I nodded with genuine sympathy because this is a real thing for plenty of people whether they’re in an altered state or not. At WCA we recognize paperwork can be a barrier. Our reason for being is to lower barriers wherever we can so it felt strange to deliberately let one stand, but that’s what I was doing. “Yes, I’m sorry. Unfortunately we need you to fill out these forms before we can treat you. Maybe today isn’t a good day? Maybe you should come back another time?”

He thought about it for a minute, then nodded. I felt calm the way a rock is calm when it’s being battered by waves. Whatever sketchy sequence of events he was hoping to set in motion, it wasn’t going to happen with me standing there, polite and immovable. It helped that I was taller than he was.

“Yeah, okay. Can I use your bathroom?”

“Sure. It’s right this way.”

One of the times that WCA was targeted for theft, a prospective patient asked to use the bathroom then slipped back into the treatment room where they nabbed a sleeping patient’s wallet, then came back out to say they’d changed their mind about getting acupuncture and left. Fortunately the sleeping patient was a very kind, forgiving regular, but of course I felt terrible and vowed to never let it happen again. So I escorted the guy in the baseball cap to the bathroom and sat down on the bench outside the door to wait for him. As soon as he emerged I popped up, smiling, to walk him to the front door.

He didn’t quite make it. He drifted over to a table, picked up some scrap paper and started writing again. I said, “Would you like to take some paper with you? I think it’s time for you to go,” and turned my back on him just long enough to go prop open the front door. Then I went back and stood next to him.

Somehow the open door did the trick, or maybe it was me sticking to him like friendly glue. He said, “Okay,” pocketed a few pieces of paper, and headed out. “Thanks, have a good night,” I said. “Thanks,” he responded, and then he was gone. I shut the door and collected the pieces of paper he’d left behind. A lot of what he wrote wasn’t legible, but the parts that were seemed to be about his mother; also God.

Later someone asked me if I was concerned about violence and I said no. I did have a tiny voice in the back of my mind wondering if things might get ugly (after all, he was a guy up to no good), but my gut said he wasn’t violent, just sketchy and altered. I felt like it was important to be polite to him and as kind as I could be. Thieves and would-be thieves are people too (indeed, some are my relatives). The criminalization of drug users and poor people in our society means that this guy probably has a very hard life and is used to getting kicked out of places and treated terribly. My experience with people like him is that they appreciate and respond to politeness, as much or more than the general population. He was easy to be polite to.

But let’s get back to altered states.

Setting aside the sketchy elements in his behavior, it wouldn’t have been safe to treat him because he was altered enough that I couldn’t trust that he could give informed consent. He didn’t understand which forms he was filling out; he was holding things upside down while pretending or believing he was reading them. Informed consent is a kind of legal boundary that patients cross over by signing their names to a form. Granted, a lot of people probably don’t really read it even though we ask them to, and plenty of our patients don’t speak English, but in general as a practitioner I can trust that the ritual of signing your name to a set of forms means you know you’re entering some kind of legal agreement, even if you’re not that interested in the particulars. With this person, I couldn’t trust that. In addition, I couldn’t be confident that he would be able to hold still enough to safely receive acupuncture. So even if he hadn’t been casing the joint, he would have had to go.

I’ve treated lots of people who I suspected were not 100% sober, but their questionable sobriety didn’t present a safety issue for them or me as they were using the clinic. Similarly, I’ve treated patients who were in altered states for reasons not related to drugs, who presented no safety problems whatsoever. People who have schizophrenia might want acupuncture for reasons related to schizophrenia (I had one patient tell me that acupuncture didn’t stop mean voices from coming out of his radio, but it made them harder to hear -- the dial on his radio didn’t turn down the volume, but acupuncture did, reliably). Or unrelated to it. People with schizophrenia have muscle pain, headaches, and want to quit smoking like anybody else. If someone is able to navigate the space and the treatment process safely, the fact they’re perceiving reality differently (like hearing voices while they’re in the clinic) shouldn’t prevent them from getting acupuncture.

This blog post is about holding safety boundaries in the clinic, but it’s also about the boundaries I hold for myself as a practitioner, related to what is and what isn’t my business. In order to be able to rise to the occasion in challenging situations like this one (I handled it but I was rattled for sure) I need to have clear definitions for myself about what is and isn’t my business so that I don’t waste any energy on what isn’t. Community acupuncture represents a long game of showing up, day in and day out, for all kinds of people.

Which gets us to a conversation I’ve been having with the interns, about politics. It’s an intense topic these days! My experience as a community acupuncturist, though, is that some of my patients have always held political views that, to me, seem delusional. One of my early lessons in boundaries was having to politely extract myself from an animated conversation about black helicopters with one of my most dedicated patients, a person of multiple marginalized identities who had gone above and beyond in supporting my clinic in the community. So for a long time (that person was a core regular for fifteen years, which is how long we steered around their sincerely held beliefs about black helicopters) I’ve quietly categorized my patients’ politics as potentially in the “altered states” category: not my business unless they interfere with navigating the clinic space and the treatment process safely.

Part of how I set my boundaries as a practitioner is: I won’t argue about the nature of reality with my patients. I won’t get into it with them. I accept that some of them live in different realities than I do, for reasons I might or might not be able to understand. I don’t want to talk about it because talking about it makes it hard for me to do my job. If their behavior in the clinic creates problems, particularly safety problems, I will intervene to address the behavior.

In my mind, this is a category of harm reduction. I can’t make the world safe or sane, but I can try to relieve what pain and stress I can reach, in the hope that makes everyone, in the long run, a little bit safer.